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Official Journal of the American College of Sports Medicine activity protocol (median=11.5%, range=6.3%-27.4%) compared to the lifestyle activity protocol (median=77.2%, range=60.6%-98.3%). Patterns of prevalence for both activity protocols were similar for sex, race/ethnicity, education, and BMI subgroups. Prevalence decreased with age for the walking/running activity protocol whereas prevalence increased for 25-44 year olds before decreasing with age for the lifestyle activity protocol. CONCLusION: Prevalence estimates for meeting Guidelines in U.S. adults varied widely, indicating the choice of cut point impacts the prevalence estimates. Whether accuracy of the prevalence for meeting Guidelines for U.S. adults may be further improved if cut points (1) captured lifestyle activities in which many U.S. adults participate and (2) were generated from samples with characteristics similar to that of the U.S. adult population should be evaluated. D-18 Clinical Case Slide - Low Back Issues May 30, 2013, 1:00 PM - 2:40 PM Room: 103 1384 Chair: Stanley A. Herring, FACSM. University of Washington Medical Center, Seattle, WA. (No relationships reported) 1385 discussant: Gary P. Chimes. Northwestern University, Chicago, IL. (No relationships reported) 1386 discussant: Lisa Colvin, FACSM. ULM, Monroe, LA. (No relationships reported) 1387 May 30, 1:00 PM - 1:20 PM spine Injury _ Gymnast Bryan Murtaugh, Ellen Casey. Northwestern McGaw Medical Center, Chicago, IL. (Sponsor: Joel Press, FACSM) (No relationships reported) hIsTOry: 16-year-old gymnast and cheerleader presenting for second opinion for 6 month history of low back pain. During the onset of pain, she was returning to gymnastics after several months of limited participation while recovering from a right knee injury. She was initially seen by another physician, and had x-rays and MRI, which were interpreted as a stress fracture of the superior endplate of S1. Initial treatment included a lumbar corset, NSAIDs, PT, and modified gymnastics. Pain persisted, so she received a different soft orthosis, and stopped all gymnastics and cheerleading 2 months prior to presentation. PhysICaL EXaMINaTION: Increased thoracic kyphosis, decreased lumbar lordosis, and pelvic obliquity. Tenderness at L5 and S1 spinous processes and bilateral sacral sulcus. Significantly restricted lumbar extension. Strength 5-/5 for right great toe extension and eversion. Seated slump and straight leg raise causes bilateral posterior thigh pain that improves with cervical extension. PhysICaL EXaMINaTION: 1.Spondylolysis 2.Persistent S1 ring apophysis fracture 3.Sacral stress fracture 4.Lumbosacral radiculopathy TEsT aNd rEsuLTs: 1.Lumbosacral xrays: No DDD, spondylosis, or spondylolisthesis. 2.Lumbosacral MRI 11/2011: L5-S1 with a linear low signal endplate irregularity in the superior margin of the superior S1 endplate, right disc bulge with encroachment upon S1. 3.Lumbosacral MRI 4/2012: L5-S1 focal depression of the posterior portion of the superior S1 endplate to the right of the midline, disc bulge L5-S1. FINaL WOrKING dIaGNOsIs: Right L5-S1 radiculopathy TrEaTMENT aNd OuTCOMEs: 1. Further imaging with a focused CT of L5-S1 obtained to determine if she truly has a persistent ring apophysis fracture. CT demonstrated that the presumed S1 endplate fracture was actually a congenital anomaly rather than an acute injury. 2. Treatment plan for R L5-S1 radiculopathy, including extension-biased mechanical diagnosis and treatment. Trial of Gabapentin 200 mg PO HS. 3. Activity modification - No gymnastics until strength normalized, and pain decreased with daily activities, then progressed to stretching and conditioning with team. 4. She had 80% improvement with the treatment, and gradually returned to cheerleading and gymnastics without limitation from pain. 1388 May 30, 1:20 PM - 1:40 PM Back Pain - Football Jesse Sally, Gary Chimes, Tanya Hagen. UPMC, Pittsburgh, PA. (No relationships reported) hIsTOry: A 22 year-old college football player presents with low back pain after being hit from behind, striking his back on the top of the opposing player’s helmet. He had acute pain in the left low back at the time of the injury, which persisted during practice the following week. He describes dull, aching pain in the left low back and paraspinal region that is worsened by prolonged standing and walking. He also reports pain with sitting upright for extended periods and bending forward to put on shoes. PhysICaL EXaMINaTION: Pain with lumbar range of motion was most Vol. 45 No. 5 Supplement S263 significant between 30-70 degrees of lumbar flexion. There was tenderness to palpation of left lower lumbar paraspinals. With the knee flexed, the patient could flex, internally rotate, and externally rotate the hip without limitation. Sensation is intact to light touch throughout his L2-S2 dermatomes bilaterally. Manual muscle testing revealed 5/5 strength throughout his L2-S2 myotomes. Muscle stretch reflexes were 2+/4 at the knee, medial hamstring, and ankle bilaterally. Stork maneuver with reproduction of low back pain bilaterally. Slump-sit test with reproduction of concordant back pain bilaterally, more intensely on the left and better with cervical extension on the left. PhysICaL EXaMINaTION: Pars interarticularis fracture Lumbar facet syndrome Sacroiliac joint inflammation Lumbar disc herniation Lumbar annular tear Lumbar radiculitis TEsT aNd rEsuLTs: Lumbar spine x-ray imaging without acute fracture or spondylolisthesis. MRI of the lumbar spine with left paracentral disc protrusion at L4-5. Bilateral facet hypertrophy also at the same level with minimal foraminal encroachment. Standing extension-based exercises performed in the clinic helped to centralize pain from the left low back into the axial spine. This confirmed the diagnosis and helped guide treatment. FINaL WOrKING dIaGNOsIs: L4-5 left paracentral disc protrusion with L5 radiculitis TrEaTMENT aNd OuTCOMEs: Left L5 transforaminal epidural steroid injection. Immediate improvement in symptoms post-injection. Prescribed physical therapy with focus on centralization (if symptoms were to recur), core stabilization, and lumbar strengthening for high level functionality. Full return to competition and practice without symptoms when evaluated for clinical follow-up. 1389 May 30, 1:40 PM - 2:00 PM Lumbar spine-professional Ladies Professional Golf association Golfer Michael W. Perry, Elizabeth M. Hudak, Michael Weiss. Laser Spine Institute, Tampa, FL. (No relationships reported) hIsTOry: In 2010, a 27-year old LPGA golfer presented with a 7-year history of intermittent shooting sharp pain in her left lower back and left hip flexors. She also noticed a sensation of weakness in her left hip. Pain severity increased with posture and rotation, spine loading, sitting, and playing golf. There were no radicular symptoms, numbing, tingling, or changes in gait. Failed attempts to alleviate pain included acupuncture, spinal decompression using the DRX-9000, chiropractic care, hydro-therapy, and yoga. In 2008, short-term pain relief was achieved through a caudal epidural and facet injections. PhysICaL EXaMINaTION: The patient had a negative straight leg raise. Dorsiflexion and plantar flexion strength was 5/5 bilaterally. There was no alteration to sensation distally. Bilateral paraventrebal tenderness was noted at the left lumbar region. Pain was noted in the lumbar-thoracic spine with flexion, hyperextension, left lateral flexion and left rotation. Motor strength was satisfactory with a score of 5/5 in all muscle groups. No pathologic deep tendon reflexes were elicited. PhysICaL EXaMINaTION: 1.lumbar disc disruption 2.lumbar facet disease 3.lumbar paraspinal muscle strain TEsT aNd rEsuLTs: MRI of the lumbar spine: •degenerative disc disease and bulge at L3-S1 •annular tear at L3/4 •degenerative facet disease at L4/5 •mild forminal narrowing at L4/5 and L5/S1 •mild spinal stenosis at L3-5 X-Ray of the lumbar spine: •no instability or acute osseus abnormalities •disc spaces relatively maintained •mild facet changes of the lower lumbar facets at L4/5 and L5/S1 X-Ray of the pelvis: •concentric hips without degenerative changes •pseudoarthrosis is not well visualized FINaL/WOrKING dIaGNOsIs: 1.facet degeneration 2.lumbar arthritis/osteoarthritis without myelopathy 3.bulging disc TrEaTMENT aNd OuTCOMEs: 1.minimally invasive endoscopic spinal surgery •destruction by thermal ablation of the paravertebral facet joint nerves at bilateral L3/4, bilateral L4/5, and bilateral L5/S1 facet joints 2.post-operative care Abstracts were prepared by the authors and printed as submitted. Thursday, May 30, 2013
Thursday, May 30, 2013 S264 Vol. 45 No. 5 Supplement •lumbar bracing •follow-up evaluations •physical therapy 3.surgical outcomes •back pain 6-months post-surgery: a short course of NSAIDs resolved all symptoms •patient is free from back pain, uses no pain medications, and playing in the LPGA tour 1390 May 30, 2:00 PM - 2:20 PM Tingling and Weakness - Gymnastics Nailah Coleman, FACSM. Children’s National Medical Center, Washington, DC. (No relationships reported) hIsTOry: 16 y/o gymnast presented with sharp right patellar tendon pain and midlower back pain after two separate vault injuries within the prior two weeks. Her pain was exacerbated by movement and use of her knee and back. She denied sedentary pain, sleep disturbance, or bowel-bladder insufficiency. She noted atraumatic “pins and needles” on her right dorsal hand over the past five days but denied neck, elbow, or jaw pain or injury. Her past medical and surgical histories were unremarkable. Her only medicine was Aleve. She had no known allergies. Exam: she was WDWN in NAD. She had symmetric appearance of her extremities and a minimal curvature of her spine. She had a normal gait and was able to heel, toe, and duck walk. She was nontender to palpation. She had full motion of her trunk and extremities but pain with lumbar extension. Strength, sensation, and neurovascular status were intact and symmetric, except for 4+/5 strength in the right upper extremity. She had right hand cramping with elevated arm stress test and right shoulder pain with empty can, O’Brien’s test, and Speed’s test. PhysICaL EXaMINaTION: •Spinal cord lesion •Nerve root compression •Peripheral nerve disease •Patellar tendinitis •Spondylolysis •Back strain TEsTs aNd rEsuLTs X-rays •Cervical spine with oblique views: increased transverse processes •Scoliosis views: minimal curvature •Lumbar spine with oblique views: normal •Shoulder: normal •Knee: normal MRI •Spine: a lesion at C4-C5 measuring 5 mm (width) x 15 mm (cranial-caudal) with mild enhancement, which could signal a demyelinating process, tumor, or trauma. •Brain: findings suggestive of volume loss without evidence of gliosis or demyelination process. Final Working Diagnosis: transverse myelitis TrEaTMENT aNd OuTCOMEs •Urgently seen by Neurology and admitted from clinic with a progressively symptomatic exam, including hyperreflexia and clonus. •CSF and serum studies for infectious and rheumatologic diseases were normal, except for an elevated ANA. A definitive etiology has not been found. •She was given a three-day course of methylprednisolone and responded well. •She was discharged home with plans for Neuro-Ophthalmology, PM&R, and repeat imaging. •New studies are pending. 1391 May 30, 2:20 PM - 2:40 PM acute Back Pain-Football Tom W. Bartsokas, FACSM. Summa Orthopaedics & Sports Medicine, Streetsboro, OH. (No relationships reported) hIsTOry: 13-yo male sustained direct blow to right lumbar area from helmet. Pain progressed over next 2 days, was constant, rated 9/10 at worst and 6/10 at least, radiated from right LB to right knee, and was associated with severe loss of spinal motion. Denied changes in bowel/bladder control, hematuria, weakness, previous episodes of LBP. PhysICaL EXaMINaTION: Standing exam revealed neutral spinal alignment. AROM: moderate restriction to flexion; severe restriction to extension (caused severe right LBP); severe restriction to right sidebending; moderate restriction to left sidebending; moderate restrictions to rotation bilateral. Gait was slightly antalgic secondary to back pain. 4+ TTP over right lumbar paraspinals, which had moderately increased tonus. No TTP at midline, SI joints, sciatic notches bilateral. DTR’s 2/4. PhysICaL EXaMINaTION: Lumbar contusion, Spondylolysis, Facet syndrome, Fracture (spinous process, transverse process, pedicle, vertebral body), Lumbar disc displacement TEsT aNd rEsuLTs: X-rays of lumbar spine: 5 lumbar vertebrae in normal MEDICINE & SCIENCE IN SPORTS & EXERCISE ® alignment. Slerotic line at right L5 pars interarticularis. No other suggestive evidence for fractures. Lumbar MRI scan: nondisplaced right L2 transverse process fracture, bone marrow edema at right L3 & L4 transverse processes. FINaL WOrKING dIaGNOsIs: Right L2 transverse process fracture TrEaTMENT aNd OuTCOMEs: First visit: TLSO brace 23 hours/day and withheld from sports/PE. Second visit: Feeling better, walking normally, throwing football without pain; continue brace use when up and rest for another 3 weeks. Third visit: Released to full activity 4.5 weeks after injury. D-19 Clinical Case Slide - Football I May 30, 2013, 1:00 PM - 2:40 PM Room: 117 1392 Chair: Jeffrey M. Anderson, FACSM. Univ. of Connecticut, Storrs, CT. (No relationships reported) 1393 discussant: Bryan Wiley. Rancho Cucamonga, CA. (No relationships reported) 1394 discussant: Aaron Rubin, FACSM. Kaiser Permanente Sports Medicine Program, Fontana, CA. (No relationships reported) 1395 May 30, 1:00 PM - 1:20 PM recurrent deep Vein Thrombosis - Football Dale C. Gold. University of Colorado, Littleton, CO. (Sponsor: Tod Sweeney, FACSM) (No relationships reported) hIsTOry: 18 year old high school football player presented with right upper extremity pain and swelling. He reported no injury to the area other than normal hits playing football. He reported recent heavy weight lifting. Ultrasound showed a right axillary DVT. Hypercoagulable workup was negative. He was treated with 6 months of warfarin therapy then cleared for athletic participation. In May 2010 the patient resumed weight lifting after a four month break and presented with pain and swelling of the right arm. Ultrasound showed a right subclavian DVT. He was restarted on warfarin and evaluated by vascular surgery in February 2011. A venogram performed April 2011 showed no acute clots. He was determined a non-surgical candidate due to the chronic nature of the occlusion. In June 2011, Warfarin was discontinued and low dose aspirin was started. In October 2011, patient presented with right arm swelling and pain after 2 weeks of lifting. Ultrasound showed an axillary vein DVT. Patient restarted on warfarin. Between acute episodes the patient had stable mild edema of the right arm after lifting, occasional bluish discoloration of the right upper extremity, and occasional pain in his right shoulder and neck. PysICaL EXaMINaTION: Examination when presenting with acute complaints reveal: 5/10: Right arm notably swollen compared to left, 2+ radial pulses bilaterally 10/11: subtle swelling of the right dorsal hand PhysICaL EXaMINaTION: 1. Paget-Schroetter Syndrome: - Increased muscle mass/impingement of vein by musculature of dominant arm - Cervical rib 2. Hypercoagulable state 3. Cervical Radiculopathy TEsT aNd rEsuLTs: Hypercoagulable workup: - Negative Factor V, Factor II DNA mutation, anticardiolipin antibodies, homocysteine level, protein C & S IMaGING: 4/08: US: thrombus right axillary vein 8/08: CTPE negative 11/08: US: no thrombus 5/10: US: thrombus right subclavian vein 2/11: US: no thrombus 4/11: Venogram: chronic occlusion of right subclavian vein at level of thoracic inlet with mature appearing collaterals. 10/11: US: thrombus right axillary vein FINaL/WOrKING dIaGNOsIs: Paget-Schroetter Syndrome due to venous impingement by musculature of dominant arm. TrEaTMENT aNd rECCOMEdaTIONs: 1. Chronic Warfarin therapy 2. Modified activity while on warfarin 3. Repeat Surgical Evaluation ACSM May 28 - June 1, 2013 Indianapolis, Indiana
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