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Official Journal of the American College of Sports Medicine 1396 May 30, 1:20 PM - 1:40 PM Wrist Injury _ Football Patrick Moreno1 , Steven Collina1 , David Webner1 , Andrew Reisman2 . 1Crozer Keystone, Springfield, PA. 2University of Delaware, Newark, DE. (Sponsor: Daniel Miles, FACSM) (No relationships reported) hIsTOry: 21 y/o male college football cornerback presented with right wrist pain after forced wrist flexion during a ball stripping drill at practice. He reported pain localized to the dorsoradial aspect of the wrist that was worse with flexion. Although he did not recall a previous injury to the wrist, he mentioned having intermittent wrist pain for 1 year in the same location. He did not experience paresthesias or weakness. PhysICaL EXaMINaTION: Passive range of motion with wrist flexion to 65 degrees, extension to 50 degrees, radial deviation to 18 degrees, ulnar deviation to 30 degrees. There was no tenderness over the anatomic snuffbox. There was tenderness over the scapholunate junction. Watson’s test was positive. PhysICaL EXaMINaTION: 1. Scaphoid fracture 2. Scapholunate ligament dissociation 3. DISI (Dorsal Intercalated Segmental Instability) 4. SLAC (Scapho-Lunate Advance Collapse) 5. CMC joint arthritis TEsT aNd rEsuLTs: Wrist A/P, lateral, and scaphoid radiographs: -widening of the scapholunate joint to 4.8mm with avulsion of the scaphoid Wrist Magnetic Resonance Imaging: -4mm scapholunate diastasis. Scapholunate angle increased to 80 degrees FINaL WOrKING dIaGNOsIs: DISI with scapholunate ligament tear TrEaTMENT aNd OuTCOMEs: 1. Initially treated with wrist splint and evaluation by hand specialist. 2. As an academic senior with 2 years of eligibility and redshirted as a freshman he elected to have custom wrist splint and continue playing the rest of the season. 3. Reconstruction of the scapholunate ligament is planned for after the season. 1397 May 30, 1:40 PM - 2:00 PM Knee Injury - Football Karen Gustafson, Aaron Provance. University of Colorado, Denver, CO. (Sponsor: John Hill, FACSM) (No relationships reported) hIsTOry: 10 year-old football player with left knee pain after sustaining two patellar contusions two weeks prior to presentation. He describes pain along the medial border of the patella that then causes his quad to spasm, along with general stiffness. He denied having any pain in his left knee prior to contusions, nor any locking or catching episodes. No right knee pain. His father states he has been grasping the banister while walking up and down the stairs for months. PhysICaL EXaMINaTION: Left Knee No swelling, deformity or ecchymosis. Tenderness to palpation over the medial border of the patella. ROM with full extension/flexion. Neurovascular exam intact with brisk pulses, 2 second capillary refill and a normal motor and sensory nerve examination in the affected limb. No laxity with valgus, varus stress testing at 0 and 30 deg. Negative anterior/posterior drawer, lachman’s, McMurray’s tests. PhysICaL EXaMINaTION: 1.Patella Contusion 2.Patella Fracture 3.Patella Osteochondral Injury TEsT aNd rEsuLTs: Left Knee 4 view-xray -bony defect is noted in the posterior patella, likely residing at the level of the middle patella facet, which measures 1 cm in the craniocaudal dimension -findings compatible with osteochondral injury of the patella. MRI Left Knee -Regional marrow edema involving three quarters of the patella. -Defect arising from the subchondral bone of the middle patella facet with dimensions of 3.5 CC x 10 AP x 1.6 cm ML mm. -Overlying hyaline cartilage remains intact. FINaL/WOrKING dIaGNOsIs: Osteochondritis Dissecans of the patella. TrEaTMENT aNd OuTCOMEs: 1.Immobilization in hinge-knee brace with limited flexion, 0 to 30 degrees, for 6 weeks. 2.No running, jumping activities. 3.Return to clinic in 6 weeks for repeat physical examination and xrays. Vol. 45 No. 5 Supplement S265 1398 May 30, 2:00 PM - 2:20 PM Leg Injury- Football David C. Waterson. Western Michigan University, Kalamazoo, MI. (Sponsor: Dilip Patel, FACSM) (No relationships reported) hIsTOry: A 17 year-old high school football offensive lineman sustained a right leg injury while blocking down field. Late in the game, he describes a hypertextension injury to the right knee. A defender missed the ball carrier and ran into his knee forcing it into hyperextension. He was unable to continue play or bear weight. There was knee swelling immediately following the injury. PhysICaL EXaMINaTION: Examination at an injury clinic the following morning revealed a large right knee effusion, slight flexion contracture, minimal active flexion secondary to pain, gapping of the medial joint line when testing near zero degrees, limited Lachman’s test due to effusion and limited range of motion, and medial joint line tenderness. The right lower extremity was neurovascularly intact. PhysICaL EXaMINaTION: 1. MCL sprain 2. Torn PCL 3. Torn ACL 4. Tibia fracture 5. Femur fracture TEST AND rEsuLTs: Right knee- anterior-posterior, lateral, and sunrise radiographs ( initial films). -effusion -fracture of the medial femoral condyle with a 2 mm step off at the trochlea -a couple of lucent areas running horizontally at the distal medial femur Right knee-anterior-posterior, lateral, and sunrise radiographs (repeated two days after initial films): -as above with increased step off at the trochlea CT scan of the right knee- sagittal and coronal images: -large hemarthrosis -horizontally oriented fracture through the medial aspect of the distal femoral physis extending in a sagittaly oriented fashion into both the intercondylar notch and the patellofemoral joint Right knee-anterior-posterior, lateral, and sunrise radiographs ( taken postoperatively): -evidence of two screws in the distal femur -anatomic reduction of the fracture in the AP and lateral views with step off of 1mm or less in the sunrise view FINaL WOrKING dIaGNOsIs: Medial femoral condyle fracture TrEaTMENT aNd OuTCOMEs: 1. Open reduction and internal fixation of the fracture. 2. Placed in a knee immobilizer and made non-weightbearing for at least two months. 3. Start with formal physical therapy one month out from the surgical intervention. This will include gentle range of motion. 4. Doing well eleven days postoperatively. The pain is decreasing and he is compliant with non-weightbearing. 1399 May 30, 2:20 PM - 2:40 PM Knee Injury - Football Lauren M. Salas, Jeffrey A. Bonacci. University of Arkansas, Fayetteville, AR. (Sponsor: Barry S Brown, FACSM) (No relationships reported) hIsTOry: A 21-year-old junior male NCAA division I football wide receiver entered the athletic training room with complaints of posterior joint line left knee pain. The athlete complained of pain with both flexion and extension. Athlete also complained of pain with running, cutting, and abrupt stopping. There was no known mechanism of injury. Athlete had history of a left knee injury which included one meniscal repair and two menisectomies of the medial meniscus. The surgeries occurred two years prior to the diagnosis, five months prior to the diagnosis, and a month prior to diagnosis. PhysICaL EXaMINaTION:Tenderness over the medial and posterior joint line of the left knee and pain on the posterior side of the knee. Passive and active range of motion was only slightly decreased and created minor pain for the athlete. Positive McMurray’s test was found for a meniscus tear. Athlete performed functional tests including running, cutting, and jumping which also created some pain, Athlete was still able to perform wide receiver duties during practice and games. PhysICaL EXaMINaTION: 1.Meniscus tear 2.Distal strain of the hamstrings (biceps femoris, semitendinosus, or semimembranosus) 3.Baker’s cyst TEsT aNd rEsuLTs: McMurray’s Test •positive for posterior medial joint line pain Manual Muscle Test •increased pain in distal hamstring tendons without weakness Magnetic resonance imaging (MRI) •normal findings for ligaments and muscles Abstracts were prepared by the authors and printed as submitted. Thursday, May 30, 2013
Thursday, May 30, 2013 S266 Vol. 45 No. 5 Supplement •cyst found in posterior compartment of the knee •cyst was not found on previous knee arthroscopy to repair meniscus FINaL WOrKING dIaGNOsIs: Symptomatic Baker’s cyst in the left knee TrEaTMENT aNd OuTCOMEs: 1.Removal of cyst through constant draining 2.Anti-inflammatory medication was used on continuous basis to control swelling 3.Increase range of motion by stretching to regain any lost flexibility 4.Strengthening of surrounding musculature including hamstrings and quadriceps 5.Kept playing during season and drained cyst four times after initial draining throughout season and since the completion of that season 6.Wore knee compression sleeve or brace to take tension off knee joint and provided support. 7.Athlete continued participation with cyst and treated systematically D-20 Clinical Case Slide - Upper Extremity II May 30, 2013, 1:00 PM - 3:00 PM Room: 123 1400 Chair: Mary Lloyd Ireland, FACSM. Kentucky Sports Medicine Clinic, Lexington, KY. (No relationships reported) 1401 discussant: Jimmy D. Bowen. Advanced Orthopedic Specialists, Cape Girardeau, MO. (No relationships reported) 1402 discussant: David L. Weldy, FACSM. University of Toledo, Toledo, OH. (No relationships reported) 1403 May 30, 1:00 PM - 1:20 PM Forearm Pain in a high school softball athlete Charles F. Ware, III1 , Thomas L. Pommering2 . 1Mount Carmel West Hospital, Columbus, OH. 2Nationwide Children’s Hospital, Columbus, OH. (No relationships reported) hIsTOry: A 14 y/o F softball pitcher with insidious onset L forearm pain. She is a L hand dominant, two sport athlete, who participates in both basketball and year round softball. She presented with L medial forearm pain for the past 2 weeks. There is no specific injury noted, but was first apparent during softball practice. She was first seen at urgent care, where XR of the forearm yielded normal results, and was placed in a sling. The aching pain starts below the elbow, radiates to the wrist, and has been increasing over the past 2 weeks. There is a throbbing pain over the ulna while throwing which worsens to a 10/10 as she continues to throw. She has a new complaint of intermittent numbness and tingling with activity and is located over the radial side of the forearm, and radiates to her ring finger. PhysICaL EXaMINaTION: Upon palpation of her LUE reveals tenderness at the olecranon, and wrist extensor. She has full ROM and 5/5 strength throughout, though notes pain with extension and supination of her LUE. There is no atrophy, motor weakness, and the elbow remains stable. Neurovascular exam reveals normal pulses, decreased sensation over the ulna distribution of the forearm and digits. PhysICaL EXaMINaTION: 1. Ulnar stress fracture 2. Extensor train / Tear 3. Tendinitis / Tenosynovitis 4. Entrapment neuropathy Tests & Results X-Rays: Initial & 2 weeks Later both normal MRI: Abnormal signal within L intramedullary space and periosteum of ulnar diaphysis indicating a stress injury EMG: Mild L ulnar neuropathy at the elbow Final Working Diagnosis Ulnar midshaft stress fracture in a softball pitcher, associated with left ulnar neuropathy TrEaTMENT aNd OuTCOME: Following the urgent care visit she was provided a tennis elbow strap brace to wear as needed for pain relief. She was recommended to abstain from participation until MRI. Once her MRI indicated a stress injury she was instructed to stop her current summer softball season. Her LUE paresthesias were now more localized to an ulnar nerve distribution, so an EMG was ordered. After a period of rest and symptom resolution, she completed a course of PT emphasizing functional progression back to sports. Her symptoms continued to improve and she was essentially pain-free at follow-up. She will enter her winter basketball season and subsequent softball season without restrictions. MEDICINE & SCIENCE IN SPORTS & EXERCISE ® 1404 May 30, 1:20 PM - 1:40 PM Elbow Injury In Female softball Player Ryan P. Cole. Rush University Medical Center, Chicago, IL. (No relationships reported) hIsTOry: Patient is a 21 year old right hand dominant softball pitcher who presents for evaluation of her right elbow. Several months prior she suffered a fall on the field and has progressive soreness over the medial aspect of her elbow. Pain is worse with overhead throwing motions and with pitching. She has attempted physical therapy, ice and heat modalities with little improvement. PhysICaL EXaMINaTION: Patient has full range of motion about the right elbow although complains of discomfort of medial aspect, she is tender to palpation medially, mild to moderate laxity with valgus stress, neurologic testing normal PhysICaL EXaMINaTION: 1. Ulnar Collateral ligament (UCL) injury 2. Flexor/Pronator tendinopathy 3. Ulnar Neuritis TEsT aNd rEsuLTs: MRI shows partial thickness tear of the UCL FINaL WOrKING dIaGNOsIs: Partial thickness tear of the right UCL TrEaTMENT aNd OuTCOMEs: Received 3 PRP injections. Repeat MRI shows improvement in UCL tear. She was pain free upon follow up exam and was able to return to play pain free. 1405 May 30, 1:40 PM - 2:00 PM acute arm swelling-Tennis Fred Reifsteck, III. University of Georgia, Athens, GA. (Sponsor: Andrew Gregory, FACSM) (No relationships reported) hIsTOry: 18 yo D I RHD female tennis player who presented with acute swelling of the right upper extremity and hand. The swelling occured during a tennis practice. Four days earlier had an IV placed for rehydration after a match for cramping in the contralateral arm. The swelling subsided and almost totally resolved a few minutes after resting. Patient relates no previous episodes or injuries. PhysICaL EXaMINaTION: Muscular hypertrophy of the right upper extremity, approriate for sport. Swelling from elbow distally. Pulses equal and strong bilaterally. Patient had full range of motion and strength was normal. Pulse did not diminish with Adson test PhysICaL EXaMINaTION: 1) Non-occlusive venous disease-Thoracic Outlet Syndrome 2) Occlusive venous disease-Padgett Schroetter 3) Lymphedema 4) Acute muscle injury, tear vs. strain TEsT aNd rEsuLTs: AP cervial radiograh- no cervical rib Venous Doppler exam right upper extremity- negative Contrast venography- presence of occlusion in the subclavian vein near the jugular/ subclavian junction FINaL WOrKING dIaGNOsIs: Transient venous occlusion of the suclavian vein TrEaTMENT aNd OuTCOMEs:1) rest-resolution of symptoms 2) Clopidogrel 75 mg daily, after a 300 mg loading dose 3) Return to play after 4 to 6 weeks of rest, finished season 4) Repeat, 2 months after initial study, contrast venography RESOLUTION of the venous clot 5) Hydration during play 6) Discontinuation of estrogen containing OCP ACSM May 28 - June 1, 2013 Indianapolis, Indiana
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