George Pujalte, MD HISTORY: 42-year-old, right-handed Caucasian male who presented to the medical orthopedics clinic with left wrist pain. Pain was aggravated by lifting things, shuffling cards, and taking trash bag out of the trash can. He reported occasional clicking and catching. He denied history of trauma, injury, or fall. He also denied numbness or tingling sensation, swelling, or redness.
PHYSICAL EXAMINATION: Examination of the left wrist showed limited extension compared to the right. There was clicking with flexion and extension of the wrist on the dorsal aspect. Mild tenderness was noticed over the distal radioulnar joint. There was ulnar and radial deviation on provocation. Anatomic snuffbox was non-tender. Neurovascular exam was intact.
Kienbock's disease (avascular necrosis of the lunate bone)
Carpometacarpal osteoarthritis. TESTS AND RESULTS:
4-view x-rays of the left wrist
--Mild radiocarpal and scapho-trapezium-trapezoid (ST-T) osteoarthritis
--Subchondral cysts seen in the lunate and scaphoid with no obvious fractures
Magnetic resonance imaging (MRI) of left wrist
--Abnormal T1 hypodense signal involving the proximal pole of the scaphoid
Preiser's Disease (Idiopathic avascular necrosis of the scaphoid)
TREATMENT AND OUTCOMES:
Initially put in wrist brace with diclofenac topical gel for pain control.
Corticosteroid steroid injection under fluoroscopy.
Pedicle bone graft reconstruction of the proximal pole of the left scaphoid and intercompartmental supra-retinacular artery vascularization.
Post-surgery thumb spica cast with the interphalangeal joint free for 6 weeks.
6 weeks post-surgery, patient able to make composite fist with his left hand.
18 weeks post op, patient was moving wrist with no pain.
Hip Pain in a Male High School Runner
Craig Betchart MD, University of Rochester
Sponsor, Mark Mirabelli MD HISTORY: This is a case of a 16yo male cross country runner who presented to the sports medicine clinic with a chief complaint of right hip and thigh pain. The pain had been present for about 2 weeks, interfered with his running, and progressed to the point where it was painful to walk. He has no significant past medical history. He is a non-smoker, non-drinking, and non-drug user. Family hx is only significant for breast cancer in his grandmother.
PHYSICAL EXAMINATION: Normal gait, no pain to palpation, no erythema, no swelling. He experienced pain with hip flexion, that was located in the anterior groin and radiated to the thigh. Full ROM, full strength. FABER and FADIR reproduced the thigh pain. He refused to jump on the right leg, stating it would hurt.
DIFFERENTIAL DIAGNOSIS: Prior to MRI: stress fracture, labral tear, FAI, tumor. Following MRI: eosiniphilic granuloma, osteoid osteoma, osteomyelitis (bacterial, fungal, tubercular), Ewing sarcoma, osteosarcoma, lymphoma, multiple myeloma, metastasis, skeletal syphilis, Brodie abscess, chondroblastoma, giant cell tumor.
TESTS AND RESULTS: CBC, CMP, CRP, were normal. Xray at the initial visit was negative. There was concern for a stress fracture, so he was sent for an MRI. The MRI showed a well circumscribed 1cmx2cm T2 enhancing lesion in the proximal femur. He was sent to pediatric orthopedic surgery for bone biopsy. Frozen section at biopsy was negative for malignancy, and was read as “myxoid lesion.” The remainder of the lesion was curretted, and a bone graft was placed. The tissue was sent for pathology and cultures. Pathology reported as acute on chronic inflammation consistent with osteomyelitis, but cultures and stains were negative.
FINAL/WORKING DIAGNOSIS: Aseptic Osteomyelitis.
TREATMENT AND OUTCOMES: The definitive treatment was surgery. The patient recovered well after surgery. No antibiotics were given due to negative culture data. He began a graduated running program at 6 weeks, and was running pain free at 12 weeks.
Acute Patella Subluxation in Crossfit Athlete, Not So Fast
Richard Davis DO, Geisinger Sports Medicine
Sponsor: Matthew McElroy DO HISTORY: A 30 CRNA active crossfit athlete sustained a right knee twisting/patella subluxation when she was doing a clean and jerk at a crossfit gym. She felt as though her patella displaced laterally and then her knee gave out. Her patella spontaneously reduced after she extended her knee. She went to the community ED later that day where her x-rays were negative; she was placed in a knee immobilizer and followed up with the sports medicine clinic 2 days later for follow-up.
PHYSICAL EXAMINATION: Right knee: TTP over suprapatellar region, 2+effusion, 3/5 extension of right knee, ligamentous structures difficult to evaluate due to guarding. Pain with forced flexion, otherwise NVI distally, compartments soft.
DIFFERENTIAL DIAGNOSIS: Patella instability, ACL tear, PCL tear, osteochondral defect, meniscal injury, quad tendon rupture, patella tendon rupture.
TESTS AND RESULTS:X-ray shows good maintenance of patellofemoral and tibiofemoral joint spaces. Decision to get MRI was made considering she had tense effusion and was a female of child bearing age. MRI shows torn ACL, tear of posterior horn of medial meniscus extending to superior articular surface, vertical tear of lateral meniscus extending to superior articular surface, 13mm full-thickness cartilage loss overlying medial femoral condyle, 5mm region of full thickness cartilage loss overlying lateral femoral condyle.
FINAL/WORKING DIAGNOSIS: ACL tear, medial and lateral meniscal tears with articular cartilage injury.
TREATMENTS AND OUTCOMES: Evaluated by Orthopedic Sports Surgeon who decided on 2 weeks of rehab and she worked on maintaining range of motion and quadriceps strengthening. She then underwent successful surgery with ACL reconstruction, medial/posteromedial reconstruction, allograft for ACL reconstruction and microfracture of medial femoral condyle.
Abbie Kelley DO, York Hospital Sports
Sponsor: Mark Lavallee MD HISTORY: 15 y.o. male football quarterback with complaint of right medial elbow pain after throwing a football at practice 5 days ago. Patient states that he heard a pop and was unable to throw the football after the injury. He denies any pain or previous injury to the elbow. Immediately following the injury, the patient describes a significant amount of pain and swelling. He treated the medial elbow with ice and compression, which did improve the swelling. He continues to complain of pain and inability to throw the football. He denies any numbness or tingling of the forearm, hand, or fingers.
PHYSICAL EXAMINATION: Inspection of right elbow reveals some fullness over the medial aspect. No ecchymosis noted. Tender to palpation over the medial epicondyle. Lacks 20 degrees of extension. Flexion is about 110 degrees. Strength in flexion and extension of the elbow is full, 5/5. Slight weakness with pronation of the hand. 5/5 strength in supination of the hand. 5/5 strength in wrist extension. Weakness in wrist flexion. Neurovascularly intact. No ulnar nerve subluxation. Negative ulnar nerve Tinel’s test. Discomfort with valgus stress testing and milking maneuver, but no definitive laxity.
DIFFERENTIAL DIAGNOSIS: 1. Ulnar Collateral Ligament Sprain, 2. Ulnar Collateral Ligament Tear, 3. Medial Epicondyle Apophysitis, 4. Strain of the flexor-pronator mass 5. Elbow Dislocation 6. Ulnar Nerve Subluxation, 7. Medial Epicondylar apophyseal fracture
TEST AND RESULTS: X-ray of the right elbow reveals an avulsion fracture of the medial epicondylar apophysis.
FINAL/WORKING DIAGNOSIS: Avulsion Fracture of the medial epicondylar apophysis, Salter-Harris 1.
TREATMENT AND OUTCOMES: Patient was placed in a sling for 2 weeks and told to wean out of the sling, only to use for comfort thereafter. Tylenol was used for pain as needed. Pt followed up 1 month after the injury, at which time the patient was completely pain free and range of motion improved. Repeat x-ray of the right elbow showed healing of the medial epicondylar fracture. Sling was discontinued and patient was told to follow up in 1 month. He was instructed NOT to participate in any type of throwing sport for at least 3 months time. If, at that point, patient is still pain free, he will start physical therapy and gradual return to play/throw protocol.
Shoulder Injury – Recreational Bowler
James F. Kelley MD and Adae Amoako MD, Penn State Hershey Family Medicine Residency
Sponsor: Jessica Butts MD HISTORY: 59-year-old gentleman presented to his primary care office with a complaint of left shoulder pain. He reported that he had thrown a snowball at a family member, when he felt a “pop” in his shoulder, followed by pain. The pain was an aching quality and intermittent, located on the lateral aspect of his shoulder. There was no impact on his arm’s range of motion. It initially responded to warm and cold compresses, but the pain worsened and he soon had difficulty putting his coat on. He used non-steroidal anti-inflammatories with moderate reduction of pain. While he had no history of acute shoulder injury or surgery in the past, the patient has been a recreational bowler for thirty years, and reported long standing discomfort with range of motion in his left shoulder for years. The patient was diagnosed with a rotator cuff injury, prescribed a prescription strength dose non-steroidal anti-inflammatory, and referred to physical therapy. Patient returned to clinic after four days of treatment due to developing ecchymosis over his anterior arm. Patient had allergies to antibiotics, but no known NSAID allergies.
PHYSICAL EXAMINATION: On initial exam: He had tenderness on palpation of his lateral left shoulder. He was documented as having 5/5 strength. Empty Can and Lift-Off Test were positive. On subsequent exam tenderness was localized in the bicipital groove and nonblanching ecchymosis was noted on the distal half of his left bicep. The gross appearance of his biceps was asymmetric, with left bicep larger than the right. He had 5/5 upper extremity testing, except for 4/5 strength on left arm flexion, abduction, internal and external rotation, left elbow flexion and left wrist supination. He had a positive Yergason’s and Speed’s test on left side.
DIFFERENTIAL DIAGNOSIS: 1. Rotator Cuff Muscle tear 2. Labrum tear 3. Subluxation of the shoulder 4. Subacromial impingement 5. Bicipital tendonitis or tear 6. Acromioclavicular joint disorders 7. Glenohumoral arthritis 8. Cervical radiculopathy with radiation to the shoulder 9. Gallbladder inflammation 10. Rheumatologic conditions 11. Paget Schroeter Syndrome (Upper extremity DVT due to exertion)
TESTS AND RESULTS: D-dimer to screen for DVT was negative.
FINAL/WORKING DIAGNOSIS: Proximal rupture of Biceps Long Head tendon, likely secondary to tendon remodeling caused by long standing supraspinatus inflammation from bowling.
TREATMENT AND OUTCOMES: 1. Initiated physical therapy 2. NSAIDs as needed for pain. 3. Began with external rotation resistance exercises and shoulder flexion. 4. Advanced to bicep curls, brachioradialis curls, and triceps extensions with light weights. 5. Progressed to shoulder rows and lateral pull downs. 6. After two months of physical therapy, patient reported 0/10 pain with passive range of shoulder motion. 7. After six physical therapy visits he was discharged with a home exercise routine, and has not complained of shoulder pain to his primary care physician in follow up visits.
Knee Injury – Fall
Michael Kraft MD, Cristiana Care Health System Sports Medicine Fellowship
Sponsor: Bradley Sandella DO HISTORY: A 50 year old female sustained a lower leg injury while running. She tripped on an uneven piece of sidewalk, felt a pop, and fell. At that time she went to the local hospital and she was found to have a left fibular head fracture, she was placed in a knee immobilizer, walking boot, and given oxycodone. She was seen in our clinic for follow-up 10 days later. At that time she was complaining of numbness/tingling as well as weakness in her foot and toes. She reported that she was unable to bear weight and unable to move her foot. The patient had no prior history of lower extremity injuries.
PHYSICAL EXAMINATION: Left lower leg – knee - positive swelling and ecchymosis about the left lateral leg, tender to palpation over lateral joint line and fibular head. Knee decreased ROM secondary to pain. Positive varus stress test, equivocal Lachman’s, positive posterior drawer. Strength – difficult to assess in knee secondary to pain.
Foot limited ROM with no dorsiflexion. Strength in foot – 3/5 plantarflexion, 0/5 dorsiflexion. Sensation – no tactile sensation over dorsum of foot. Dorsalis pedis 2+, skin warm
DIFFERENTIAL DIAGNOSIS: 1.) fibular head fracture with peroneal nerve injury 2.) PCL and LCL tear
TESTS AND RESULTS: 1.) Left knee x-ray – comminuted avulsion fracture of proximal fibula 2.) MRI without contrast left knee – (a.) Acute avulsion fracture of the lateral tibial rim cortex with subjacent reactive marrow edema and avulsion of the lateral capsular ligament suggestive of a Segond fracture. At least high-grade partial tearing at the femoral attachment of the ACL. (b.) Acute avulsion fracture of the fibular head tip with the dominant fragment displaced 2.3 cm superiorly. Full-thickness tear of the fibular collateral ligament with a large hematoma. (c.) Nondisplaced trabecular fracture of the anterolateral medial femoral condyle with extensive reactive marrow edema. (d.) The peroneal nerve is thickened and edematous compatible with nerve injury, no evidence of complete transection of the nerve.
FINAL/WORKING DIAGNOSIS: ACL tear with proximal fibular head fracture and peroneal nerve injury
TREATMENT AND OUTCOMES: 1.) ACL reconstruction with allograft, LCL and posterolateral collateral ligament repairs and peroneal nerve neurolysis. 2.) A course of physical therapy. 3.) Patient’s pain improved but foot drop persisted at 5 month follow-up. 3.) Referred to fracture liaison of the strong bones program for the fragility fracture.
Bilateral Lower Extremity Cramping in a Lacrosse Player
Jill Kropa MD, Thomas Jefferson University Primary Care Sports Medicine
Sponsor: Sunny Gupta DO HISTORY: A 19-year old female collegiate lacrosse player presented to the outpatient office for evaluation of bilateral lower extremity cramping during running exercises. She described it as a tightening of her calf and thigh muscles to the point of being “rock hard.” These muscles were very sore the day following activity. This had occurred on countless occasions in the past few competitive seasons. She had already been worked up with blood work, all of which was negative for abnormalities. She was on an extensive fluid and electrolyte regimen but did not see any improvement in frequency or intensity of these episodes. While at college she had also participated in three months of dedicated physical therapy including Graston and soft tissue techniques again with no progress.
PHYSICAL EXAMINATION: Examination in the office revealed a well-developed, age appropriate female. She had full range of motion of her neck, back, hip, and ankle. She had full knee flexion and extension but lacked 30 degrees of extension when the hip was flexed to 90 degrees. She had 5/5 bilateral strength of hip flexion, knee extension, knee flexion, ankle dorsi- and plantar flexion. She had 2+ distal pulses bilaterally. Sensation to light touch was intact and equal in her bilateral lower extremities. Bilateral hip exam produced no pain with log roll. FABER and FADIR testing were negative. She had no tenderness at the hip joint, greater trochanter, pubic symphysis, or ASIS. Bilateral knee exam revealed no ligamentous laxity, tenderness to palpation or bony deformities. She had negative Lachman, McMurray, anterior and posterior drawer testing as well as negative valgus and varus stress testing. Her bilateral calves revealed no edema, erythema, ecchymosis or warmth. She was non-tender to palpation over this musculature.
DIFFERENTIAL DIAGNOSIS: 1. Exertional Compartment Syndrome 2. Electrolyte abnormality 3. Metabolic disorder such as glycogen storage disease 4. Popliteal artery entrapment 5. Lymphatic obstruction
TESTS AND RESULTS: Exertional Compartment testing: Negative bilaterally for increase in compartment pressures after running on a track. Dynamic Arterial Duplex Scan with maneuvers: Positive for Popliteal Artery Entrapment bilaterally.
FINAL/WORKING DIAGNOSIS: Bilateral Popliteal Artery Entrapment
TREATMENT AND OUTCOMES: Referred for further evaluation with a vascular surgeon.
Primary Care Sports Medicine Fellowship-State College
Sponsor: Peter H. Seidenberg MD HISTORY: A 59-year-old Caucasian male with an 80-pack-year history of tobacco abuse and COPD reports mild bilateral posterior ankle discomfort while changing the battery in the bottom of his boat. The following day, he notes an acute onset of posterior left ankle pain followed by pain in the posterior right ankle associated with significant gait impairment. He denies any precipitating injury or event. Weeks prior, he reports being treated for an acute COPD exacerbation with several medications. At the time of evaluation, 9 weeks had past from the initial onset of ankle discomfort.
PHYSICAL EXAMINATION: The patient was alert, oriented and in no acute distress. Lower extremity skin was warm and dry without rashes or lesions. There was decreased sensation to light touch in bilateral S1 nerve root distributions. Bilateral gastrocnemius muscles were without masses or tenderness. There was a small, tender palpable defect appreciated in both Achilles tendons approximately 5 cm proximal to their insertion onto the calcaneus. Thompson testing while lying supine was equivocal with slight toe flexion. There was 5/5 strength in both tibialis anterior and EHL muscles and decreased strength in bilateral gastroc-soleus muscles. Distal pulses were intact with brisk capillary refill.
DIFFERNTIAL DIAGNOSIS: 1) Achilles tendonitis 2) Gastrocnemius muscle tear
TEST & RESULTS: Sports ultrasonography demonstrated evidence of extensive tendinosis and complete tendon rupture bilaterally.
FINAL/WORKING DIAGNOSIS: Bilateral acute Achilles tendon rupture
TREATMENT & OUTCOMES: Static and dynamic ultrasound evaluation demonstrated complete discontinuity of both Achilles tendons at the area of tenderness and palpable defect. Interval monthly sports ultrasonography over 3 months showed progressive bridging of the defects with increased scar formation and fiber realignment, representing tendon healing. These morphological changes corresponded directly with improved clinical symptoms and functional capacity. Musculoskeletal ultrasonography can play an important role in the assessment and evaluation of healing during non-operative management of Achilles tendon ruptures.
Acute Abdominal Injury in a Collegiate Hockey Player
Jayson R Loeffert DO, Pennsylvania State University
Primary Care Sports Medicine Fellowship-Hershey
Sponsors: Matthew Silvis MD, Cayce Onks DO, Shawn Phillips MD HISTORY: 19yo male, collegiate ice hockey player, suffered an abdominal injury in a game. Hit into the boards by another player. This occurred at his team’s bench, and he had to be helped over the boards. He was then moved to the locker room for evaluation. He was pale, diaphoretic, and complained of acute left upper quadrant pain. Pain was 7/10, sharp, radiating to his left shoulder. He was transferred to the local ED for further evaluation, due to concern for intra-abdominal trauma.
Skin: no rashes/erythema/ecchymosis over abdomen DIFFERENTIAL DIAGNOSIS:
Splenic laceration/ contusion
Abdominal wall strain
Injury to pancreas
Injury to stomach
Rib Fracture, contusion
TESTS AND RESULTS:
CBC, CMP, and Lipase normal.CT chest/abdomen - Small sub centimeter splenic contusion involving the lower pole. No other traumatic injury identified. Thickening of the bowel, appreciated by general surgery, questionable significance, concerning for possible laceration.
Small bowel laceration
TREATMENT AND OUTCOME:
Following initial studies and evaluation, he was observed overnight, due to pain and possible spleen injury. Overnight, pt was seen to have increased heart rate, pain, and WBC. He was taken for exploratory laparotomy which revealed a small bowel perforation. This was surgically repaired. No other injury, including that to the spleen, could be appreciated. Pt remained in the hospital for 6 days, which were uneventful, then discharged home. One month later, he was seen in follow up by trauma. His exam was unremarkable. He was held from hockey for the remainder of the season. He was otherwise released to full activity and cleared to participate in next year’s hockey season.