Poster 332 Viscosupplementation Usage Pattern in Knee Osteoarthritis: A Retrospective Review in a Veteran Population

Abstracts / PM R 7 (2015) S83-S222 syndrome are: buttock pain, aggravation with sitting, external tenderness over the piriformis, and augmentation of pain with maneuvers that increase piriformis tension. Conclusion: This patient exhibited the most common clinical features of piriformis syndrome. Excessive eccentric contraction of the piriformis during stance phase of running directly led to piriformis hypertrophy. Identification and correction of this gait abnormality enabled a successful clinical outcome and return to running for our patient. Poster 330 Hypertrophic Pulmonary Osteoarthropathy: A Case Report Michael Auriemma, MD (MedStar National Rehabilitation Hospital, Washington, DC, United States), Robert D. Bunning, MD, Kritis Dasgupta, MD, MBA Disclosures: M. Auriemma: Employment - Spouse was previously employed by GlaxoSmithKline. Case Description: A 65-year-old woman was admitted to inpatient rehabilitation after suffering a subarachnoid hemorrhage secondary to a fall. She carried a pre-morbid diagnosis of rheumatoid arthritis that had been diagnosed 2-3 years prior to admission. The patient described a 2-3 year history of persistent bilateral wrist and hand pain despite treatment. She had been seen by 5 different rheumatologists in the outpatient setting and was being treated with methotrexate and prednisone. Outpatient records were obtained and indicated that her erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and rheumatoid factor (RF) were all within normal limits. Her past medical history was also significant for a 50 pack year smoking history and lung cancer diagnosed 1.5 years earlier, now status post chemotherapy. While still inpatient, repeat ESR, CRP, and RF labs, as well as cyclic citrullinated peptide (CCP), were obtained and all were within normal limits. Bilateral hand and wrist X-rays were negative for the presence of erosions but did indicate bilateral periarticular osteopenia and a chronic periosteal reaction involving the bilateral radius, ulna, and metacarpal bones. This constellation of findings suggested that hypertrophic pulmonary osteoarthropathy was more likely than rheumatoid arthritis. The patient’s hematologist/oncologist was contacted and informed of these findings and a positron emission tomography (PET) scan was scheduled so as to further investigate the possibility of a recurrent pulmonary malignancy. Setting: Inpatient rehabilitation unit. Results or Clinical Course: The patient’s history of smoking, lung cancer, negative inflammatory markers, treatment-resistant rheumatoid arthritis, and X-ray findings were more suggestive of hypertrophic pulmonary osteoarthropathy than rheumatoid arthritis. Discussion: Hypertrophic pulmonary osteoarthropathy is a rare condition that can mimic rheumatoid arthritis. It is associated with pulmonary disease, most often pulmonary malignancy, and its chief feature is swollen, painful joints that are resistant to analgesic medications. X-rays typically demonstrate a periosteal reaction involving the appendicular skeleton. Conclusion: In a patient with a history of malignancy, hypertrophic pulmonary osteoarthropathy should be kept in the differential diagnosis of new-onset arthritis. Poster 331 Ankle Eversion-Inversion Injury with Syndesmotic Sprain in a Collegiate Volley Player: A Case Report Kamara M. Savage, MD (University of Arkansas for Medical Sciences, Little Rock, AR, United States), Roopa Ram, MD, John Vandershilden, MD, Alexandra Rivera Vega, MD Disclosures: K. M. Savage: I Have No Relevant Financial Relationships To Disclose.

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Case Description: A 21-year-old female collegiate volleyball player presented to our clinic with left ankle pain and swelling with activity since an eversion injury to the left ankle during practice 2 months earlier. Immediately after injury she was unable to bear weight. Hours later she experienced severe swelling and limited mobility. She was managed conservatively. Seven weeks after injury she was evaluated in our clinic. Physical examination shows left ankle edema, tenderness at deltoid ligament, medial and lateral malleoli, anterior talofibular ligament (ATFL) and talar dome. Talar tilt for deltoid ligament and squeeze tests were positive. She could not perform a single leg stance or squat. Plain films show no fractures and normal mortise. MRI shows a high grade lesion of deltoid ligament (deep layer), hypertrophy of ATFL, hypertrophy of calcaneofibular ligament (CFL) and altered signal of the syndesmosis along the anterior inferior tibiofibular ligament (AITFL). Setting: Outpatient sports medicine clinic Results or Clinical Course: Thirteen weeks post-injury and after intensive rehabilitation, she returned to practice. At one year, she reported pain only with full dorsiflexion. She could jump, run and squat although with some limitations in proprioception and balance. Discussion: A syndesmosis sprain without mortise widening should be highly suspected in patients with eversion injuries and resultant inability to walk, hop or with positive squeeze test. This is also an unusual case of a concurrent sprain of the medial and lateral ankle. Eversion of her ankle was the original injury, however it was superimposed by an inversion injury causing a lateral ankle sprain as well. Conclusion: Syndesmosis sprains, can be difficult to diagnosis. Negative radiographs in the setting of a mechanism of injury and positive findings on physical examination should raise your clinical suspicion to confirm the diagnosis with CT scan or MRI. Physical examination and mechanism of injury are also significantly important to identify concomitant eversion and inversion injuries that can result in long term comorbidities in young athletes.

Poster 332 Viscosupplementation Usage Pattern in Knee Osteoarthritis: A Retrospective Review in a Veteran Population Agnes Wallbom, MD, MS (GLAVAHS/UCLA, Los Angeles, CA, United States), David Benton, DO, Wayman Lee, PhD, Anne Nastasi, MD, Katelyn Corey, BS, Frances Abad, MSN Disclosures: A. Wallbom: I Have No Relevant Financial Relationships To Disclose. Objective: To evaluate the general usage pattern of viscosupplemention in knee osteoarthritis in a Veteran population in an archival review. Design: Retrospective chart review. Setting: Outpatient musculoskeletal clinics. Participants: 76 subjects with osteoarthritic knee joints who were prescribed viscosupplementation. Interventions: Subjects received course(s) of viscosupplementation (3 injections in a series) within a 2 year period. Main Outcome Measures: Visual Numerical Scale (VNS) scores. Results or Clinical Course: Repeated 2 sample T tests for each injection series demonstrated mean VNS scores pre- and post-injection were statistically significant overall (Injection #3 compared to Injection #1 Mean difference in VNS scores¼ -1.568627, P<.05). Statistically significant differences occurred by the second injection (Injection #1 Mean difference in VNS scores¼0.89, P<.05; Injection #2 Mean difference in VNS scores¼0.55, P<.05; Injection #3 Mean difference in VNS scores¼0.20, P .05, n.s.). Regression analysis showed negative factors for injection effectiveness i.e. trauma.

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Conclusion: Viscosupplementation injections to the knee joint appear to be effective in those with osteoarthritis. Most appear to be effective by injection #2 of 3 in a series. Any sub-groups, i.e. those with post-traumatic osteoarthritis, may need to be further stratified in future studies. However, positive predictive factors in reducing VNS scores may include ligamentous involvement moreso than meniscal tear.

Poster 333 Activity Limitation of Individuals with Chronic Lower Extremity Injury Armando Miciano, MD (Nevada Rehabilitation Institute, Las Vegas, NV, United States), Chad Cross, PhD, PStat(R) Disclosures: A. Miciano: I Have No Relevant Financial Relationships To Disclose. Objective: To quantify the activity limitation (AL) of individuals with chronic lower extremity injury (LEI) and chronic pain (CP), and to investigate the correlation between the AL status and scores from clinician-derived Performance-Based Assessment tests (PBA). Design: Retrospective cross-sectional study. Setting: Comprehensive Outpatient Rehabilitation Facility. Participants: 100 subjects completed the Self-Administered Comorbidity Questionnaire, and 26 were determined to have LEI and CP. Interventions: Not applicable. Main Outcome Measures: The Lower Limb Questionnaire v2.0 (LLQ), from the American Academy of Orthopedic Surgeon’s (AAOS) toolbox and recommended by the AMA Guides 6th Ed., was designated as the patient-reported outcome (PRO) to describe activity limitation. LLQ scoring for comparative purposes was done via computation of a standardized (score 0 is MOST disability and 100 is LEAST disability) and normative score (mean set at 50, standard deviation 10). The 6-Minute Walk Test (6MWT), Berg Balance Scale (BBS), Dynamic Gait Index (DGI), Sit-to-Stand test (STS), and 50-Feet Walk Fastest (FWF) were used as clinician-derived PBAs also to describe activity limitation. Results or Clinical Course: We used Pearson’s correlation coefficient to examine associations between LLQ and PBA results, which did not differ in terms of significance from Spearman’s rank correlation in this case. There were strong correlations between LLQ scores and the BBS (r¼ .404; p¼ .040) and 6MWT metabolic equivalents METS (r¼ .371; p¼ .062) scores. There were no demonstrable differences between genders. Conclusion: The self-reported activity limitation of individuals with LEI had a statistically significant correlation with the clinician-derived physical performance test scores (specifically the balance and exercise capacity) of these individuals. These findings suggest that the LLQ is a suitable indicator of functional outcome status of individuals with LEI and would be valuable as an alternative to PBAs in a busy clinical practice. Further research should be conducted on the relationship of this activity limitation measure with measures of body function and of participation restriction.

Poster 334 Unique Presentation of a Morel-Lavallee Injury of the Knee: A Case Report Hans Knopp, DO (Tufts Medical Center, Boston, MA, United States), Julio Martinez-Silvestrini, MD Disclosures: H. Knopp: I Have No Relevant Financial Relationships To Disclose. Case Description: The patient, a 17-year-old male high school wrestler, initially came to our clinic for lateral knee pain s/p knee injury during wrestling. He failed NSAID and knee immobilizer treatment. A previous MRI, done 2 weeks prior to procedure, had shown extensive edema in the subcutaneous fat extending between the subcutaneous

fat and muscular fascia typical of a Morel-Lavallee lesion. Aspiration of this edema revealed 21 mL of blood. Aspiration was followed with steroid injection and local anesthetic at the site. This injection consisted of 1 ml of a solution containing Kenalog 10 mL and lidocaine 1% 4 mL. A 22 gauge 1.5” needle used for the procedure. Following the procedure, a tight compressive garment was applied for 24 hours with an ace bandage to be applied upon afterwards. Setting: Outpatient sports medicine practice. Results or Clinical Course: The patient had knee pain for two to three weeks prior to visiting our sports medicine clinic. On post injection day #3 the patient came back to clinic complaining of increased pain on the anterior knee. This was found to be patellofemoral in nature and was treated with diclofenac sodium along with a consideration for physical therapy in the future. By post injection day #6 the patient had improved symptoms of patellofemoral syndrome. At 3 weeks post injection, the patient was back to participating in wrestling practice followed by a regional wrestling meet. Discussion: To date, degloving injuries, such as Morel-Lavallee injuries, when found in the knee have been described at the anterior aspect. This particular injury, in a high school wrestler, was found to be at the anterolateral aspect of the knee, over the vastus lateralis and iliotibial band, not over the patella. This is unique presentation for a degloving injury not typically found in medical literature. The proposed mechanism for this injury was friction against the mat or opponent during wrestling competition. Conclusion: Despite the unusual location for this Morel-Lavallee lesion, traditional treatments improved this patient’s condition and he was able to return back to competition.

Poster 335 Inter-Rater Reliability and Precision of Measurements of the Piriformis Muscle Using Ultrasound: An Observational Cross Sectional Study Joshua Rothenberg, DO (Miller School of Medicine at the University of Miami, Miami, FL, United States), Usker Naqvi, MD, Douglas Johnson-Greene, PhD, Jose Perez, BA, Spencer Summers, BA, Alexander Harrington, BS, MBA, Ricardo J. Vasquez-Duarte, MD, Clifton Page, MD Disclosures: J. Rothenberg: I Have No Relevant Financial Relationships To Disclose. Objective: To test the hypothesis that in healthy controls where no clinical suspicion of piriformis syndrome exists, more reliable ultrasound measurements will be obtained following education with a standard protocol and use of the same ultrasound equipment across providers on the same day, enhanced group (G2), compared to measurements obtained by providers who have only baseline ultrasound knowledge of the piriformis alone, baseline group (G1). Design: Cross-sectional intervention study. Setting: Ultrasound suite at a tertiary care academic medical center. Participants: 15 volunteer subjects, with an age range of 21-29 years old, were assigned to Group 1 (n¼6) or Group 2 (n¼9). Interventions: Volunteer subjects in the G1 group underwent piriformis ultrasound in phase I of the study by two independent sports medicine fellowship trained physicians with general ultrasound knowledge using two different ultrasound machines at different time periods. Following education in the use of a standard protocol on piriformis ultrasound, and having watched an associated video, volunteer subjects in the G2 group underwent piriformis ultrasound in phase II of the study by the same two independent sports medicine fellowship trained physicians using the same ultrasound machine on the same day. Main Outcome Measures: Inter-rater reliability of piriformis ultrasound measurements. Results or Clinical Course: Cohen’s Kappa coefficients were computed for group 1 baseline group and for group 2 enhanced group ultrasound measurements. Group 1 coefficients were well