- Email: [email protected]
Poster 70
ACADEMY ANNUAL ASSEMBLY ABSTRACTS Poster 65 Correlates of Achilles’ Tendon Pain in Runners. Dinesh A. Kumbhare, MD, MSc, FRCP (C) (McMaster University, Hamilton, ON, Canada); Mark Bayley, MD; Narry Muhn, MD; William L. Parkinson, PhD; Alexandra Papaioannou, MD; Brad Balsor, BSc, e-mail: [email protected]. Disclosure: None. Objective: To investigate the frequency of symptoms and symptom correlates of achillodynia in recreational runners. Design: Quantitative correlation study. Setting: Subjects were recruited at a “runners room” in Ontario. Participants: 87 women and men with a history of “recreational running,” which was defined as running at least 3 times/wk, ⱖ5km/wk. Interventions: Not applicable. Main Outcome Measures: Data were collected immediately after runs of 10km or 20km. Subjects underwent a physical examination of the Achilles’ tendon bilaterally involving measures of pain on palpation of the tendon at 5 points with a pressure of 4kg/cm, calf girth, and pain on plantarflexion. Measures of exercise history were obtained from questionnaires. Comparisons were made between symptomatic and nonsymptomatic subjects. The chi-square statistic was used to analyze proportions. The t test was used to compare means. Results: Of the 87 runners, 25 had pain on examination in at least 1 of 5 tendon locations in either leg. Symptomatic subjects did not differ from nonsymptomatic subjects with respect to differences between left and right calf diameter or the frequency of palpable nodules. The symptomatic subjects were older (P⬍.05), heavier (P⬍.05), and shorter (P⬍.05) than the pain-free group. There were no group differences in years of running, number of organized runs in the past year, kilometers run per week, use of weight training, or running regimens. Conclusions: Achilles’ pain in runners was associated with shorter stature, heavier body weight, and older age but not with the amount of running. Achillodynia in runners is a useful model for studying repetitive trauma injury. Key Words: Achillodynia; Rehabilitation; Repetitive trauma; Runners.
Poster 66 Osteochondroma Associated With Ruptured Bursa Presenting as Hamstring Injury and Hematoma: A Case Report. Julie T. Lin, MD (Hospital for Special Surgery, New York, NY); Svetlana Ilizarov, MD, e-mail: [email protected]. Disclosure: None. Setting: Academic outpatient physiatric private practice. Patient: A 53-year-old man. Case Description: The patient presented with complaints of left posterior thigh and knee pain and hematoma 4 days after twisting his left leg. He developed buttock pain, followed by a “baseballsized” gluteal mass, both of which resolved over the next 2 days. Physical findings included tenderness to palpation over the ischial tuberosity, large ecchymosis, and swelling suggestive of hematoma extending from the left gluteal area to the calf. Neurologic exam was normal except for mild left hamstring weakness. Assessment/Results: Clinical presentation was consistent with hamstring injury with hematoma formation. Radiographs of the pelvis were negative for hamstring avulsion, however, they demonstrated the incidental findings of calcifications over the neck of the femur, suggestive of cartilaginous lesions. Subsequent magnetic resonance imaging demonstrated a large osteochondroma and a large, partially ruptured bursa formation with intact hamstrings, fluid collection causing partial encasement of the sciatic nerve, and effacement of the proximal hamstrings, gluteus maximus, and adductus magnus. Discussion: This is the first reported case, to our knowledge, of osteochondroma of the femur associated with large bursa formation presenting as hamstring injury in an older patient. Osteochondroma is a common tumor, which usually presents in adolescence. Large bursa formation in association with osteochondroma of the femur is a rare complication that may represent malignant transformation and must be ruled out. Conclusion: Osteochondroma with large bursa formation can have unusual presentations, including the appearance of hamstring injury and hematoma. Presumed hamstring injuries are commonly managed conservatively and, in most cases, imaging studies do not play a significant role in the work-up. However, diagnostic imaging can play a central role in the diagnosis of bone tumors. Key Words: Bursa; Osteochondroma; Rehabilitation.
Poster 67 Lumbar Intraspinal Synovial Cyst: A Case Report. Ibrahim A. Aksoy, MD, PhD (Mayo Clinic, Rochester, MN); Stephen F. Noll, MD, e-mail: [email protected]. Disclosure: None. Setting: Tertiary medical center physical medicine and rehabilitation unit. Patient: A 67-yearold woman with intractable right lower-extremity pain and paresthesias. Case Description: The patient presented with a 2 month-history of acute onset right buttock pain with radiation into calf and foot. She also had numbness and tingling in her right foot. There was no trauma or unusual activity, however, she had subtle right leg discomfort for many years prior to onset of pain. The patient had no subjective weakness or difficulty in bowel or bladder control. Neurologic examination revealed absent right ankle jerk and reduced sensation in S1 distribution. Motor strength was normal. Lumbar spine magnetic resonance imaging (MRI) revealed a juxta-facet intraspinal synovial cyst at the right L5-S1 level. This caused deformity and compression of the right S1 nerve root. There were also smaller extraspinal synovial cysts at L5-S1 level posteriorly. Assessment/Results: The patient underwent right L5 partial, inferior hemilaminectomy, L5-S1 medial facetectomy, foraminotomy of the S1 nerve root, and gross total resection of the L5-S1 level synovial cyst. Postoperatively, she reported relief of right lower-extremity pain for several hours. She then developed recurrence of right leg pain without weakness. MRI revealed hematoma formation at the operative bed. The hematoma was evacuated promptly, resulting in complete resolution of symptoms. Discussion: This case represents a classic presentation of a large intraspinal synovial cyst causing radiculopathy and outcome of surgical excision with the infrequent postoperative complication of hematoma. Conclusion: Intraspinal synovial cysts can cause intractable radicular pain. MRI studies are warranted for intractable radiculopathies. Key Words: Radiculopathy; Rehabilitation; Synovial cyst.
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Poster 68 Improved Clinical Outcomes in Trigger Points Injections by Combined Use of Lidocaine, Toradol, and Steroids. Shalabh K. Gupta, MD (Rusk Institute of Rehabilitation Medicine/ NYU Medical Center, New York, NY); Todd R. Schlifstein, DO; Gerard P. Varlotta, DO, e-mail: [email protected]. Disclosure: None. Objective: To test the use of a combination of lidocaine, ketorolac (Toradol), and steroids in trigger point injections. Design: Case-control study. Setting: Outpatient-based sports medicine practice at a major university hospital. Participants: 187 patients diagnosed with trigger points. With age- and sex-matched cases (group 1) and controls (group 2), 47 patients in the group 1 were treated with lidocaine alone and 42 in the group 2 were treated with a combination of lidocaine, Toradol, and steroid. Interventions: A combination of lidocaine, Toradol, and steroid injections. Main Outcome Measures: Patients were asked to chart pain on visual analog scale (VAS) for 7 days and to return to clinic for 1- and 3-month follow-ups. Results: Reported average pain relief on VAS in the group 1 was 6 points during the first 7 days compared with 2.5 points in the group 2. Complete resolution of symptoms (27% in group 1; 39% in group 2) and need or repeat injections (36% in group 1; 24% in group 2) were also noted. Conclusions: Patients treated with a combination of lidocaine, Toradol, and steroid had better pain control, needed fewer repeat injections, and had better resolution of symptoms than patients treated with lidocaine alone. Lidocaine offers pain relief within 1 to 2 minutes and persists for 15 to 20 minutes, Toradol offers pain relief after 45⫾30 minutes, and steroids take 3 to 5 days to affect the site. Besides the different time for onset of action, they also act on different pain receptors and thus offer a combined mode of treatment. This combination, however, should be used with caution and all the contraindications and drug interactions must be kept in mind. Key Words: Ketorolac; Lidocaine; Rehabilitation; Trigger point injections.
Poster 69 Brachial Plexopathy in Patient Undergoing Surgical Repair of Rotator Cuff Rupture: A Case Report. Shalabh K. Gupta, MD (Rusk Institute of Rehabilitation Medicine/NYU Medical Center, New York, NY); Todd R. Schlifstein, DO; Gerard P. Varlotta, DO, e-mail: [email protected]. Disclosure: None. Setting: Tertiary care university hospital. Patient: A 45-year-old athletic male. Case Description: The patient had difficulty in overhead abduction of arm and complained of pain, which on radiographic investigation was found to be secondary to partial tear of rotator cuff tendons. The patient underwent a trial of physical therapy for 2 months but did not find any improvement. He decided to undergo surgical intervention. A brachial plexus block was planned for the anesthesia. After several attempts, a successful plexus block was given and the patient underwent repair and was discharged postoperatively using a sling. He started developing numbness and tingling over the entire arm, including hands and fingers, within days after surgery. After 2 weeks, he was also found to have limited range of motion (ROM) at the shoulder joint. 4 weeks after his clinical symptoms appeared during postoperative rehabilitation, physiatrists conducted on electromyographic study and magnetic resonance imaging (MRI). The electromyographic results showed upper trunk plexopathy and the MRI showed inflammation the around the upper trunk. Assessment/Results: The patient was treated aggressively with pain medications, and physical therapy (PT) exercises, but after 9 months of therapy he still had weakness in all the rotator cuff muscles and limited ROM. Discussion: Physiatrists often assume care for patients after orthopedic procedures and they should be aware of the complications that surgical interventions can cause. Although brachial plexopathy was not a complication of the surgery per se, it probably occurred secondary to the difficult brachial plexus block. A high degree of suspicion in this case helped the physiatrists to do the necessary tests and to find out the cause. When appropriately diagnosed PT prescriptions can be tailored to address this problem with appropriate expectations of clinical outcome. Conclusion: Brachial plexopathy may develop as a complication due to anesthesia in the patients undergoing rotator cuff repair. Key Words: Brachial plexopathy; Postoperative complications; Rehabilitation; Rotator cuff.
Poster 70 Rehabilitation Implications of Stress Fracture of Hip in Young and Atheletic Men. Shalabh K. Gupta, MD (Rusk Institute of Rehabilitation Medicine/NYU Medical Center, New York, NY); Todd R. Schlifstein, DO; Gerard P. Varlotta, DO, e-mail: [email protected]. Disclosure: None. Objective: To examine the clinical manifestations, radiologic investigations, and rehabilitation protocol of stress fracture of the hip in athletic and young patient population. Design: Clinical case series. Setting: Outpatient-based sports medicine practice at a major university hospital. Participants: 87 patients referred to outpatient rehabilitation clinic with pain in the hip and groin and who were clinically thought to have some hip pathology contributing to the pain. Interventions: Not applicable. Main Outcome Meaures: After a thorough history and clinical examination, magnetic resonance imaging of the hip joints was ordered in all patients. Results: 3 of 87 patients (3.4%), all men, had a stress fracture of the hip. The average age of the patients was 33 years and 16 (18.4%) were women. The clinical presentations, in order of frequency, were groin pain (100%), limited range of motion at the hip (66%), and pain exacerbated by any ambulation (66%). 2 of the 3 patients were long distance runners and the third worked at a grocery store, climbing up and down stairs several times a day. None had any medical comorbidities. Rehabilitation protocol for these patients included avoiding any impact or weight-bearing activity. For the first 2 weeks, patients used crutches for ambulation, followed by gradual physical therapy, including non–weight-bearing and nonimpact exercises, and strengthening of the hip girdle muscles and especially the hip extensors and abductors. Conclusions: Physiatrists should be aware of the varied clinical manifestation of stress fracture of the hip, an uncommon cause of hip pain, and be able to order the necessary radiologic test. Accurate diagnosis will alter physical therapy prescription, which should include non–weightbearing status for 1 to 2 weeks and avoiding high impact exercises and activities. Key Words: Fractures, stress; Hip joint; Rehabilitation.
Arch Phys Med Rehabil Vol 84, September 2003
Poster 66 Osteochondroma Associated With Ruptured Bursa Presenting as Hamstring Injury and Hematoma: A Case Report. Julie T. Lin, MD (Hospital for Special Surgery, New York, NY); Svetlana Ilizarov, MD, e-mail: [email protected]. Disclosure: None. Setting: Academic outpatient physiatric private practice. Patient: A 53-year-old man. Case Description: The patient presented with complaints of left posterior thigh and knee pain and hematoma 4 days after twisting his left leg. He developed buttock pain, followed by a “baseballsized” gluteal mass, both of which resolved over the next 2 days. Physical findings included tenderness to palpation over the ischial tuberosity, large ecchymosis, and swelling suggestive of hematoma extending from the left gluteal area to the calf. Neurologic exam was normal except for mild left hamstring weakness. Assessment/Results: Clinical presentation was consistent with hamstring injury with hematoma formation. Radiographs of the pelvis were negative for hamstring avulsion, however, they demonstrated the incidental findings of calcifications over the neck of the femur, suggestive of cartilaginous lesions. Subsequent magnetic resonance imaging demonstrated a large osteochondroma and a large, partially ruptured bursa formation with intact hamstrings, fluid collection causing partial encasement of the sciatic nerve, and effacement of the proximal hamstrings, gluteus maximus, and adductus magnus. Discussion: This is the first reported case, to our knowledge, of osteochondroma of the femur associated with large bursa formation presenting as hamstring injury in an older patient. Osteochondroma is a common tumor, which usually presents in adolescence. Large bursa formation in association with osteochondroma of the femur is a rare complication that may represent malignant transformation and must be ruled out. Conclusion: Osteochondroma with large bursa formation can have unusual presentations, including the appearance of hamstring injury and hematoma. Presumed hamstring injuries are commonly managed conservatively and, in most cases, imaging studies do not play a significant role in the work-up. However, diagnostic imaging can play a central role in the diagnosis of bone tumors. Key Words: Bursa; Osteochondroma; Rehabilitation.
Poster 67 Lumbar Intraspinal Synovial Cyst: A Case Report. Ibrahim A. Aksoy, MD, PhD (Mayo Clinic, Rochester, MN); Stephen F. Noll, MD, e-mail: [email protected]. Disclosure: None. Setting: Tertiary medical center physical medicine and rehabilitation unit. Patient: A 67-yearold woman with intractable right lower-extremity pain and paresthesias. Case Description: The patient presented with a 2 month-history of acute onset right buttock pain with radiation into calf and foot. She also had numbness and tingling in her right foot. There was no trauma or unusual activity, however, she had subtle right leg discomfort for many years prior to onset of pain. The patient had no subjective weakness or difficulty in bowel or bladder control. Neurologic examination revealed absent right ankle jerk and reduced sensation in S1 distribution. Motor strength was normal. Lumbar spine magnetic resonance imaging (MRI) revealed a juxta-facet intraspinal synovial cyst at the right L5-S1 level. This caused deformity and compression of the right S1 nerve root. There were also smaller extraspinal synovial cysts at L5-S1 level posteriorly. Assessment/Results: The patient underwent right L5 partial, inferior hemilaminectomy, L5-S1 medial facetectomy, foraminotomy of the S1 nerve root, and gross total resection of the L5-S1 level synovial cyst. Postoperatively, she reported relief of right lower-extremity pain for several hours. She then developed recurrence of right leg pain without weakness. MRI revealed hematoma formation at the operative bed. The hematoma was evacuated promptly, resulting in complete resolution of symptoms. Discussion: This case represents a classic presentation of a large intraspinal synovial cyst causing radiculopathy and outcome of surgical excision with the infrequent postoperative complication of hematoma. Conclusion: Intraspinal synovial cysts can cause intractable radicular pain. MRI studies are warranted for intractable radiculopathies. Key Words: Radiculopathy; Rehabilitation; Synovial cyst.
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Poster 68 Improved Clinical Outcomes in Trigger Points Injections by Combined Use of Lidocaine, Toradol, and Steroids. Shalabh K. Gupta, MD (Rusk Institute of Rehabilitation Medicine/ NYU Medical Center, New York, NY); Todd R. Schlifstein, DO; Gerard P. Varlotta, DO, e-mail: [email protected]. Disclosure: None. Objective: To test the use of a combination of lidocaine, ketorolac (Toradol), and steroids in trigger point injections. Design: Case-control study. Setting: Outpatient-based sports medicine practice at a major university hospital. Participants: 187 patients diagnosed with trigger points. With age- and sex-matched cases (group 1) and controls (group 2), 47 patients in the group 1 were treated with lidocaine alone and 42 in the group 2 were treated with a combination of lidocaine, Toradol, and steroid. Interventions: A combination of lidocaine, Toradol, and steroid injections. Main Outcome Measures: Patients were asked to chart pain on visual analog scale (VAS) for 7 days and to return to clinic for 1- and 3-month follow-ups. Results: Reported average pain relief on VAS in the group 1 was 6 points during the first 7 days compared with 2.5 points in the group 2. Complete resolution of symptoms (27% in group 1; 39% in group 2) and need or repeat injections (36% in group 1; 24% in group 2) were also noted. Conclusions: Patients treated with a combination of lidocaine, Toradol, and steroid had better pain control, needed fewer repeat injections, and had better resolution of symptoms than patients treated with lidocaine alone. Lidocaine offers pain relief within 1 to 2 minutes and persists for 15 to 20 minutes, Toradol offers pain relief after 45⫾30 minutes, and steroids take 3 to 5 days to affect the site. Besides the different time for onset of action, they also act on different pain receptors and thus offer a combined mode of treatment. This combination, however, should be used with caution and all the contraindications and drug interactions must be kept in mind. Key Words: Ketorolac; Lidocaine; Rehabilitation; Trigger point injections.
Poster 69 Brachial Plexopathy in Patient Undergoing Surgical Repair of Rotator Cuff Rupture: A Case Report. Shalabh K. Gupta, MD (Rusk Institute of Rehabilitation Medicine/NYU Medical Center, New York, NY); Todd R. Schlifstein, DO; Gerard P. Varlotta, DO, e-mail: [email protected]. Disclosure: None. Setting: Tertiary care university hospital. Patient: A 45-year-old athletic male. Case Description: The patient had difficulty in overhead abduction of arm and complained of pain, which on radiographic investigation was found to be secondary to partial tear of rotator cuff tendons. The patient underwent a trial of physical therapy for 2 months but did not find any improvement. He decided to undergo surgical intervention. A brachial plexus block was planned for the anesthesia. After several attempts, a successful plexus block was given and the patient underwent repair and was discharged postoperatively using a sling. He started developing numbness and tingling over the entire arm, including hands and fingers, within days after surgery. After 2 weeks, he was also found to have limited range of motion (ROM) at the shoulder joint. 4 weeks after his clinical symptoms appeared during postoperative rehabilitation, physiatrists conducted on electromyographic study and magnetic resonance imaging (MRI). The electromyographic results showed upper trunk plexopathy and the MRI showed inflammation the around the upper trunk. Assessment/Results: The patient was treated aggressively with pain medications, and physical therapy (PT) exercises, but after 9 months of therapy he still had weakness in all the rotator cuff muscles and limited ROM. Discussion: Physiatrists often assume care for patients after orthopedic procedures and they should be aware of the complications that surgical interventions can cause. Although brachial plexopathy was not a complication of the surgery per se, it probably occurred secondary to the difficult brachial plexus block. A high degree of suspicion in this case helped the physiatrists to do the necessary tests and to find out the cause. When appropriately diagnosed PT prescriptions can be tailored to address this problem with appropriate expectations of clinical outcome. Conclusion: Brachial plexopathy may develop as a complication due to anesthesia in the patients undergoing rotator cuff repair. Key Words: Brachial plexopathy; Postoperative complications; Rehabilitation; Rotator cuff.
Poster 70 Rehabilitation Implications of Stress Fracture of Hip in Young and Atheletic Men. Shalabh K. Gupta, MD (Rusk Institute of Rehabilitation Medicine/NYU Medical Center, New York, NY); Todd R. Schlifstein, DO; Gerard P. Varlotta, DO, e-mail: [email protected]. Disclosure: None. Objective: To examine the clinical manifestations, radiologic investigations, and rehabilitation protocol of stress fracture of the hip in athletic and young patient population. Design: Clinical case series. Setting: Outpatient-based sports medicine practice at a major university hospital. Participants: 87 patients referred to outpatient rehabilitation clinic with pain in the hip and groin and who were clinically thought to have some hip pathology contributing to the pain. Interventions: Not applicable. Main Outcome Meaures: After a thorough history and clinical examination, magnetic resonance imaging of the hip joints was ordered in all patients. Results: 3 of 87 patients (3.4%), all men, had a stress fracture of the hip. The average age of the patients was 33 years and 16 (18.4%) were women. The clinical presentations, in order of frequency, were groin pain (100%), limited range of motion at the hip (66%), and pain exacerbated by any ambulation (66%). 2 of the 3 patients were long distance runners and the third worked at a grocery store, climbing up and down stairs several times a day. None had any medical comorbidities. Rehabilitation protocol for these patients included avoiding any impact or weight-bearing activity. For the first 2 weeks, patients used crutches for ambulation, followed by gradual physical therapy, including non–weight-bearing and nonimpact exercises, and strengthening of the hip girdle muscles and especially the hip extensors and abductors. Conclusions: Physiatrists should be aware of the varied clinical manifestation of stress fracture of the hip, an uncommon cause of hip pain, and be able to order the necessary radiologic test. Accurate diagnosis will alter physical therapy prescription, which should include non–weightbearing status for 1 to 2 weeks and avoiding high impact exercises and activities. Key Words: Fractures, stress; Hip joint; Rehabilitation.
Arch Phys Med Rehabil Vol 84, September 2003