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Axillary Mass After Golfing Injury
PM&R
Case Description: 73 symptomatic knee osteoarthritis (OA) patients participating in the multidisciplinary OA management program were evaluated for all potential local and systemic risk factors associated with the progression of knee OA. This included a dynamic assessment of local knee mechanical factors during treadmill walking. 3D knee kinematic data were captured using a knee functional assessment device. Presence of mechanical OA risk factors was identified such as varus thrust and increased internal tibial rotation. Physicians were given a copy of the dynamic assessment report and option to include data in the clinical decision-making process to personalize the treatment. Setting: Knee assessment clinic affiliated with multidisciplinary orthopaedic and sport medicine practices and physical therapy center. Results or Clinical Course: At the initial clinical investigation, physicians only identified static alignment risk factors (standing frontal plane alignment, knee flexum), but did not note any dynamic mechanical deficiencies such as varus thrust, flexum or increased internal tibial rotation. After reviewing the dynamic mechanical reports, physicians concluded that 32 knees in 25 patients exhibited significant varus thrust (range 2.5 to 5.1 ). For all these 25 patients, adjustments were made to their treatment plan based on the dynamic data. Furthermore, 3D dynamic knee alignment had a direct correlation to the affected knee compartment in 85% of the cases, for which the physicians prescribed more targeted therapies based on the identified dynamic deficiencies. Discussion: Dynamic assessment of mechanical factors allowed objective quantification of kinematic factors known to be involved in the progression of OA and to better personalize the treatment plan. This methodology is also transferable to other knee pathologies such as patellofemoral pain syndrome and tendonitis. Conclusions: Dynamic mechanical assessment of the knee and resulting objective data help improve therapeutic decision-making process and patient care by giving novel clinical information not easily seen during clinical assessment. Poster 270 True Arterial Thoracic Outlet Syndrome in a High School Baseball Pitcher: A Case Report. Christopher Connor, DO (Temple University Hospital, Philadelphia, PA, United States); David S. Stolzenberg, DO; Michael M. Weinik, DO. Disclosures: C. Connor, No Disclosures: I Have Nothing To Disclose. Case Description: A 17-year old high school baseball pitcher presenting with progressive left medial elbow pain and left 4th/5th digit parasthesias, causing him to be unable to pitch and bat. Physical exam was positive for symptom reproduction with left arm abduction and external rotation, positive Roos test noted within five seconds and Adson’s test positive for loss of pulse. Setting: Outpatient Musculoskeletal Clinic at an Academic Medical Center. Results or Clinical Course: Seen in consultation, prior testing reviewed, which included a MRI of elbow, cervical spine and shoulder and electrodiagnostic testing, all of which were unremarkable. MRA of chest with left arm abducted and externally rotated revealed focal left subclavian arterial stenosis. A dynamic upper extremity arteriogram confirmed a fixed stenosis of
Vol. 5, Iss. 9S, 2013
S233
the subclavian artery distal to vertebral artery in neutral arm position suggestive of a slip of muscle crossing the artery, and complete occlusion with arm in abduction. Patient underwent thoracic outlet decompression with resolution of symptoms and returned to pitching pain free three months post-operatively. Discussion: Thoracic outlet syndrome (TOS) refers to the constellation of signs and symptoms arising from compression of the neurovascular bundle by specific anatomic structures, which include: space between anterior and middle scalenes, costoclavicular space and pectoralis minor space. Structures affected can be divided into neurologic (> 95% of cases, with further subdivision into disputed neurologic versus true neurologic), venous (3%) and arterial (1%). Provocative tests are often used as a screening tool, with Ultrasound, CTA or MRA or conventional angiography/venography and EMG used for confirmation. Treatment depends on type of TOS and severity, ranging from physical therapy to surgical decompression. Conclusions: This case highlights the rarest form of TOS and a very unlikely cause of medial elbow pain in a young athlete. Poster 271 Axillary Mass After Golfing Injury. Natalia Covarrubias, MD (UC Irvine, Orange, CA, United States); Bianca Tribuzio, DO; Ronald Takemoto, MD. Disclosures: N. Covarrubias, No Disclosures: I Have Nothing To Disclose. Case Description: A 65-year-old man presented with right shoulder pain for 2 months. His pain began during a golfing swing when he felt a tearing sensation at the right anterior lateral chest. He developed a lump with pain, swelling, and bruising. He referred pain in the axilla when lying on the right side. He denied neck pain or paresthesias in his arm. He denied fever, chills or weight loss. His past medical history was positive for melanoma with resection, with no residual melanoma reported. He presented to the clinic 2 months after the initial injury. On physical exam, there was no evidence of erythema, discoloration, swelling, or atrophy in shoulder or cervical region. He did have a tender palpable mass on right anterior lateral chest wall. Shoulder range of motion was normal except for increased right shoulder external rotation. Impingement tests were negative. Strength was 5/5 in bilateral upper extremities except for right shoulder internal and external rotation which were 4/5. Sensation and reflexes were normal. Program Description: Long Beach Veterans Hospital. Setting: Outpatient rehabilitation clinic. Results or Clinical Course: An MRI of the shoulder showed a conglomerate of multiple cystic and hemorrhagic masses in the right axillary region. Edema was also noted extending throughout the right pectoralis minor muscle and mild edema within the right pectoralis major muscle. A fine needle biopsy revealed a poorly differentiated malignant neoplasm. CT of the thorax and PET scan revealed metastasis to the T3 vertebral body and right 5th rib. Pathology report of the right breast showed high grade undifferentiated sarcoma. Discussion: The patient’s presentation seemed most compatible with a shoulder muscle tear. The MRI revealed a vastly different diagnosis of metastatic sarcoma with a pectoralis major and minor muscle strain. Conclusions: In patients with a history of cancer, a more thorough investigation of an injury should be sought.
Case Description: 73 symptomatic knee osteoarthritis (OA) patients participating in the multidisciplinary OA management program were evaluated for all potential local and systemic risk factors associated with the progression of knee OA. This included a dynamic assessment of local knee mechanical factors during treadmill walking. 3D knee kinematic data were captured using a knee functional assessment device. Presence of mechanical OA risk factors was identified such as varus thrust and increased internal tibial rotation. Physicians were given a copy of the dynamic assessment report and option to include data in the clinical decision-making process to personalize the treatment. Setting: Knee assessment clinic affiliated with multidisciplinary orthopaedic and sport medicine practices and physical therapy center. Results or Clinical Course: At the initial clinical investigation, physicians only identified static alignment risk factors (standing frontal plane alignment, knee flexum), but did not note any dynamic mechanical deficiencies such as varus thrust, flexum or increased internal tibial rotation. After reviewing the dynamic mechanical reports, physicians concluded that 32 knees in 25 patients exhibited significant varus thrust (range 2.5 to 5.1 ). For all these 25 patients, adjustments were made to their treatment plan based on the dynamic data. Furthermore, 3D dynamic knee alignment had a direct correlation to the affected knee compartment in 85% of the cases, for which the physicians prescribed more targeted therapies based on the identified dynamic deficiencies. Discussion: Dynamic assessment of mechanical factors allowed objective quantification of kinematic factors known to be involved in the progression of OA and to better personalize the treatment plan. This methodology is also transferable to other knee pathologies such as patellofemoral pain syndrome and tendonitis. Conclusions: Dynamic mechanical assessment of the knee and resulting objective data help improve therapeutic decision-making process and patient care by giving novel clinical information not easily seen during clinical assessment. Poster 270 True Arterial Thoracic Outlet Syndrome in a High School Baseball Pitcher: A Case Report. Christopher Connor, DO (Temple University Hospital, Philadelphia, PA, United States); David S. Stolzenberg, DO; Michael M. Weinik, DO. Disclosures: C. Connor, No Disclosures: I Have Nothing To Disclose. Case Description: A 17-year old high school baseball pitcher presenting with progressive left medial elbow pain and left 4th/5th digit parasthesias, causing him to be unable to pitch and bat. Physical exam was positive for symptom reproduction with left arm abduction and external rotation, positive Roos test noted within five seconds and Adson’s test positive for loss of pulse. Setting: Outpatient Musculoskeletal Clinic at an Academic Medical Center. Results or Clinical Course: Seen in consultation, prior testing reviewed, which included a MRI of elbow, cervical spine and shoulder and electrodiagnostic testing, all of which were unremarkable. MRA of chest with left arm abducted and externally rotated revealed focal left subclavian arterial stenosis. A dynamic upper extremity arteriogram confirmed a fixed stenosis of
Vol. 5, Iss. 9S, 2013
S233
the subclavian artery distal to vertebral artery in neutral arm position suggestive of a slip of muscle crossing the artery, and complete occlusion with arm in abduction. Patient underwent thoracic outlet decompression with resolution of symptoms and returned to pitching pain free three months post-operatively. Discussion: Thoracic outlet syndrome (TOS) refers to the constellation of signs and symptoms arising from compression of the neurovascular bundle by specific anatomic structures, which include: space between anterior and middle scalenes, costoclavicular space and pectoralis minor space. Structures affected can be divided into neurologic (> 95% of cases, with further subdivision into disputed neurologic versus true neurologic), venous (3%) and arterial (1%). Provocative tests are often used as a screening tool, with Ultrasound, CTA or MRA or conventional angiography/venography and EMG used for confirmation. Treatment depends on type of TOS and severity, ranging from physical therapy to surgical decompression. Conclusions: This case highlights the rarest form of TOS and a very unlikely cause of medial elbow pain in a young athlete. Poster 271 Axillary Mass After Golfing Injury. Natalia Covarrubias, MD (UC Irvine, Orange, CA, United States); Bianca Tribuzio, DO; Ronald Takemoto, MD. Disclosures: N. Covarrubias, No Disclosures: I Have Nothing To Disclose. Case Description: A 65-year-old man presented with right shoulder pain for 2 months. His pain began during a golfing swing when he felt a tearing sensation at the right anterior lateral chest. He developed a lump with pain, swelling, and bruising. He referred pain in the axilla when lying on the right side. He denied neck pain or paresthesias in his arm. He denied fever, chills or weight loss. His past medical history was positive for melanoma with resection, with no residual melanoma reported. He presented to the clinic 2 months after the initial injury. On physical exam, there was no evidence of erythema, discoloration, swelling, or atrophy in shoulder or cervical region. He did have a tender palpable mass on right anterior lateral chest wall. Shoulder range of motion was normal except for increased right shoulder external rotation. Impingement tests were negative. Strength was 5/5 in bilateral upper extremities except for right shoulder internal and external rotation which were 4/5. Sensation and reflexes were normal. Program Description: Long Beach Veterans Hospital. Setting: Outpatient rehabilitation clinic. Results or Clinical Course: An MRI of the shoulder showed a conglomerate of multiple cystic and hemorrhagic masses in the right axillary region. Edema was also noted extending throughout the right pectoralis minor muscle and mild edema within the right pectoralis major muscle. A fine needle biopsy revealed a poorly differentiated malignant neoplasm. CT of the thorax and PET scan revealed metastasis to the T3 vertebral body and right 5th rib. Pathology report of the right breast showed high grade undifferentiated sarcoma. Discussion: The patient’s presentation seemed most compatible with a shoulder muscle tear. The MRI revealed a vastly different diagnosis of metastatic sarcoma with a pectoralis major and minor muscle strain. Conclusions: In patients with a history of cancer, a more thorough investigation of an injury should be sought.