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Poster 165 Exertional Rhabdomyolysis after Endurance Training
S216
Abstracts / PM R 8 (2016) S151-S332
Poster 165 Exertional Rhabdomyolysis after Endurance Training Suzanne Gutierrez Teissonniere, MD (NY Sports Medicine - Orthology, New York, NY, United States) Disclosures: Suzanne Gutierrez Teissonniere: I Have No Relevant Financial Relationships To Disclose Case/Program Description: Four patients, aged between 28 and 39, presented for evaluation of swelling, tightness, weakness and tenderness in bilateral upper or lower extremities at least a day after completing an endurance exercise. Two female patients had bilateral arm symptoms after completing CrossFit. The third female presented with bilateral hamstrings and calves symptoms, along with dark urine, after completing NYC marathon. The male patient presented with bilateral thigh symptoms and dark urination, after a spinning class. The latter patient did not exercise regularly; the other three exercised regularly. Setting: Outpatient Office. Results: All patients were referred for immediate rhabdomyolysis workup. One female CrossFit patient with creatine kinase (CK) of 6540 received aggressive oral hydration. The female runner with CK of 5000 received 3 liters of intravenous fluids (IVF). The other female CrossFit patient was hospitalized with CK of 33,000, and completed IVF management. The male spinning patient was hospitalized with CK of 94,000, and was started on IVF with bicarbonate drips. All patients had normal renal function, and recovered fully with hydration and rest. Discussion: Acute Exertional Rhabdomyolysis (AER) is a result of skeletal muscle injury from strenuous exercise. Patients usually present with delayed-onset pain, soreness and swelling of the affected muscles. This is associated with the release of different proteins, including CK, lactate dehydrogenase and myoglobin, into circulation system. AER has been reported in endurance athletes, or jobs that require extreme physical work. Eccentric exercises tend to have the highest risk for muscle injury. Both CrossFit and spinning have been linked with several cases. Conclusions: Early diagnosis of AER is important to prevent severe complications, including electrolyte abnormalities, dehydration, renal failure, compartment syndrome, disseminated intravascular coagulation, and death. Adequate fluid replacement is an essential management. Furosemide and Mannitol are used in the presence of renal failure. Physicians have to educate athletes about proper prevention techniques. Level of Evidence: Level V Poster 166 A Reliability Study of Ultrasound Detection of Myofascial Trigger Points Dinesh A. Kumbhare, MD (University of Toronto, Toronto, Ontario, Canada), Liza Grosman-Rimon, PhD, Brian Vadasz Disclosures: Dinesh Kumbhare: I Have No Relevant Financial Relationships To Disclose Objective: Myofascial pain syndrome is a common pain disorder that currently lacks an imaging gold standard. Ultrasound has been proposed as a candidate to fill this role. However, limited data are available on intra and inter ereliability. Design: Cross-sectional reliability study. Setting: Pain clinic at an academic center. Participants: 10 patients with neck pain. Interventions: An educational session was provided for the raters. It included the characteristics of the MTrP as described in the literature. Ultrasound of the upper trapezius with independent blinded analysis by 2 inexperienced and one experienced rater. Each rater examined each US image twice. Main Outcome Measures: Test retest reliability assessments of the US images were performed.
Results: For the detection of a myofascial trigger point: Inexperienced intra-rater Cohen’s kappa were 0.28 to 0.49, inter-rater were -0.13 to 0.18. Experienced intra-rater Cohen’s kappa 0.69. Conclusions: Inexperienced raters demonstrated poor intra- and inter- rater reliability. Good intra-rater reliability was found in the experienced examiner. If ultrasound is used for the diagnosis of MTrP, it is essential that the clinician receive the appropriate training. Level of Evidence: Level III Poster 167 Ovarian Cyst Rupture as an Unusual Etiology for Hip Pain in a Young Female Runner: A Case Report Samuel T. Dona, MD (Rush University Medical Center, Chicago, Illinois, United States), Nancy Vuong, MD, Mark R. Hutchinson, MD, Terry L. Nicola, MD, MS Disclosures: Samuel Dona: I Have No Relevant Financial Relationships To Disclose Case/Program Description: An 18-year-old female runner presented with a two-week history of gradually increasing left hip pain without trauma or known inciting event. She had initially sought consult in the ED and was treated empirically with clindamycin for suspected lymphadenopathy versus abscess despite unremarkable ultrasound imaging. Her pain remained unchanged and she was referred to sports medicine clinic to evaluate for concerns of musculoskeletal injury. On presentation, her pain was rated 6/10 and localized along the left anterior hip into the groin. Pain worsened with prolonged sitting and weight bearing of the left leg. Patient was afebrile and reported regular menses. She is not sexually active and ED urine pregnancy testing was negative. Setting: Multidisciplinary Outpatient Sports Medicine Clinic. Results: Examination revealed an antalgic gait favoring external rotation of the left leg. Internal rotation reproduced left groin pain. Severe tenderness to palpation over the left greater trochanter, left groin, and left lower quadrant. Pelvic compression reproduced left hip pain. CBC/ESR and plain radiographs of the hip and pelvis were unremarkable. Emergent MRI of the hip was ordered to evaluate for iliopsoas abscess and revealed an edematous left ovary with concerns for ovarian torsion. OB-GYN evaluation and ultrasound was scheduled. However, her pain acutely worsened with associated nausea and vomiting. She was consented for emergent laparoscopy with intraoperative findings revealing a ruptured left ovarian cyst. Suction irrigation was performed for moderate serous fluid found in the pelvis resulting in clinical improvement. Discussion: Ovarian cyst rupture can present as a surgical emergency requiring immediate intervention. In this example, the definitive diagnosis may be unclear with the presentation masquerading musculoskeletal injury. Assessing for hemodynamic instability and performing MRI is critical to management in these circumstances. Conclusions: When evaluating for hip and pelvic injury in the orthopedic setting it is important to consider intra-abdominal or gynecologic etiologies as possible sources of referred pain. Level of Evidence: Level V Poster 169 Anticoagulation-Induced Dissecting Hematoma Following Rupture of a Baker’s Cyst: A Case Report Mark Bauernfeind, MD (University of Rochester Medical Center, Rochester, NY, United States), Katarzyna Iwan, MD, Franchesca Konig Toro, MD, Mark H. Mirabelli, MD Disclosures: Mark Bauernfeind: I Have No Relevant Financial Relationships To Disclose Case/Program Description: Healthy 59-year-old man with a history of recent cross-country driving trip and treatment for right knee gout with corticosteroids and indomethacin presented with lower limb
Abstracts / PM R 8 (2016) S151-S332
Poster 165 Exertional Rhabdomyolysis after Endurance Training Suzanne Gutierrez Teissonniere, MD (NY Sports Medicine - Orthology, New York, NY, United States) Disclosures: Suzanne Gutierrez Teissonniere: I Have No Relevant Financial Relationships To Disclose Case/Program Description: Four patients, aged between 28 and 39, presented for evaluation of swelling, tightness, weakness and tenderness in bilateral upper or lower extremities at least a day after completing an endurance exercise. Two female patients had bilateral arm symptoms after completing CrossFit. The third female presented with bilateral hamstrings and calves symptoms, along with dark urine, after completing NYC marathon. The male patient presented with bilateral thigh symptoms and dark urination, after a spinning class. The latter patient did not exercise regularly; the other three exercised regularly. Setting: Outpatient Office. Results: All patients were referred for immediate rhabdomyolysis workup. One female CrossFit patient with creatine kinase (CK) of 6540 received aggressive oral hydration. The female runner with CK of 5000 received 3 liters of intravenous fluids (IVF). The other female CrossFit patient was hospitalized with CK of 33,000, and completed IVF management. The male spinning patient was hospitalized with CK of 94,000, and was started on IVF with bicarbonate drips. All patients had normal renal function, and recovered fully with hydration and rest. Discussion: Acute Exertional Rhabdomyolysis (AER) is a result of skeletal muscle injury from strenuous exercise. Patients usually present with delayed-onset pain, soreness and swelling of the affected muscles. This is associated with the release of different proteins, including CK, lactate dehydrogenase and myoglobin, into circulation system. AER has been reported in endurance athletes, or jobs that require extreme physical work. Eccentric exercises tend to have the highest risk for muscle injury. Both CrossFit and spinning have been linked with several cases. Conclusions: Early diagnosis of AER is important to prevent severe complications, including electrolyte abnormalities, dehydration, renal failure, compartment syndrome, disseminated intravascular coagulation, and death. Adequate fluid replacement is an essential management. Furosemide and Mannitol are used in the presence of renal failure. Physicians have to educate athletes about proper prevention techniques. Level of Evidence: Level V Poster 166 A Reliability Study of Ultrasound Detection of Myofascial Trigger Points Dinesh A. Kumbhare, MD (University of Toronto, Toronto, Ontario, Canada), Liza Grosman-Rimon, PhD, Brian Vadasz Disclosures: Dinesh Kumbhare: I Have No Relevant Financial Relationships To Disclose Objective: Myofascial pain syndrome is a common pain disorder that currently lacks an imaging gold standard. Ultrasound has been proposed as a candidate to fill this role. However, limited data are available on intra and inter ereliability. Design: Cross-sectional reliability study. Setting: Pain clinic at an academic center. Participants: 10 patients with neck pain. Interventions: An educational session was provided for the raters. It included the characteristics of the MTrP as described in the literature. Ultrasound of the upper trapezius with independent blinded analysis by 2 inexperienced and one experienced rater. Each rater examined each US image twice. Main Outcome Measures: Test retest reliability assessments of the US images were performed.
Results: For the detection of a myofascial trigger point: Inexperienced intra-rater Cohen’s kappa were 0.28 to 0.49, inter-rater were -0.13 to 0.18. Experienced intra-rater Cohen’s kappa 0.69. Conclusions: Inexperienced raters demonstrated poor intra- and inter- rater reliability. Good intra-rater reliability was found in the experienced examiner. If ultrasound is used for the diagnosis of MTrP, it is essential that the clinician receive the appropriate training. Level of Evidence: Level III Poster 167 Ovarian Cyst Rupture as an Unusual Etiology for Hip Pain in a Young Female Runner: A Case Report Samuel T. Dona, MD (Rush University Medical Center, Chicago, Illinois, United States), Nancy Vuong, MD, Mark R. Hutchinson, MD, Terry L. Nicola, MD, MS Disclosures: Samuel Dona: I Have No Relevant Financial Relationships To Disclose Case/Program Description: An 18-year-old female runner presented with a two-week history of gradually increasing left hip pain without trauma or known inciting event. She had initially sought consult in the ED and was treated empirically with clindamycin for suspected lymphadenopathy versus abscess despite unremarkable ultrasound imaging. Her pain remained unchanged and she was referred to sports medicine clinic to evaluate for concerns of musculoskeletal injury. On presentation, her pain was rated 6/10 and localized along the left anterior hip into the groin. Pain worsened with prolonged sitting and weight bearing of the left leg. Patient was afebrile and reported regular menses. She is not sexually active and ED urine pregnancy testing was negative. Setting: Multidisciplinary Outpatient Sports Medicine Clinic. Results: Examination revealed an antalgic gait favoring external rotation of the left leg. Internal rotation reproduced left groin pain. Severe tenderness to palpation over the left greater trochanter, left groin, and left lower quadrant. Pelvic compression reproduced left hip pain. CBC/ESR and plain radiographs of the hip and pelvis were unremarkable. Emergent MRI of the hip was ordered to evaluate for iliopsoas abscess and revealed an edematous left ovary with concerns for ovarian torsion. OB-GYN evaluation and ultrasound was scheduled. However, her pain acutely worsened with associated nausea and vomiting. She was consented for emergent laparoscopy with intraoperative findings revealing a ruptured left ovarian cyst. Suction irrigation was performed for moderate serous fluid found in the pelvis resulting in clinical improvement. Discussion: Ovarian cyst rupture can present as a surgical emergency requiring immediate intervention. In this example, the definitive diagnosis may be unclear with the presentation masquerading musculoskeletal injury. Assessing for hemodynamic instability and performing MRI is critical to management in these circumstances. Conclusions: When evaluating for hip and pelvic injury in the orthopedic setting it is important to consider intra-abdominal or gynecologic etiologies as possible sources of referred pain. Level of Evidence: Level V Poster 169 Anticoagulation-Induced Dissecting Hematoma Following Rupture of a Baker’s Cyst: A Case Report Mark Bauernfeind, MD (University of Rochester Medical Center, Rochester, NY, United States), Katarzyna Iwan, MD, Franchesca Konig Toro, MD, Mark H. Mirabelli, MD Disclosures: Mark Bauernfeind: I Have No Relevant Financial Relationships To Disclose Case/Program Description: Healthy 59-year-old man with a history of recent cross-country driving trip and treatment for right knee gout with corticosteroids and indomethacin presented with lower limb