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Poster 175 Positional Femoral Entrapment Neuropathy: A Case Report
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fibers of the left gluteus medius. Patient 1 stopped oral NSAIDs and was given tramadol 50 mg q6h prn used in combination with acetaminophen and ice. A PRP injection was performed with ultrasound guidance of the proximal right anterior gluteus medius. 2 weeks post-injection, she had reduction of pain and an ability to gradually return to activity. She began physical therapy to restore flexibility and strength to the right gluteus medius. Patient 2 received prescription of physical therapy to restore strength and function of the left gluteus medius. Discussion: Typically, when the gluteus medius is involved in lateral hip pain it is implicated in greater trochanteric bursa syndrome. In such situations there is often insertional tendinosis or tear of the gluteus medius at the distal musculotendinous junction. However, these two cases represent very rare and previously unreported proximal gluteus medius tendon tears. Conclusions: Though very rare, proximal gluteus medius tendon tears should be considered in the differential diagnosis of lateral hip pain that lies in proximity to the iliac crest. Poster 174 Ultrasound-Guided Costotransverse Joint Injection: A CT Controlled Feasibility Study. George W. Deimel, MD (Mayo Clinic, Rochester, MN, United States); Joseph Cartwright, MD; Mark-Friedrich B. Hurdle, MD; Naveen Murthy, MD; Matthew J. Pingree, MD. Disclosures: G. W. Deimel, No Disclosures. Objective: To describe and assess the feasibility of a new injection technique of the costotransverse (CT) joint under ultrasound (US) guidance. Design: A pain physician with experience in US-guided axial procedures used US to localize paired CT joints from T3-T10 on a fresh frozen cadaver utilizing a 2-5 MHz linear array transducer. After identification, injections were performed using a long-axis or “in-line” approach with continual visualization of the needle into the CT joint. After needle placement, computed images were obtained for a fluoroscopy machine capable of coned beam computed tomography with 3-dimensional acquisition and multi-planar reformatting to assess the location of the needle tips. An iodinated contrast agent was injected and another acquisition was performed to assess the location of the injected agent. An experienced radiologist reviewed the computed images in multiple planes including standard coronal, axial, and sagittal planes to verify intra-articular placement of the contrast. Setting: A procedural suite at an academic medical institution. Participants: One unembalmed cadaveric specimen. Interventions: Not applicable. Main Outcome Measures: Verification of this technique was confirmed using contrast and computed tomography reconstruction. Accuracy of needle placement and contrast location was graded as either intra-articular or extra-articular. Results: 14 (87.5%) of 16 ultrasound-guided approaches showed successful placement of the needle tip within the targeted CT joint. 11 CT joint injections (68.75%) performed showed intra-articular contrast spread. Conclusions: We describe a relatively feasible technique for performing CT joint injections using ultrasound guidance. Given the equivalent accuracy when compared to previously reported fluoroscopically guided injection techniques and the potential to safely
PRESENTATIONS
and efficiently complete this procedure without exposure to ionizing radiation, we recommend further studies exploring the use of ultrasound for CT joint injections. Poster 175 Positional Femoral Entrapment Neuropathy: A Case Report. Giridhar Gundu, MD (University of Kentucky, Lexington, KY, United States); Oscar O. Ortiz Vargas, MD. Disclosures: G. Gundu, No Disclosures. Case Description: A 63-year-old man with 8 month duration of left anterior-medial leg burning pain, radiating to the ankle, relieved with lying flat or upon standing and worse with sitting, not exacerbated with walking, nor associated with weakness. Upon physical examination, skin was intact without trophic changes, erythema, or swelling around the area of interest. There was no tenderness or allodynia on palpation, normal motor and sensory examination with symmetric deep tendon reflexes. It is noteworthy that the patient sat with left hip and knee in full extension. He had already undergone extensive diagnostic studies, including bone scan and electro-diagnostic (EDx) testing, with no abnormal results. However, considering the positional nature of reproduction of patient’s symptoms, a repeat EDx testing was performed in sitting and supine positions, focusing on the left femoral nerve above and below the inguinal ligament. Setting: Outpatient clinic. Results or Clinical Course: Positional dynamic EDx of the left femoral nerve revealed a partial conduction block below the inguinal ligament in the sitting position that corrects with patient in supine. Contra-lateral side did not demonstrate these findings. This highly suggests an entrapment of the femoral nerve at the left inguinal ligament associated with hip flexion. Discussion: This is the first reported case, to our knowledge, of positional femoral entrapment neuropathy at the inguinal ligament. This case also illustrates a novel EDx approach that can be performed with patient in different positions. Conclusions: Posture can be a possible etiology for femoral entrapment neuropathy. EDx testing being an extension of the physical examination should be adapted according to the patient’s symptom presentation. Poster 176 Post-Partum Non-Displaced Ramus Stress Fracture in a Runner: A Case Report. Gloria G. Rho, MD (Rehabilitation Institute of Chicago, Chicago, IL, United States); Monica Rho, MD. Disclosures: G. G. Rho, No Disclosures. Case Description: Patient presented with severe left buttock pain and mild left groin pain for 2 months. She initially saw a chiropractor who initiated McKenzie type extension-based exercises. After one session of repetitive extension-based exercises she had a severe flare of left anterior groin pain that slowly improved after a week. The pain was exacerbated with walking and relieved with sitting. Notable examination findings included tenderness over the left ischial tuberosity, pubic symphysis and bilateral pubic rami, buttock pain with resisted left knee flexion, and anterior pelvic pain with resisted hip adduction bilaterally. Setting: Outpatient Musculoskeletal Clinic. Results or Clinical Course: MRI of pelvis showed bone marrow edema about the pubic symphysis extending into the left inferior
fibers of the left gluteus medius. Patient 1 stopped oral NSAIDs and was given tramadol 50 mg q6h prn used in combination with acetaminophen and ice. A PRP injection was performed with ultrasound guidance of the proximal right anterior gluteus medius. 2 weeks post-injection, she had reduction of pain and an ability to gradually return to activity. She began physical therapy to restore flexibility and strength to the right gluteus medius. Patient 2 received prescription of physical therapy to restore strength and function of the left gluteus medius. Discussion: Typically, when the gluteus medius is involved in lateral hip pain it is implicated in greater trochanteric bursa syndrome. In such situations there is often insertional tendinosis or tear of the gluteus medius at the distal musculotendinous junction. However, these two cases represent very rare and previously unreported proximal gluteus medius tendon tears. Conclusions: Though very rare, proximal gluteus medius tendon tears should be considered in the differential diagnosis of lateral hip pain that lies in proximity to the iliac crest. Poster 174 Ultrasound-Guided Costotransverse Joint Injection: A CT Controlled Feasibility Study. George W. Deimel, MD (Mayo Clinic, Rochester, MN, United States); Joseph Cartwright, MD; Mark-Friedrich B. Hurdle, MD; Naveen Murthy, MD; Matthew J. Pingree, MD. Disclosures: G. W. Deimel, No Disclosures. Objective: To describe and assess the feasibility of a new injection technique of the costotransverse (CT) joint under ultrasound (US) guidance. Design: A pain physician with experience in US-guided axial procedures used US to localize paired CT joints from T3-T10 on a fresh frozen cadaver utilizing a 2-5 MHz linear array transducer. After identification, injections were performed using a long-axis or “in-line” approach with continual visualization of the needle into the CT joint. After needle placement, computed images were obtained for a fluoroscopy machine capable of coned beam computed tomography with 3-dimensional acquisition and multi-planar reformatting to assess the location of the needle tips. An iodinated contrast agent was injected and another acquisition was performed to assess the location of the injected agent. An experienced radiologist reviewed the computed images in multiple planes including standard coronal, axial, and sagittal planes to verify intra-articular placement of the contrast. Setting: A procedural suite at an academic medical institution. Participants: One unembalmed cadaveric specimen. Interventions: Not applicable. Main Outcome Measures: Verification of this technique was confirmed using contrast and computed tomography reconstruction. Accuracy of needle placement and contrast location was graded as either intra-articular or extra-articular. Results: 14 (87.5%) of 16 ultrasound-guided approaches showed successful placement of the needle tip within the targeted CT joint. 11 CT joint injections (68.75%) performed showed intra-articular contrast spread. Conclusions: We describe a relatively feasible technique for performing CT joint injections using ultrasound guidance. Given the equivalent accuracy when compared to previously reported fluoroscopically guided injection techniques and the potential to safely
PRESENTATIONS
and efficiently complete this procedure without exposure to ionizing radiation, we recommend further studies exploring the use of ultrasound for CT joint injections. Poster 175 Positional Femoral Entrapment Neuropathy: A Case Report. Giridhar Gundu, MD (University of Kentucky, Lexington, KY, United States); Oscar O. Ortiz Vargas, MD. Disclosures: G. Gundu, No Disclosures. Case Description: A 63-year-old man with 8 month duration of left anterior-medial leg burning pain, radiating to the ankle, relieved with lying flat or upon standing and worse with sitting, not exacerbated with walking, nor associated with weakness. Upon physical examination, skin was intact without trophic changes, erythema, or swelling around the area of interest. There was no tenderness or allodynia on palpation, normal motor and sensory examination with symmetric deep tendon reflexes. It is noteworthy that the patient sat with left hip and knee in full extension. He had already undergone extensive diagnostic studies, including bone scan and electro-diagnostic (EDx) testing, with no abnormal results. However, considering the positional nature of reproduction of patient’s symptoms, a repeat EDx testing was performed in sitting and supine positions, focusing on the left femoral nerve above and below the inguinal ligament. Setting: Outpatient clinic. Results or Clinical Course: Positional dynamic EDx of the left femoral nerve revealed a partial conduction block below the inguinal ligament in the sitting position that corrects with patient in supine. Contra-lateral side did not demonstrate these findings. This highly suggests an entrapment of the femoral nerve at the left inguinal ligament associated with hip flexion. Discussion: This is the first reported case, to our knowledge, of positional femoral entrapment neuropathy at the inguinal ligament. This case also illustrates a novel EDx approach that can be performed with patient in different positions. Conclusions: Posture can be a possible etiology for femoral entrapment neuropathy. EDx testing being an extension of the physical examination should be adapted according to the patient’s symptom presentation. Poster 176 Post-Partum Non-Displaced Ramus Stress Fracture in a Runner: A Case Report. Gloria G. Rho, MD (Rehabilitation Institute of Chicago, Chicago, IL, United States); Monica Rho, MD. Disclosures: G. G. Rho, No Disclosures. Case Description: Patient presented with severe left buttock pain and mild left groin pain for 2 months. She initially saw a chiropractor who initiated McKenzie type extension-based exercises. After one session of repetitive extension-based exercises she had a severe flare of left anterior groin pain that slowly improved after a week. The pain was exacerbated with walking and relieved with sitting. Notable examination findings included tenderness over the left ischial tuberosity, pubic symphysis and bilateral pubic rami, buttock pain with resisted left knee flexion, and anterior pelvic pain with resisted hip adduction bilaterally. Setting: Outpatient Musculoskeletal Clinic. Results or Clinical Course: MRI of pelvis showed bone marrow edema about the pubic symphysis extending into the left inferior