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Poster 179 Ultrasound Guided Percutaneous Tenotomy for Refractory Lateral Epicondylitis
S220
Abstracts / PM R 8 (2016) S151-S332
purposes of this study were to: 1) quantify the effects of LBP on key kinematic parameters of the lacrosse shot, and 2) determine the contribution of the severity of LBP on specific kinematic parameters of shooting motion. Design: Descriptive laboratory study. Setting: Research laboratory of an academic institution. Participants: Male high-school and collegiate players (N¼24; 18.6 3.0 yr) were stratified into two groups based on back pain symptoms (LBP or No Pain). Interventions: Not applicable. Main Outcome Measures: Numerical pain rating scale (NRSpain) for LBP during movement;Three-dimensional motion capture of overhead throws was used to collect data on knee, pelvis, trunk and shoulder kinematics, crosse and ball speed. Results: Mean low back NRSpain rating was 2.9 points. The knee flexion angle at ball release was less in the LBP than no pain group (151.1 vs 160.6 , respectively; P¼.04. The LBP group demonstrated a lower incremental increase in angular velocity from pelvis to trunk than the No Pain group (P¼.05). In the LBP group, total range of motion of the pelvis and shoulders during the shot and follow-through were less than in the control (83.6 24.5 vs 75.9 24.5 , P¼.05). Age and sex-adjusted regression analyses revealed that the low back NRSpain rating contributed 6.3% to 25.0% of the variance to the models of shoulder transverse rotation range of motion, trunk and shoulder rotation angular velocities and knee flexion angle (P<.05). Conclusions: Lumbopelvic and core training, leg power and prehabilitation programs for high school and collegiate players may help these affected players reduce pain, attain appropriate motion parameters and avoid secondary musculoskeletal injuries. Level of Evidence: Level III Poster 179 Ultrasound Guided Percutaneous Tenotomy for Refractory Lateral Epicondylitis Diana Barayeva, DO (SUNY at Stony Brook, Ronkonkoma, NY, United States), Yudell Edelstein, MD, Susan M. Stickevers, MD Disclosures: Diana Barayeva: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 39-year-old woman presented with 6month history of right lateral elbow pain. Tenderness to palpation was noted and Cozen’s and Mill’s tests were positive. She had received a counterforce brace, physical therapy, anti-inflammatories and a corticosteroid injection without clinical improvement. Diagnostic ultrasound revealed severe tendinosis and enthesopathy at the common extensor tendon (CET) origin. An ultrasound guided percutaneous needle tenotomy of the CET was performed following injection of local anesthetic. A 20-gauge 1.5-inch needle was introduced into the CET. The CET was repeatedly fenestrated parallel to its longitudinal axis until sonography confirmed that the entire CET had been fenestrated. Periosteal abrasion of the lateral epicondyle was then performed with the 20-gauge needle. Post procedure the patient was instructed to perform isometric wrist extension exercises and to passively stretch the CET as tolerated five times daily followed by ice application for 2 weeks. She was permitted to use the upper extremity for ADL, however she was restricted from lifting objects weighing more than 5 pounds for 2 weeks. Two weeks after the procedure physical therapy was instituted for active stretching, isometrics, and eccentric loading of the tendon. Setting: Tertiary care center. Results: At 12 weeks post procedure, she reported a 66% reduction in pain. Discussion: Tendinosis of the CET can be painful, debilitating and difficult to treat. Histologic studies indicate that this disorder results from tendon degeneration leading to replacement of normal tissue by a disorganized arrangement of collagen. Percutaneous needling of CET may promote healing by breaking down scar tissue and stimulating
blood vessel and collagen precursor recruitment. According to Dr McShane et al, needling of the extensor tendon achieves a healing response that promotes blood vessel and collagen precursor recruitment. The rehabilitation protocol involves passively stretching the tendon as often as possible right after the injection. The program involves stretching, isometric and eccentric loading of the tendon, and a progression toward restoring full elbow function. The post procedure rehabilitation protocol may prevent adhesions and promote newly regenerated collagen to align in an organized, linear fashion. Conclusions: Ultrasound guided percutaneous needle tenotomy for lateral elbow tendinosis is a safe and effective treatment without corticosteroid injections. This procedure breaks up the scar tissue that has formed in the tendon and it also stimulates a healing response. Percutaneous needle tenotomy of the CET warrants further study as it represents an inexpensive, non-surgical treatment modality for refractory lateral epicondylosis. Level of Evidence: Level V Poster 180 Rectus Femoris Avulsion of the Direct and Reflected Heads in a Kickball Player: MRI Diagnosis and Nonoperative Outcome Chihyung K. Park, BS (The University of Queensland - Ochsner Clinical School, New Orleans, LA, United States), Vinko Zlomislic, MD, Douglas G. Chang, MD, PhD Disclosures: Chihyung Park: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 37-year-old man was playing in a kickball game and ruptured his rectus femoris muscle during the match. MRI revealed a grade III musculotendinous junction injury with complete tearing of the musculotendinous junctions at the direct and reflected heads. The patient elected non-operative management. Setting: Tertiary care hospital. Results: With 12 weeks of physical therapy rehabilitation, deformity from the detached muscle heads was unnoticed and the patient returned to full sport activity. The patient occasionally reported tenderness over the traumatic area with intense activity but was not limited from any sports activities. Discussion: Rupture of the direct head of the rectus femoris at the site of AIIS has been documented. There has not been a documented case of musculotendinous junction rupture involving both the direct and the reflected heads of the rectus femoris. This report summarizes a rarely documented case of rupture of both origin sites of the rectus femoris in a recreational kickball player. Conclusions: There is an increased number of organized recreational sports leagues, and kickball is gaining more popularity among adults, which may result in a greater occurrence of this type of injury in general population. This case demonstrates a recreational athlete’s return to play protocol involving non-operative management. Level of Evidence: Level V Poster 181 Botox Application for Recurrent Wrist Pain Rucha Kharod, MD (Washington University, Wildwood, MO, United States), Prateek Grover, MD, PhD, Rimma Ruvinskaya, MD Disclosures: Rucha Kharod: I Have No Relevant Financial Relationships To Disclose Case/Program Description: 17-year-old female swimmer developed progressively worsening dominant wrist pain during swim season 2.5 years ago, exacerbated with activities such as typing and gripping. During the first year, multiple imaging studies were inconclusive. Conservative analgesia and wrist splinting were unsuccessful in improving pain and hand function. At 1 year, the orthopedic diagnosis of Flexor Carpi Radialis (FCR) tendonitis was addressed with
Abstracts / PM R 8 (2016) S151-S332
purposes of this study were to: 1) quantify the effects of LBP on key kinematic parameters of the lacrosse shot, and 2) determine the contribution of the severity of LBP on specific kinematic parameters of shooting motion. Design: Descriptive laboratory study. Setting: Research laboratory of an academic institution. Participants: Male high-school and collegiate players (N¼24; 18.6 3.0 yr) were stratified into two groups based on back pain symptoms (LBP or No Pain). Interventions: Not applicable. Main Outcome Measures: Numerical pain rating scale (NRSpain) for LBP during movement;Three-dimensional motion capture of overhead throws was used to collect data on knee, pelvis, trunk and shoulder kinematics, crosse and ball speed. Results: Mean low back NRSpain rating was 2.9 points. The knee flexion angle at ball release was less in the LBP than no pain group (151.1 vs 160.6 , respectively; P¼.04. The LBP group demonstrated a lower incremental increase in angular velocity from pelvis to trunk than the No Pain group (P¼.05). In the LBP group, total range of motion of the pelvis and shoulders during the shot and follow-through were less than in the control (83.6 24.5 vs 75.9 24.5 , P¼.05). Age and sex-adjusted regression analyses revealed that the low back NRSpain rating contributed 6.3% to 25.0% of the variance to the models of shoulder transverse rotation range of motion, trunk and shoulder rotation angular velocities and knee flexion angle (P<.05). Conclusions: Lumbopelvic and core training, leg power and prehabilitation programs for high school and collegiate players may help these affected players reduce pain, attain appropriate motion parameters and avoid secondary musculoskeletal injuries. Level of Evidence: Level III Poster 179 Ultrasound Guided Percutaneous Tenotomy for Refractory Lateral Epicondylitis Diana Barayeva, DO (SUNY at Stony Brook, Ronkonkoma, NY, United States), Yudell Edelstein, MD, Susan M. Stickevers, MD Disclosures: Diana Barayeva: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 39-year-old woman presented with 6month history of right lateral elbow pain. Tenderness to palpation was noted and Cozen’s and Mill’s tests were positive. She had received a counterforce brace, physical therapy, anti-inflammatories and a corticosteroid injection without clinical improvement. Diagnostic ultrasound revealed severe tendinosis and enthesopathy at the common extensor tendon (CET) origin. An ultrasound guided percutaneous needle tenotomy of the CET was performed following injection of local anesthetic. A 20-gauge 1.5-inch needle was introduced into the CET. The CET was repeatedly fenestrated parallel to its longitudinal axis until sonography confirmed that the entire CET had been fenestrated. Periosteal abrasion of the lateral epicondyle was then performed with the 20-gauge needle. Post procedure the patient was instructed to perform isometric wrist extension exercises and to passively stretch the CET as tolerated five times daily followed by ice application for 2 weeks. She was permitted to use the upper extremity for ADL, however she was restricted from lifting objects weighing more than 5 pounds for 2 weeks. Two weeks after the procedure physical therapy was instituted for active stretching, isometrics, and eccentric loading of the tendon. Setting: Tertiary care center. Results: At 12 weeks post procedure, she reported a 66% reduction in pain. Discussion: Tendinosis of the CET can be painful, debilitating and difficult to treat. Histologic studies indicate that this disorder results from tendon degeneration leading to replacement of normal tissue by a disorganized arrangement of collagen. Percutaneous needling of CET may promote healing by breaking down scar tissue and stimulating
blood vessel and collagen precursor recruitment. According to Dr McShane et al, needling of the extensor tendon achieves a healing response that promotes blood vessel and collagen precursor recruitment. The rehabilitation protocol involves passively stretching the tendon as often as possible right after the injection. The program involves stretching, isometric and eccentric loading of the tendon, and a progression toward restoring full elbow function. The post procedure rehabilitation protocol may prevent adhesions and promote newly regenerated collagen to align in an organized, linear fashion. Conclusions: Ultrasound guided percutaneous needle tenotomy for lateral elbow tendinosis is a safe and effective treatment without corticosteroid injections. This procedure breaks up the scar tissue that has formed in the tendon and it also stimulates a healing response. Percutaneous needle tenotomy of the CET warrants further study as it represents an inexpensive, non-surgical treatment modality for refractory lateral epicondylosis. Level of Evidence: Level V Poster 180 Rectus Femoris Avulsion of the Direct and Reflected Heads in a Kickball Player: MRI Diagnosis and Nonoperative Outcome Chihyung K. Park, BS (The University of Queensland - Ochsner Clinical School, New Orleans, LA, United States), Vinko Zlomislic, MD, Douglas G. Chang, MD, PhD Disclosures: Chihyung Park: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 37-year-old man was playing in a kickball game and ruptured his rectus femoris muscle during the match. MRI revealed a grade III musculotendinous junction injury with complete tearing of the musculotendinous junctions at the direct and reflected heads. The patient elected non-operative management. Setting: Tertiary care hospital. Results: With 12 weeks of physical therapy rehabilitation, deformity from the detached muscle heads was unnoticed and the patient returned to full sport activity. The patient occasionally reported tenderness over the traumatic area with intense activity but was not limited from any sports activities. Discussion: Rupture of the direct head of the rectus femoris at the site of AIIS has been documented. There has not been a documented case of musculotendinous junction rupture involving both the direct and the reflected heads of the rectus femoris. This report summarizes a rarely documented case of rupture of both origin sites of the rectus femoris in a recreational kickball player. Conclusions: There is an increased number of organized recreational sports leagues, and kickball is gaining more popularity among adults, which may result in a greater occurrence of this type of injury in general population. This case demonstrates a recreational athlete’s return to play protocol involving non-operative management. Level of Evidence: Level V Poster 181 Botox Application for Recurrent Wrist Pain Rucha Kharod, MD (Washington University, Wildwood, MO, United States), Prateek Grover, MD, PhD, Rimma Ruvinskaya, MD Disclosures: Rucha Kharod: I Have No Relevant Financial Relationships To Disclose Case/Program Description: 17-year-old female swimmer developed progressively worsening dominant wrist pain during swim season 2.5 years ago, exacerbated with activities such as typing and gripping. During the first year, multiple imaging studies were inconclusive. Conservative analgesia and wrist splinting were unsuccessful in improving pain and hand function. At 1 year, the orthopedic diagnosis of Flexor Carpi Radialis (FCR) tendonitis was addressed with