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Poster 187 Groin Pain Can Be Quite Painful With the Wrong Diagnosis: A Case Report
S234
strengthening and gait training. On postoperative day 3, she was admitted to acute inpatient rehabilitation. She demonstrated decreased balance with gait secondary to quadriceps weakness. After 10 days of therapy, she achieved modified independence with transfers and ambulation by using a rolling walker. Setting: A tertiary care hospital. Results: At 6 weeks after surgery, electromyography and nerve conduction studies revealed axonal injury to the femoral nerves bilaterally. At 12 weeks after surgery, the patient noted significant improvement in her lower extremity strength. Hip flexion was 4⫹/5 bilaterally, right knee extension was 4⫹/5, and left knee extension was 4/5. She progressed to ambulation by using a cane in the community. Discussion: Lithotomy positioning can lead to bilateral femoral neuropathy due to prolonged hip flexion, extreme hip abduction, and external rotation. This position may not only compress the femoral nerve but also stretch it beneath the inguinal ligament, which results in demyelinating or axonal nerve injuries. This complication may be prevented by modifying posture and decreasing operating time. Conclusions: Bilateral femoral neuropathy is a rare complication of prolonged surgery in the lithotomy position. Clinicians should timely recognize this condition and promptly initiate a comprehensive rehabilitation program to address the significant functional impairments and associated psychological stress.
Poster 185 Miller Fisher Variant of Guillain-Barré Syndrome With an Unusual Presentation: A Case Report. Lisa R. Kroopf, MD (Loma Linda University Medical Center, Loma Linda, CA, United States); Murray Brandstater, MD, Menandro Cunanan, MD. Disclosures: L. R. Kroopf, none. Patients or Programs: A 64-year-old man with hypertension and diabetes mellitus. Program Description: The patient presented with blurred vision, bilateral hand numbness, unsteady gait, dysarthria, and dysphagia for several days. He was unable to stand up unassisted. The initial diagnosis was a small brainstem stroke although brain magnetic resonance imaging was normal. The patient was transferred to the acute rehabilitation unit for stroke rehabilitation 8 days after initial presentation. The physical examination was notable for slight dysarthria, nystagmus, diplopia, ptosis of the right eye, and ataxia. There was no motor weakness, and deep tendon reflexes were symmetric and normal. The patient progressed poorly. He had severe truncal ataxia. On the fourth day of admission, he fell from his wheelchair and sustained a head injury. He was transferred to the acute medical ward for further workup. Setting: Veterans Affairs inpatient rehabilitation center. Results: Three weeks later, the patient was readmitted to the acute rehabilitation unit. He had undergone a full neurologic workup and was now diagnosed with Miller Fisher variant of Guillain-Barré syndrome. Ganglioside GQ1b auto antibody test was positive, and cerebrospinal fluid showed high protein levels without white cells, features indicative of Guillain-Barré syndrome. A nerve conduction test was nondiagnostic, with mild abnormalities. Intravenous immunoglobulins were not administered. Discussion: Miller Fisher syndrome is a rare clinical variant of Guillain-Barré syndrome, an acute inflammatory polyneuropathy,
PRESENTATIONS
and a diagnosis of this variant may be difficult. It typically presents with ataxia, ophthalmoplegia, and areflexia, and there may be oropharyngeal weakness. Anti-GQ1b antiganglioside antibodies are present in 90% of cases. Conclusions: Patients usually show significant improvement in neurologic function within several weeks after diagnosis and full neurologic recovery in approximately 10 weeks. It is important to confirm the diagnosis because of the expected good recovery and because this gives therapists the opportunity to create a customized rehabilitation program to address the patient’s specific deficits.
Poster 186 Avulsion of the Adductor Muscle at the Symphysis Pubis Diagnosed With Ultrasound: A Case Report. David J. Chen, MD (University of Pennsylvania, Philadelphia, PA, United States); Franklin E. Caldera, DO, MBA, Woojin Kim, MD. Disclosures: D. J. Chen, none. Patients or Programs: A 58-year-old woman with obstructive sleep apnea and hyperlipidemia, presented to the clinic with left hip and left groin pain for 1 month, which began after taking a misstep. Program Description: We describe the use of ultrasound in diagnosing an avulsion tear at the insertion of the adductor muscles at the symphysis pubis, predominantly involving the adductor longus and brevis muscles. Setting: Tertiary care academic teaching hospital. Results: The patient ultimately was treated conservatively with nonsteroidal anti-inflammatory drugs for pain control, and physical therapy for muscle strengthening and balance improvement, and subsequently did well on follow-up. Discussion: The long adductor, short adductor, and gracilis muscles insert into the symphysis pubis and inferior pubic ramus. Avulsion injuries have previously been described at the symphysis pubis, with patients experiencing pain localizing to the groin. It is most common in adolescent athletes, and commonly mistaken for muscle or tendon injuries. The differential diagnosis of such chronic avulsion injury also includes infection or sarcomas. The standard treatment includes conservative measures, with rest and limited weight-bearing status for several weeks. The accepted method of diagnosis includes reviewing the history; physical examination; and radiologic imaging, such as the use of bone scans (which will demonstrate increased linear uptake) and the use of magnetic resonance (can have findings of bone marrow edema with enhancing periostitis). Conclusions: The use of ultrasound can be helpful in the diagnosis of avulsion tear at the insertion of the adductor muscles, as well as adductor insertion avulsion syndrome at the symphysis pubis. Sonography is becoming an increasingly used imaging modality in evaluating the musculoskeletal system because of its portability, absence of ionizing radiation, and relatively low cost compared with other cross-sectional imaging modalities.
Poster 187 Groin Pain Can Be Quite Painful With the Wrong Diagnosis: A Case Report. Sebastian Klisiewicz, DO (MCW, Wauwatosa, WI, United States); Thomas Kotsonis, MD. Disclosures: S. Klisiewicz, none.
PM&R
Patients or Programs: A 28-year-old man with groin and thigh pain. Program Description: This patient presented with a 4-year history of left groin and medial thigh pain that started insidiously without any trauma. The pain was worse with prolonged walking, stair climbing, and squatting. Initial AP/lat radiographs were normal. He was diagnosed with an inguinal hernia; however, during surgery, no hernia was found. He was evaluated for an upper lumbar radiculopathy by his PCP. He was treated for an adductor strain with injections and therapy that provided minimal relief. His pain persisted and he was referred to our clinic. Setting: Veterans Affairs outpatient clinic. Results: Positive hip impingement signs were noted on examination. Magnetic resonance arthrogram demonstrated femoral head asphericity, mildly increased ␣ angle, and a small tear within the superior labrum at the chondral-labral junction. His history, physical examination, and imaging findings were consistent with femoroacetabular impingement (FAI) with a resulting labral tear. Discussion: FAI has been reported in 10% of the general public, and it plays a role in development of early hip osteoarthritis. This diagnosis is often missed, and the average time from symptom onset to proper treatment is 30 months. Plain AP/lat radiographs are often normal. Hip internal rotation of 15° or 45° of flexion may help with the sensitivity of the radiographs but magnetic resonance arthrogram is quickly becoming the standard imaging. Asphericity of the femoral head, decreased head-neck offset, and a labral tear are often demonstrated. Nonoperative management often only provides temporary relief. Open or arthroscopic surgery often provides good pain relief with a quick return to activity. Conclusions: This case illustrates that standard imaging of the hip can be falsely negative in patients with FAI. This may lead to an incorrect diagnosis, unnecessary interventions, and unnecessarily high medical costs. Early recognition can prevent disability related to early onset of hip DJD and labral tears. In any young patients with a complaint of hip and/or groin pain, FAI should be high on the differential diagnosis.
Poster 188 Careful Consideration of Medial Patellar Retinaculum. A Rare Presentation of a Partial Sprain: A Case Report. Ryan Roza, MD (UPENN, Langhorne, PA, United States); Franklin E. Caldera, DO, MBA. Disclosures: R. Roza, none. Patients or Programs: A 45-year-old woman, with a medical history of allergic rhinitis, sickle-cell trait, gastroesophageal reflux disease, smoking, knee pain. Program Description: After a fall with immediate persistent pain over the medial aspect of right knee, described as 5/10 severity, sharp-dull; physical examination revealed tenderness to palpation over the medial joint line, swelling and/or effusions, no instability; a negative Lachman test; range of motion, 10°-50°; and no lymphadenopathy. Magnetic resonance imaging results revealed severe patellofemoral osteoarthritis; intermediate grade sprain of the proximal aspect of the right lateral collateral ligament; cystic changes of the right posterior cruciate ligament with laxity, in keeping with chronic sprain; small effusion within the right knee. The patient completed 6 weeks of physical therapy and occupational therapy. Setting: An office.
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Results: A subsequent examination revealed the following: continued pain, although of all joints, without crepitus, locking, effusions, warmth, or instability; 5/5 strength bilaterally; and no edema. An imaging study was revisited. The medial knee pain could be explained by a sprain of the medial retinaculum. Upon further magnetic resonance imaging review the diagnosis was a change to intermediate grade sprain of the femoral attachment of the right medial patellar retinaculum. Discussion: Historically, the anatomy of the medial patellar retinaculum has been an area that is somewhat controversial. Injury to the medial patellar retinaculum appears as a rare injury. In a study of knee dislocations that affect amateur athletes, fewer than half of the patients sustained retinacular injury. Although magnetic resonance imaging has been helpful to define patellar retinacular and associated osteochondral injuries, we must have high clinical suspicion for retinacular injury. Conclusions: Despite careful physical examination and magnetic resonance imaging, medial patellar retinaculum injury remains difficult to evaluate. Careful consideration needs to be taken with expanding our medical knowledge of the anatomical relevance and exchange of information in a systems-based practice. Future studies that focus on the potential use of diagnostic musculoskeletal ultrasound and its relevance to the evaluation of knee pain should be considered.
Poster 189 Biomechanical Assessment of Unloading Capacity in Ankle-Foot Orthoses. Eric M. Shoemaker, DO (University of Colorado, Denver, CO, United States); Cory Christiansen, PhD, Bradley Davidson, PhD, Deborah Saint-Phard, MD. Disclosures: E. M. Shoemaker, none. Objective: A pneumatic controlled ankle motion (CAM) walker brace is commonly used in the setting of tibial stress fractures; however, no comparative data exist to suggest whether the types of lower extremity braces available possess superior unloading capability. The purpose of this investigation is to compare the degree of unloading of the distal lower extremity provided by 3 different ankle-foot orthoses (pneumatic CAM walker brace, corset-style ankle-foot orthosis, and patella tendon-bearing orthosis). Design: Biomechanical comparison study in a controlled laboratory experiment. Setting: Medical center based interdisciplinary movement science laboratory. Participants: 15 participants are being recruited. The first 2 groups are from a sports medicine clinic and the third group is from the community: (1) 5 participants with a history of a lower extremity injury that has healed and who possess their custom corset-style ankle-foot orthosis (AFO), (2) 5 participants with a history of a lower extremity injury that has healed and who posses their custom patella-tendon– bearing (PTB) orthosis, and (3) 5 healthy volunteers (control group). Interventions: The subjects are evaluated during quiet stance and ambulation at a self-selected speed while wearing a pneumatic CAM walker and then again while wearing either a corset-style AFO (n⫽5) or a PTB orthosis (n⫽5). The control group (n⫽5) is evaluated only in the pneumatic CAM walker. Ground reaction forces are recorded by using a force platform. The force between the orthosis
strengthening and gait training. On postoperative day 3, she was admitted to acute inpatient rehabilitation. She demonstrated decreased balance with gait secondary to quadriceps weakness. After 10 days of therapy, she achieved modified independence with transfers and ambulation by using a rolling walker. Setting: A tertiary care hospital. Results: At 6 weeks after surgery, electromyography and nerve conduction studies revealed axonal injury to the femoral nerves bilaterally. At 12 weeks after surgery, the patient noted significant improvement in her lower extremity strength. Hip flexion was 4⫹/5 bilaterally, right knee extension was 4⫹/5, and left knee extension was 4/5. She progressed to ambulation by using a cane in the community. Discussion: Lithotomy positioning can lead to bilateral femoral neuropathy due to prolonged hip flexion, extreme hip abduction, and external rotation. This position may not only compress the femoral nerve but also stretch it beneath the inguinal ligament, which results in demyelinating or axonal nerve injuries. This complication may be prevented by modifying posture and decreasing operating time. Conclusions: Bilateral femoral neuropathy is a rare complication of prolonged surgery in the lithotomy position. Clinicians should timely recognize this condition and promptly initiate a comprehensive rehabilitation program to address the significant functional impairments and associated psychological stress.
Poster 185 Miller Fisher Variant of Guillain-Barré Syndrome With an Unusual Presentation: A Case Report. Lisa R. Kroopf, MD (Loma Linda University Medical Center, Loma Linda, CA, United States); Murray Brandstater, MD, Menandro Cunanan, MD. Disclosures: L. R. Kroopf, none. Patients or Programs: A 64-year-old man with hypertension and diabetes mellitus. Program Description: The patient presented with blurred vision, bilateral hand numbness, unsteady gait, dysarthria, and dysphagia for several days. He was unable to stand up unassisted. The initial diagnosis was a small brainstem stroke although brain magnetic resonance imaging was normal. The patient was transferred to the acute rehabilitation unit for stroke rehabilitation 8 days after initial presentation. The physical examination was notable for slight dysarthria, nystagmus, diplopia, ptosis of the right eye, and ataxia. There was no motor weakness, and deep tendon reflexes were symmetric and normal. The patient progressed poorly. He had severe truncal ataxia. On the fourth day of admission, he fell from his wheelchair and sustained a head injury. He was transferred to the acute medical ward for further workup. Setting: Veterans Affairs inpatient rehabilitation center. Results: Three weeks later, the patient was readmitted to the acute rehabilitation unit. He had undergone a full neurologic workup and was now diagnosed with Miller Fisher variant of Guillain-Barré syndrome. Ganglioside GQ1b auto antibody test was positive, and cerebrospinal fluid showed high protein levels without white cells, features indicative of Guillain-Barré syndrome. A nerve conduction test was nondiagnostic, with mild abnormalities. Intravenous immunoglobulins were not administered. Discussion: Miller Fisher syndrome is a rare clinical variant of Guillain-Barré syndrome, an acute inflammatory polyneuropathy,
PRESENTATIONS
and a diagnosis of this variant may be difficult. It typically presents with ataxia, ophthalmoplegia, and areflexia, and there may be oropharyngeal weakness. Anti-GQ1b antiganglioside antibodies are present in 90% of cases. Conclusions: Patients usually show significant improvement in neurologic function within several weeks after diagnosis and full neurologic recovery in approximately 10 weeks. It is important to confirm the diagnosis because of the expected good recovery and because this gives therapists the opportunity to create a customized rehabilitation program to address the patient’s specific deficits.
Poster 186 Avulsion of the Adductor Muscle at the Symphysis Pubis Diagnosed With Ultrasound: A Case Report. David J. Chen, MD (University of Pennsylvania, Philadelphia, PA, United States); Franklin E. Caldera, DO, MBA, Woojin Kim, MD. Disclosures: D. J. Chen, none. Patients or Programs: A 58-year-old woman with obstructive sleep apnea and hyperlipidemia, presented to the clinic with left hip and left groin pain for 1 month, which began after taking a misstep. Program Description: We describe the use of ultrasound in diagnosing an avulsion tear at the insertion of the adductor muscles at the symphysis pubis, predominantly involving the adductor longus and brevis muscles. Setting: Tertiary care academic teaching hospital. Results: The patient ultimately was treated conservatively with nonsteroidal anti-inflammatory drugs for pain control, and physical therapy for muscle strengthening and balance improvement, and subsequently did well on follow-up. Discussion: The long adductor, short adductor, and gracilis muscles insert into the symphysis pubis and inferior pubic ramus. Avulsion injuries have previously been described at the symphysis pubis, with patients experiencing pain localizing to the groin. It is most common in adolescent athletes, and commonly mistaken for muscle or tendon injuries. The differential diagnosis of such chronic avulsion injury also includes infection or sarcomas. The standard treatment includes conservative measures, with rest and limited weight-bearing status for several weeks. The accepted method of diagnosis includes reviewing the history; physical examination; and radiologic imaging, such as the use of bone scans (which will demonstrate increased linear uptake) and the use of magnetic resonance (can have findings of bone marrow edema with enhancing periostitis). Conclusions: The use of ultrasound can be helpful in the diagnosis of avulsion tear at the insertion of the adductor muscles, as well as adductor insertion avulsion syndrome at the symphysis pubis. Sonography is becoming an increasingly used imaging modality in evaluating the musculoskeletal system because of its portability, absence of ionizing radiation, and relatively low cost compared with other cross-sectional imaging modalities.
Poster 187 Groin Pain Can Be Quite Painful With the Wrong Diagnosis: A Case Report. Sebastian Klisiewicz, DO (MCW, Wauwatosa, WI, United States); Thomas Kotsonis, MD. Disclosures: S. Klisiewicz, none.
PM&R
Patients or Programs: A 28-year-old man with groin and thigh pain. Program Description: This patient presented with a 4-year history of left groin and medial thigh pain that started insidiously without any trauma. The pain was worse with prolonged walking, stair climbing, and squatting. Initial AP/lat radiographs were normal. He was diagnosed with an inguinal hernia; however, during surgery, no hernia was found. He was evaluated for an upper lumbar radiculopathy by his PCP. He was treated for an adductor strain with injections and therapy that provided minimal relief. His pain persisted and he was referred to our clinic. Setting: Veterans Affairs outpatient clinic. Results: Positive hip impingement signs were noted on examination. Magnetic resonance arthrogram demonstrated femoral head asphericity, mildly increased ␣ angle, and a small tear within the superior labrum at the chondral-labral junction. His history, physical examination, and imaging findings were consistent with femoroacetabular impingement (FAI) with a resulting labral tear. Discussion: FAI has been reported in 10% of the general public, and it plays a role in development of early hip osteoarthritis. This diagnosis is often missed, and the average time from symptom onset to proper treatment is 30 months. Plain AP/lat radiographs are often normal. Hip internal rotation of 15° or 45° of flexion may help with the sensitivity of the radiographs but magnetic resonance arthrogram is quickly becoming the standard imaging. Asphericity of the femoral head, decreased head-neck offset, and a labral tear are often demonstrated. Nonoperative management often only provides temporary relief. Open or arthroscopic surgery often provides good pain relief with a quick return to activity. Conclusions: This case illustrates that standard imaging of the hip can be falsely negative in patients with FAI. This may lead to an incorrect diagnosis, unnecessary interventions, and unnecessarily high medical costs. Early recognition can prevent disability related to early onset of hip DJD and labral tears. In any young patients with a complaint of hip and/or groin pain, FAI should be high on the differential diagnosis.
Poster 188 Careful Consideration of Medial Patellar Retinaculum. A Rare Presentation of a Partial Sprain: A Case Report. Ryan Roza, MD (UPENN, Langhorne, PA, United States); Franklin E. Caldera, DO, MBA. Disclosures: R. Roza, none. Patients or Programs: A 45-year-old woman, with a medical history of allergic rhinitis, sickle-cell trait, gastroesophageal reflux disease, smoking, knee pain. Program Description: After a fall with immediate persistent pain over the medial aspect of right knee, described as 5/10 severity, sharp-dull; physical examination revealed tenderness to palpation over the medial joint line, swelling and/or effusions, no instability; a negative Lachman test; range of motion, 10°-50°; and no lymphadenopathy. Magnetic resonance imaging results revealed severe patellofemoral osteoarthritis; intermediate grade sprain of the proximal aspect of the right lateral collateral ligament; cystic changes of the right posterior cruciate ligament with laxity, in keeping with chronic sprain; small effusion within the right knee. The patient completed 6 weeks of physical therapy and occupational therapy. Setting: An office.
Vol. 3, Iss. 10S1, 2011
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Results: A subsequent examination revealed the following: continued pain, although of all joints, without crepitus, locking, effusions, warmth, or instability; 5/5 strength bilaterally; and no edema. An imaging study was revisited. The medial knee pain could be explained by a sprain of the medial retinaculum. Upon further magnetic resonance imaging review the diagnosis was a change to intermediate grade sprain of the femoral attachment of the right medial patellar retinaculum. Discussion: Historically, the anatomy of the medial patellar retinaculum has been an area that is somewhat controversial. Injury to the medial patellar retinaculum appears as a rare injury. In a study of knee dislocations that affect amateur athletes, fewer than half of the patients sustained retinacular injury. Although magnetic resonance imaging has been helpful to define patellar retinacular and associated osteochondral injuries, we must have high clinical suspicion for retinacular injury. Conclusions: Despite careful physical examination and magnetic resonance imaging, medial patellar retinaculum injury remains difficult to evaluate. Careful consideration needs to be taken with expanding our medical knowledge of the anatomical relevance and exchange of information in a systems-based practice. Future studies that focus on the potential use of diagnostic musculoskeletal ultrasound and its relevance to the evaluation of knee pain should be considered.
Poster 189 Biomechanical Assessment of Unloading Capacity in Ankle-Foot Orthoses. Eric M. Shoemaker, DO (University of Colorado, Denver, CO, United States); Cory Christiansen, PhD, Bradley Davidson, PhD, Deborah Saint-Phard, MD. Disclosures: E. M. Shoemaker, none. Objective: A pneumatic controlled ankle motion (CAM) walker brace is commonly used in the setting of tibial stress fractures; however, no comparative data exist to suggest whether the types of lower extremity braces available possess superior unloading capability. The purpose of this investigation is to compare the degree of unloading of the distal lower extremity provided by 3 different ankle-foot orthoses (pneumatic CAM walker brace, corset-style ankle-foot orthosis, and patella tendon-bearing orthosis). Design: Biomechanical comparison study in a controlled laboratory experiment. Setting: Medical center based interdisciplinary movement science laboratory. Participants: 15 participants are being recruited. The first 2 groups are from a sports medicine clinic and the third group is from the community: (1) 5 participants with a history of a lower extremity injury that has healed and who possess their custom corset-style ankle-foot orthosis (AFO), (2) 5 participants with a history of a lower extremity injury that has healed and who posses their custom patella-tendon– bearing (PTB) orthosis, and (3) 5 healthy volunteers (control group). Interventions: The subjects are evaluated during quiet stance and ambulation at a self-selected speed while wearing a pneumatic CAM walker and then again while wearing either a corset-style AFO (n⫽5) or a PTB orthosis (n⫽5). The control group (n⫽5) is evaluated only in the pneumatic CAM walker. Ground reaction forces are recorded by using a force platform. The force between the orthosis