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Poster 190: Perplexing Leg Pain and the Value of Musculoskeletal Ultrasound: A Case Report
PM&R
vascular surgery who used pulse volume recording (PVR) of the artery to confirm the diagnosis of PVD. Setting: Tertiary care teaching hospital. Results: 18 months after the onset of the forefoot pain, the etiology was finally attributed to PVD, likely secondary to atherosclerosis. Discussion: The pain associated with early onset PVD can present similar to pain attributed to metatarsalgia. It is estimated that almost 1 in 5 patients between the ages of 55 and 74 are identified as having asymptomatic PVD. Conclusions: Failure to recognize severe arterial insufficiency can lead to serious local ischemic complications. PVD should be considered as a cause of foot pain in older individuals who are resistant to treatment.
Poster 190 Perplexing Leg Pain and the Value of Musculoskeletal Ultrasound: A Case Report. John M. Vasudevan, MD (Thomas Jefferson University Hospital, Philadelphia, PA); Sherin K. Fetouh, MD; Mitchell Freedman, DO. Disclosures: J. M. Vasudevan, None. Patients or Programs: A 42-year-old woman with progressive pain, paresthesias, and mild weakness in her left leg. Program Description: Patient presented with a 1 year history of posterolateral knee pain. There was no redness, warmth, or swelling of the knee at the time of injury (playing soccer). Symptoms progressed with pain and paresthesias radiating to the lateral leg and foot. Pain worsened with activity and knee extension and improved with rest. On physical examination, there was tenderness over the fibular head, and normal strength except mild weakness of her left tibialis anterior (4/5) and extensor hallucis longus (4/5). Sensation and reflexes were normal. MRI of the lumbar spine revealed disk desiccation at L4-5 and L5-S1. MR arthrogram of the left knee revealed patellofemoral osteoarthritis and a small stable partially ruptured popliteal cyst. Electrodiagnostic studies (EMG/NCS) of the lower limbs were normal. Ultrasonography of the knee revealed a mobile popliteal mass compressing the common peroneal nerve with knee extension. Setting: Outpatient physiatric practice. Results: Surgical exploration revealed a lipoma compressing the common peroneal nerve at its bifurcation into its deep and superficial branches. Nerve compression increased with leg extension. After excision of the lipoma, symptoms resolved and follow-up examination improved. Discussion: Peroneal entrapment neuropathy is a common cause of sensory and motor dysfunction in the leg, resulting in decreased sensation in the dorsolateral leg and foot and weakness in the dorsiflexors and everters of the foot and ankle. Typically, neuropathy can be identified with physical examination and EMG/NCS. A source of compression may be
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identified with MRI or musculoskeletal ultrasound. In this case, only musculoskeletal ultrasound was able to identify the etiology of this patient’s symptoms, allowing for appropriate treatment and subsequent clinical improvement. Conclusions: Musculoskeletal ultrasound is a useful diagnostic tool in the evaluation of peroneal entrapment neuropathy.
Poster 191 Persistent Thoracic Back Pain in a Young Athlete: A Case Report. Gregory Gazzillo, MD (Mayo Clinic, Rochester, MN). Disclosures: G. Gazzillo, None. Patients or Programs: An 18-year-old woman with a 6-month history of thoracic back pain. Program Description: The patient is an 18-year-old female basketball player who fell during practice. She developed right mid-thoracic back pain and went a local physician. A lumbar radiograph showed minor narrowing of the L4-L5 interspace and a right scapula radiograph was normal. Physical therapy was prescribed, involving rotator cuff strengthening, scapular stabilization, and E-stim. She was compliant but 6 months later, her pain still persisted and was reevaluated in the sports medicine clinic. Setting: Outpatient tertiary care academic center. Results: Her pain was described as a dull ache over her right mid-thoracic back. It was exacerbated by trunk turning and relieved with rest, stretching, and ice. She denied radicular symptoms or weakness. On physical examination, she was tender to palpation over the right lower thoracic paraspinals, back rotation reproduced pain, and neurologic examination was normal. A T-spine MRI was obtained due to the persistence of her pain despite conservative management. It demonstrated a facet cyst on the right at T12-L1. Discussion: Facet cysts can be either synovial or ganglion types and caused by ligamentum flavum or facet joint degeneration, spinal instability, or increased joint motion. Proliferation or herniation of articular tissue through a joint capsule defect occurs and is filled with fibroblast secretions. There is also an 8.6% prevalence after decompressive surgery for lumbar stenosis. Most are found in the L-spine (88%-99%) and rarely found in cervical (1%-4%) or thoracic (2%-8%) regions. Anterior facet cysts can mimic radiculopathy, neurogenic claudication, or myelopathy and have been found in 2.3% of people with back pain or radicular symptoms. Treatment can be conservative, minimally invasive, or surgical. Minimally invasive includes steroid injection with either cyst aspiration or rupture. Relief of symptoms varies, cysts can recur, or may require subsequent surgery. Surgery includes microsurgery or decompressive laminectomy, but can cause spinal instability and require fusion. Conclusions: Thoracic facet cysts, although rare, should be considered in the differential for patients with persistent thoracic back pain, despite a trial of conservative management.
vascular surgery who used pulse volume recording (PVR) of the artery to confirm the diagnosis of PVD. Setting: Tertiary care teaching hospital. Results: 18 months after the onset of the forefoot pain, the etiology was finally attributed to PVD, likely secondary to atherosclerosis. Discussion: The pain associated with early onset PVD can present similar to pain attributed to metatarsalgia. It is estimated that almost 1 in 5 patients between the ages of 55 and 74 are identified as having asymptomatic PVD. Conclusions: Failure to recognize severe arterial insufficiency can lead to serious local ischemic complications. PVD should be considered as a cause of foot pain in older individuals who are resistant to treatment.
Poster 190 Perplexing Leg Pain and the Value of Musculoskeletal Ultrasound: A Case Report. John M. Vasudevan, MD (Thomas Jefferson University Hospital, Philadelphia, PA); Sherin K. Fetouh, MD; Mitchell Freedman, DO. Disclosures: J. M. Vasudevan, None. Patients or Programs: A 42-year-old woman with progressive pain, paresthesias, and mild weakness in her left leg. Program Description: Patient presented with a 1 year history of posterolateral knee pain. There was no redness, warmth, or swelling of the knee at the time of injury (playing soccer). Symptoms progressed with pain and paresthesias radiating to the lateral leg and foot. Pain worsened with activity and knee extension and improved with rest. On physical examination, there was tenderness over the fibular head, and normal strength except mild weakness of her left tibialis anterior (4/5) and extensor hallucis longus (4/5). Sensation and reflexes were normal. MRI of the lumbar spine revealed disk desiccation at L4-5 and L5-S1. MR arthrogram of the left knee revealed patellofemoral osteoarthritis and a small stable partially ruptured popliteal cyst. Electrodiagnostic studies (EMG/NCS) of the lower limbs were normal. Ultrasonography of the knee revealed a mobile popliteal mass compressing the common peroneal nerve with knee extension. Setting: Outpatient physiatric practice. Results: Surgical exploration revealed a lipoma compressing the common peroneal nerve at its bifurcation into its deep and superficial branches. Nerve compression increased with leg extension. After excision of the lipoma, symptoms resolved and follow-up examination improved. Discussion: Peroneal entrapment neuropathy is a common cause of sensory and motor dysfunction in the leg, resulting in decreased sensation in the dorsolateral leg and foot and weakness in the dorsiflexors and everters of the foot and ankle. Typically, neuropathy can be identified with physical examination and EMG/NCS. A source of compression may be
Vol. 2, Iss. 9S, 2010
S87
identified with MRI or musculoskeletal ultrasound. In this case, only musculoskeletal ultrasound was able to identify the etiology of this patient’s symptoms, allowing for appropriate treatment and subsequent clinical improvement. Conclusions: Musculoskeletal ultrasound is a useful diagnostic tool in the evaluation of peroneal entrapment neuropathy.
Poster 191 Persistent Thoracic Back Pain in a Young Athlete: A Case Report. Gregory Gazzillo, MD (Mayo Clinic, Rochester, MN). Disclosures: G. Gazzillo, None. Patients or Programs: An 18-year-old woman with a 6-month history of thoracic back pain. Program Description: The patient is an 18-year-old female basketball player who fell during practice. She developed right mid-thoracic back pain and went a local physician. A lumbar radiograph showed minor narrowing of the L4-L5 interspace and a right scapula radiograph was normal. Physical therapy was prescribed, involving rotator cuff strengthening, scapular stabilization, and E-stim. She was compliant but 6 months later, her pain still persisted and was reevaluated in the sports medicine clinic. Setting: Outpatient tertiary care academic center. Results: Her pain was described as a dull ache over her right mid-thoracic back. It was exacerbated by trunk turning and relieved with rest, stretching, and ice. She denied radicular symptoms or weakness. On physical examination, she was tender to palpation over the right lower thoracic paraspinals, back rotation reproduced pain, and neurologic examination was normal. A T-spine MRI was obtained due to the persistence of her pain despite conservative management. It demonstrated a facet cyst on the right at T12-L1. Discussion: Facet cysts can be either synovial or ganglion types and caused by ligamentum flavum or facet joint degeneration, spinal instability, or increased joint motion. Proliferation or herniation of articular tissue through a joint capsule defect occurs and is filled with fibroblast secretions. There is also an 8.6% prevalence after decompressive surgery for lumbar stenosis. Most are found in the L-spine (88%-99%) and rarely found in cervical (1%-4%) or thoracic (2%-8%) regions. Anterior facet cysts can mimic radiculopathy, neurogenic claudication, or myelopathy and have been found in 2.3% of people with back pain or radicular symptoms. Treatment can be conservative, minimally invasive, or surgical. Minimally invasive includes steroid injection with either cyst aspiration or rupture. Relief of symptoms varies, cysts can recur, or may require subsequent surgery. Surgery includes microsurgery or decompressive laminectomy, but can cause spinal instability and require fusion. Conclusions: Thoracic facet cysts, although rare, should be considered in the differential for patients with persistent thoracic back pain, despite a trial of conservative management.