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Poster 213 Idiopathic Charcot Arthropathy of the Foot: Not an Easy Diagnosis. A Case Report
S244
Setting: A state championship HBP tournament. Participants: Men and women (N⫽38; 25.5⫾5.4 years; 18% women) playing in the All Florida Tournament, December 2010. Average weekly play was 2.3⫾1.1 days. Interventions: A deidentified survey was provided to participants of the HBP tournament. Main Outcome Measures: Main outcomes of the survey included number of annual injuries, location, nature and type of injury, helmet use and medical attention sought and received. Results: 42.1% reported no annual injury. Those who reported, experienced 1 major injury; 55.3% of players reported new injuries; 2.6% reported old injuries. The most common injury sites were the lower extremity (48% of all injuries) and the upper extremity (38% of all injuries). Among lower extremity injuries, the most frequent sites were the calf and/or shin (3), the ankle (3), and the knee (2). Upper extremity injuries occurred in the hand (3) and wrist (2), with the remaining locations along the arm to the shoulder. Injury severity ranged from bone fractures (30%) and abrasions and/or cuts (22%); the remaining injuries were composed of muscle strains, hematomas, and various other soft-tissue injuries. Collisions with the ground, with other players, and with equipment were the 3 main causes. Helmet use was confirmed by 28.9% of players when the injury was sustained; 29% of players (6) sought medical attention, 3 cases of which were emergent. Conclusions: Main sites of injury were those in distal locations (calf, ankle, hand). Protective gear for the hand and lower leg may reduce injury rates specific to this sport. Medical providers should be prepared to assess and treat the variety of bone and soft-tissue injuries seen in these athletes.
Poster 212 Musculoskeletal Disorders of Upper Limbs Functional Compromise, Evaluator’s Perspective. Angela M. Suarez-Moya (Universidad Nacional de Colombia, Bogota, Colombia); Jorge Diaz-Ruiz, Professor, Fernando Ortiz-Corredor. Disclosures: A. M. Suarez-Moya, none. Objective: Identify the factors considered in determining earning capacity loss (ECL) secondary to work-related musculoskeletal disorders (MSD) of upper limb, in a Colombian Professional Risks Insurance Company. Design: A descriptive study. We reviewed the reports of the ECL score of 2008. We searched for common MSD diagnoses and established the relationship of each of them with the ECL. They were grouped as follows: (1) carpal tunnel syndrome (CTS), (2) shoulder (tendinitis), (3) elbow (epicondylitis), and (4) wrist tenosynovitis. Setting: Colombian Professional Risks Insurance Company. Participants: 814 cases with work-related musculoskeletal disorders of upper limb, submitted for determining ECL. Interventions: Not applicable. Main Outcome Measures: Not applicable. Results: There were 413 women (50.7%) and 401 men (49.3%) (average [SD] age, 45.6⫾8.54 years). %ECL was women, 16.46% and men, 15.51% (P⫽.014). MSD mainly affects people who are between 40 and 54 years old. The CTS was the most frequent diagnosis (46.1% [67.6% women]), followed by shoulder tendinitis (14.1% [80% men]), epicondylitis (10.1% [55% women]), and finally wrist tenosynovitis (1,7% [77.7% women]). The CTS had the
PRESENTATIONS
highest ECL 18.5%, followed by shoulder tendinitis, 15.3%; wrist tenosynovitis, 12.9%; and epicondylitis, 11.9%. There were associations between the different groups, especially between groups 1-2 and 1-3. Conclusions: In Colombia, the most common work-related musculoskeletal disorder of the upper limb is the CTS. This condition prevails in women as well as wrist tenosynovitis. Shoulder tendinitis is the second most common diagnosis, predominantly in men. According to the evaluator perspective, the higher ECL was found in CTS, which is attributed to the high quantification of this disease in the current manual of disability rating. This finding contrasts with previous studies that have assessed the patient’s perception with the DASH scale, in which it was found that epicondylitis is the MSD that generates greater functional impact.
Poster 213 Idiopathic Charcot Arthropathy of the Foot: Not an Easy Diagnosis. A Case Report. German Ojeda, MD (University of Miami, Miami, FL, United States); L. Adriana Arenas, MD. Disclosures: G. Ojeda, none. Patients or Programs: A 67-year-old man with a history of right foot swelling. Program Description: A 67-year-old man with a 1-month history of progressive right foot swelling, numbness, low-intensity pain, with no previous traumatic event or fever episodes; and a medical history of gout for which he was on medications on a regular basis and under control. The right foot was significantly swollen from the ankle down. There were no skin with color or temperature changes; pedal pulses were present, although distant. Decreased range of motion of the ankle and toes. Homan test was negative. The toes were numb. Setting: An outpatient clinic. Results: Doppler ultrasound was negative for deep venous thrombosis. Radiography and magnetic resonance imaging of the foot and ankle showed severe destructive changes in the mid foot joints, swelling, and joint effusion as well as degeneration of the plantar fascia and tendinosis of the Achilles and tibialis posterior tendons. Multiple blood tests were within normal values. A short leg cast was placed on with non-weight bearing as an initial approach. Nonsteroidal anti-inflammatory medication was prescribed. The patient was instructed to start a rehabilitation program for isometrics, gait training, and home exercise program. After 2 months with the cast the patient was feeling much better and the swelling had decreased about 50%. The patient continued with periodic follow-ups until the acute phase ceased. Discussion: This case represents a Charcot arthropathy, with a good response to treatment but unclear etiology, which made difficult an early diagnosis. The average in the delay for the diagnosis is approximately 29 weeks, creating continuous trauma over this period of time, and worsening of the pathology. A swollen foot as the main complaint in a patient should rise the suspicion of couple of differentials such as Charcot arthropathy, especially in the absence of an infectious process. Sometimes like in our case it could be idiopathic, but, most of the time, it is related to diabetes. Conclusions: Charcot arthropathy has significant detrimental effects in the quality of life of the patient to minimize these effects
PM&R
and to improve the functional status a prompt diagnosis and a multidisciplinary treatment is required.
Poster 214 Rupture of Bilateral Quadriceps Tendon and Left Rotator Cuff in a 59-Year-Old Man: A Case Report. Hamilton Chen, MD (UCI Medical Center, Orange, CA, United States). Disclosures: H. Chen, none. Patients or Programs: We present a case in which a patient sustained both a bilateral quadriceps tendon rupture and a complete rotator cuff tear. Program Description: A 59-year-old man presented with bilateral knee and left shoulder pain and/or weakness. For the 3 months before injury, he had exercised for 3 hours per day on an elliptical trainer. A few days before evaluation, the patient had a misstep while walking downstairs and felt his right knee pop, which resulted in a fall. When attempting to ambulate with his right knee, he heard his left knee pop and fell on his left arm. Evaluation at an outside hospital determined no fractures on radiographs, and he was discharged home. Unable to ambulate, he brought himself to our facility. On magnetic resonance imaging, he was found to have bilateral quadriceps tendon rupture and a complete left rotator cuff tear. Setting: Tertiary care center. Results: The patient underwent surgical repair. Weight bearing was restricted in the lower extremities. He was transferred to the subacute rehabilitation unit to facilitate healing and undergo physiotherapy. With disuse of 3 limbs, he was granted an electric wheelchair. Discussion: Quadriceps tendon rupture is an uncommon injury that has been well documented in the literature. Bilateral rupture combined with a rotator cuff tear is an extremely rare presentation. Known risk factors for bilateral quadriceps tendon rupture include the following: renal failure, chronic steroid and/or quinolone use, metabolic diseases, rheumatic diseases, infection, history of rupture, and advanced age. Even though our patient was at risk for his injuries because of his age, he had no other risk factors. The only other anomaly in his presentation was a strenuous exercise program by using an elliptical trainer, which suggests that overuse can be a potential risk for quadriceps tendon rupture and rotator cuff tear. Conclusions: Overuse is a known risk factor for rotator cuff tears, but this case suggests that it also can be a risk factor for quadriceps tendon rupture. This case also stresses the importance of consideration of tendon injury as a differential, especially when x-ray imaging is negative, and there is a subjective history of a traumatic incident. Reliance on physical examination of the knee may be difficult due to pain and swelling from injury.
Poster 215 Myositis Ossificans Traumatica of the Upper Arm in a High School Football Player: A Case Report. Antwon L. Morton, DO (Eastern Virginia Medical School, Norfolk, VA, United States); Peter Gonzalez, MD, Brian Waters, ATC. Disclosures: A. L. Morton, none. Patients or Programs: A 17-year-old male athlete presenting with a hard mass in right lateral arm.
Vol. 3, Iss. 10S1, 2011
S245
Program Description: The patient was a high school football player who presented with right lateral arm pain of 1-year duration. Patient initially reported pain after taking a helmet hit to his right arm during a football game. He was evaluated and treated for a contusion. Over time, his symptoms of pain decreased, but the mass did not. One year later, he was hit again over this region and had increasing pain. Setting: An academic sports medicine clinic. Results: He underwent a limited musculoskeletal ultrasound examination of the right upper extremity, which demonstrated a hyperechoic focus consistent with calcification in the lateral head of the triceps muscle. An adjacent hematoma superficial to the mass was noted. Plain radiograph of the humerus revealed an ovoid area of calcification without evidence of periosteal reaction or a fracture. No bone destruction or other osseous lesions were seen. Discussion: Myositis ossificans traumatica is defined as a localized formation of heterotopic, non-neoplastic bone caused by physical trauma, usually occurring near bone and in muscle. In this case, the athlete had minimal range of motion deficits and resolving pain. He returned to play with padding to protect the lateral arm from further injury and with recommendations to follow up after the season. Conclusions: Myositis ossificans traumatica is frequently encountered in adolescent and young adult men as a consequence of a sports-related injury. A comprehensive understanding of the etiology and clinical presentation will often lead to the diagnosis of this benign extraskeletal formation of bone. Musculoskeletal ultrasound examination is an excellent and cost-effective method to assist in the diagnosis of Myositis ossificans traumatica and monitor the progression over time.
Poster 216 Ankle Inversion Injury With a Tibial Plafond Fracture in a Collegiate Runner: A Case Report. Joshua R. Johnson, MD (University of Louisville, Louisville, KY, United States); Jonathan Becker, MD. Disclosures: J. R. Johnson, none. Patients or Programs: A healthy 21-year-old white male collegiate track and field athlete. Program Description: The patient presented to the athletic training room with a history of right lateral ankle pain. He indicated an initial ankle inversion injury that occurred in the weight room 4 weeks earlier. The patient experienced a second acute inversion event during a race approximately 2 weeks before physician evaluation. Plain films were negative for a fracture or dislocation, and he had since been managed conservatively for a lateral ankle sprain. He was participating in modified running activities but indicated persistent discomfort. The patient had no obvious bruising or swelling but had pain on palpation of the lateral malleolus and near the anterior talofibular ligament. He had positive anterior drawer and talar tilt tests but negative squeeze test. Magnetic resonance imaging of the right ankle indicated complete tear of the anterior talofibular ligament, high-grade calcaneal fibular ligament injury, and a nondisplaced anterolateral tibial plafond fracture. The patient was placed in a fracture boot and was withheld from competitive activities. Setting: Collegiate training room. Results: He remained in a fracture boot for 4 weeks until free of discomfort and was gradually returned to weight-bearing activities.
Setting: A state championship HBP tournament. Participants: Men and women (N⫽38; 25.5⫾5.4 years; 18% women) playing in the All Florida Tournament, December 2010. Average weekly play was 2.3⫾1.1 days. Interventions: A deidentified survey was provided to participants of the HBP tournament. Main Outcome Measures: Main outcomes of the survey included number of annual injuries, location, nature and type of injury, helmet use and medical attention sought and received. Results: 42.1% reported no annual injury. Those who reported, experienced 1 major injury; 55.3% of players reported new injuries; 2.6% reported old injuries. The most common injury sites were the lower extremity (48% of all injuries) and the upper extremity (38% of all injuries). Among lower extremity injuries, the most frequent sites were the calf and/or shin (3), the ankle (3), and the knee (2). Upper extremity injuries occurred in the hand (3) and wrist (2), with the remaining locations along the arm to the shoulder. Injury severity ranged from bone fractures (30%) and abrasions and/or cuts (22%); the remaining injuries were composed of muscle strains, hematomas, and various other soft-tissue injuries. Collisions with the ground, with other players, and with equipment were the 3 main causes. Helmet use was confirmed by 28.9% of players when the injury was sustained; 29% of players (6) sought medical attention, 3 cases of which were emergent. Conclusions: Main sites of injury were those in distal locations (calf, ankle, hand). Protective gear for the hand and lower leg may reduce injury rates specific to this sport. Medical providers should be prepared to assess and treat the variety of bone and soft-tissue injuries seen in these athletes.
Poster 212 Musculoskeletal Disorders of Upper Limbs Functional Compromise, Evaluator’s Perspective. Angela M. Suarez-Moya (Universidad Nacional de Colombia, Bogota, Colombia); Jorge Diaz-Ruiz, Professor, Fernando Ortiz-Corredor. Disclosures: A. M. Suarez-Moya, none. Objective: Identify the factors considered in determining earning capacity loss (ECL) secondary to work-related musculoskeletal disorders (MSD) of upper limb, in a Colombian Professional Risks Insurance Company. Design: A descriptive study. We reviewed the reports of the ECL score of 2008. We searched for common MSD diagnoses and established the relationship of each of them with the ECL. They were grouped as follows: (1) carpal tunnel syndrome (CTS), (2) shoulder (tendinitis), (3) elbow (epicondylitis), and (4) wrist tenosynovitis. Setting: Colombian Professional Risks Insurance Company. Participants: 814 cases with work-related musculoskeletal disorders of upper limb, submitted for determining ECL. Interventions: Not applicable. Main Outcome Measures: Not applicable. Results: There were 413 women (50.7%) and 401 men (49.3%) (average [SD] age, 45.6⫾8.54 years). %ECL was women, 16.46% and men, 15.51% (P⫽.014). MSD mainly affects people who are between 40 and 54 years old. The CTS was the most frequent diagnosis (46.1% [67.6% women]), followed by shoulder tendinitis (14.1% [80% men]), epicondylitis (10.1% [55% women]), and finally wrist tenosynovitis (1,7% [77.7% women]). The CTS had the
PRESENTATIONS
highest ECL 18.5%, followed by shoulder tendinitis, 15.3%; wrist tenosynovitis, 12.9%; and epicondylitis, 11.9%. There were associations between the different groups, especially between groups 1-2 and 1-3. Conclusions: In Colombia, the most common work-related musculoskeletal disorder of the upper limb is the CTS. This condition prevails in women as well as wrist tenosynovitis. Shoulder tendinitis is the second most common diagnosis, predominantly in men. According to the evaluator perspective, the higher ECL was found in CTS, which is attributed to the high quantification of this disease in the current manual of disability rating. This finding contrasts with previous studies that have assessed the patient’s perception with the DASH scale, in which it was found that epicondylitis is the MSD that generates greater functional impact.
Poster 213 Idiopathic Charcot Arthropathy of the Foot: Not an Easy Diagnosis. A Case Report. German Ojeda, MD (University of Miami, Miami, FL, United States); L. Adriana Arenas, MD. Disclosures: G. Ojeda, none. Patients or Programs: A 67-year-old man with a history of right foot swelling. Program Description: A 67-year-old man with a 1-month history of progressive right foot swelling, numbness, low-intensity pain, with no previous traumatic event or fever episodes; and a medical history of gout for which he was on medications on a regular basis and under control. The right foot was significantly swollen from the ankle down. There were no skin with color or temperature changes; pedal pulses were present, although distant. Decreased range of motion of the ankle and toes. Homan test was negative. The toes were numb. Setting: An outpatient clinic. Results: Doppler ultrasound was negative for deep venous thrombosis. Radiography and magnetic resonance imaging of the foot and ankle showed severe destructive changes in the mid foot joints, swelling, and joint effusion as well as degeneration of the plantar fascia and tendinosis of the Achilles and tibialis posterior tendons. Multiple blood tests were within normal values. A short leg cast was placed on with non-weight bearing as an initial approach. Nonsteroidal anti-inflammatory medication was prescribed. The patient was instructed to start a rehabilitation program for isometrics, gait training, and home exercise program. After 2 months with the cast the patient was feeling much better and the swelling had decreased about 50%. The patient continued with periodic follow-ups until the acute phase ceased. Discussion: This case represents a Charcot arthropathy, with a good response to treatment but unclear etiology, which made difficult an early diagnosis. The average in the delay for the diagnosis is approximately 29 weeks, creating continuous trauma over this period of time, and worsening of the pathology. A swollen foot as the main complaint in a patient should rise the suspicion of couple of differentials such as Charcot arthropathy, especially in the absence of an infectious process. Sometimes like in our case it could be idiopathic, but, most of the time, it is related to diabetes. Conclusions: Charcot arthropathy has significant detrimental effects in the quality of life of the patient to minimize these effects
PM&R
and to improve the functional status a prompt diagnosis and a multidisciplinary treatment is required.
Poster 214 Rupture of Bilateral Quadriceps Tendon and Left Rotator Cuff in a 59-Year-Old Man: A Case Report. Hamilton Chen, MD (UCI Medical Center, Orange, CA, United States). Disclosures: H. Chen, none. Patients or Programs: We present a case in which a patient sustained both a bilateral quadriceps tendon rupture and a complete rotator cuff tear. Program Description: A 59-year-old man presented with bilateral knee and left shoulder pain and/or weakness. For the 3 months before injury, he had exercised for 3 hours per day on an elliptical trainer. A few days before evaluation, the patient had a misstep while walking downstairs and felt his right knee pop, which resulted in a fall. When attempting to ambulate with his right knee, he heard his left knee pop and fell on his left arm. Evaluation at an outside hospital determined no fractures on radiographs, and he was discharged home. Unable to ambulate, he brought himself to our facility. On magnetic resonance imaging, he was found to have bilateral quadriceps tendon rupture and a complete left rotator cuff tear. Setting: Tertiary care center. Results: The patient underwent surgical repair. Weight bearing was restricted in the lower extremities. He was transferred to the subacute rehabilitation unit to facilitate healing and undergo physiotherapy. With disuse of 3 limbs, he was granted an electric wheelchair. Discussion: Quadriceps tendon rupture is an uncommon injury that has been well documented in the literature. Bilateral rupture combined with a rotator cuff tear is an extremely rare presentation. Known risk factors for bilateral quadriceps tendon rupture include the following: renal failure, chronic steroid and/or quinolone use, metabolic diseases, rheumatic diseases, infection, history of rupture, and advanced age. Even though our patient was at risk for his injuries because of his age, he had no other risk factors. The only other anomaly in his presentation was a strenuous exercise program by using an elliptical trainer, which suggests that overuse can be a potential risk for quadriceps tendon rupture and rotator cuff tear. Conclusions: Overuse is a known risk factor for rotator cuff tears, but this case suggests that it also can be a risk factor for quadriceps tendon rupture. This case also stresses the importance of consideration of tendon injury as a differential, especially when x-ray imaging is negative, and there is a subjective history of a traumatic incident. Reliance on physical examination of the knee may be difficult due to pain and swelling from injury.
Poster 215 Myositis Ossificans Traumatica of the Upper Arm in a High School Football Player: A Case Report. Antwon L. Morton, DO (Eastern Virginia Medical School, Norfolk, VA, United States); Peter Gonzalez, MD, Brian Waters, ATC. Disclosures: A. L. Morton, none. Patients or Programs: A 17-year-old male athlete presenting with a hard mass in right lateral arm.
Vol. 3, Iss. 10S1, 2011
S245
Program Description: The patient was a high school football player who presented with right lateral arm pain of 1-year duration. Patient initially reported pain after taking a helmet hit to his right arm during a football game. He was evaluated and treated for a contusion. Over time, his symptoms of pain decreased, but the mass did not. One year later, he was hit again over this region and had increasing pain. Setting: An academic sports medicine clinic. Results: He underwent a limited musculoskeletal ultrasound examination of the right upper extremity, which demonstrated a hyperechoic focus consistent with calcification in the lateral head of the triceps muscle. An adjacent hematoma superficial to the mass was noted. Plain radiograph of the humerus revealed an ovoid area of calcification without evidence of periosteal reaction or a fracture. No bone destruction or other osseous lesions were seen. Discussion: Myositis ossificans traumatica is defined as a localized formation of heterotopic, non-neoplastic bone caused by physical trauma, usually occurring near bone and in muscle. In this case, the athlete had minimal range of motion deficits and resolving pain. He returned to play with padding to protect the lateral arm from further injury and with recommendations to follow up after the season. Conclusions: Myositis ossificans traumatica is frequently encountered in adolescent and young adult men as a consequence of a sports-related injury. A comprehensive understanding of the etiology and clinical presentation will often lead to the diagnosis of this benign extraskeletal formation of bone. Musculoskeletal ultrasound examination is an excellent and cost-effective method to assist in the diagnosis of Myositis ossificans traumatica and monitor the progression over time.
Poster 216 Ankle Inversion Injury With a Tibial Plafond Fracture in a Collegiate Runner: A Case Report. Joshua R. Johnson, MD (University of Louisville, Louisville, KY, United States); Jonathan Becker, MD. Disclosures: J. R. Johnson, none. Patients or Programs: A healthy 21-year-old white male collegiate track and field athlete. Program Description: The patient presented to the athletic training room with a history of right lateral ankle pain. He indicated an initial ankle inversion injury that occurred in the weight room 4 weeks earlier. The patient experienced a second acute inversion event during a race approximately 2 weeks before physician evaluation. Plain films were negative for a fracture or dislocation, and he had since been managed conservatively for a lateral ankle sprain. He was participating in modified running activities but indicated persistent discomfort. The patient had no obvious bruising or swelling but had pain on palpation of the lateral malleolus and near the anterior talofibular ligament. He had positive anterior drawer and talar tilt tests but negative squeeze test. Magnetic resonance imaging of the right ankle indicated complete tear of the anterior talofibular ligament, high-grade calcaneal fibular ligament injury, and a nondisplaced anterolateral tibial plafond fracture. The patient was placed in a fracture boot and was withheld from competitive activities. Setting: Collegiate training room. Results: He remained in a fracture boot for 4 weeks until free of discomfort and was gradually returned to weight-bearing activities.