Poster 238: Eyrthromelalgia Case Series - Diagnostic and Treatment Challenges

Abstracts / PM R 9 (2017) S131-S290 Poster 235: Refractory Right Triceps Calcific Tendinopathy Treated with Ultrasound Guided Needle Barbotage and Lavage: A Case Report and Review of the Literature Philip Chang (New York, NY, USA), Richard G. Chang, MD, MPH, Jeffrey Okada, MD (The orthopedic c. association, DO) Disclosures: Philip Chang: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 35-year-old right-handed male bus driver presented with a 6-month history of persistent posterior right elbow pain refractory to Tylenol, NSAIDs, and physical therapy. His injury started when performing a triceps curl. He developed immediate pain and heard a popping sound but had no swelling or ecchymosis. X-rays revealed calcific tendinitis of the right triceps insertion. Ultrasound confirmed calcification of the distal triceps and tendinopathy with changes secondary to a chronic distal insertion tear. His symptoms prevented him from upper extremity weight lifting and driving without discomfort. The procedure was performed with a 19 gauge 1.5 inch needle and 1% lidocaine. Small calcific fragments were noted upon aspiration. The patient refrained from weight bearing activities and performed ROM exercises for 1 week. Thereafter, he started physical therapy, focusing on eccentric strengthening and cryotherapy. After 2 weeks he reported 20% relief. Four weeks later, the patient underwent the same procedure, with the goal of providing further improved pain relief and function. The procedure was repeated, but instead an 18 gauge 1.5-inch needle was used. The region was lavaged with 1% lidocaine and aspiration yielded a sizable calcified fragment compared to the last visit. Setting: Sports and Musculoskeletal Medicine Clinic. Results: At 1 week and 1 month follow-up the patient reported 85% improvement in pain. He could engage in weight lifting activities, drive, and place his elbow on hard surfaces without pain. Discussion: To our knowledge, there is only one other reported case of triceps calcific tendinopathy successfully treated with ultrasound guided needle barbotage and lavage. Conclusions: Similar to results found in calcific rotator cuff and lateral/medial extensor tendinosis, US guided needle barbotage, lavage, and aspiration may potentially provide positive outcomes for chronic, calcific tendinopathy affecting the triceps tendon, unresponsive to nonsurgical treatment. Level of Evidence: Level V Poster 236: Sensorimotor Polyneuropathy in a Patient with Copper Deficiency: A Case Report Ajaya T. Moturu, MD (Vidant Rehab Ctr/East Carolina Univ/Brod) Disclosures: Ajaya Moturu: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 66-year-old woman initially presented with recurrent falls and right upper and lower extremity weakness and inability to walk for 24 hours. On exam patient was found to have 2/5 strength in the proximal right lower extremity, 2/5 strength throughout the right upper extremity and also found to have a right wrist drop. Patient was admitted with concern for stroke however work up including magnetic resonance imaging was negative for any acute abnormality. Electromyography of the upper extremity showed findings consistent with sensorimotor polyneuropathy. Patient had a history of gastric bypass 8 years prior and has been compliant with vitamin therapy since her surgery. Extensive vitamin workup was done and patient was found to have severe copper deficiency with a level of 42. The patient was started on intravenous copper replacement. At time of discharge patient was able to regain right upper and lower extremity movement. Setting: General Inpatient Rehabilitation Center.

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Results: Patient received 5 days of intravenous copper replacement and was then continued on long term oral copper replacement. With intensive rehabilitation patient regained complete movement in the right lower extremity and had significant improvement in the right upper extremity with some residual right wrist drop. Discussion: There have been other case reports showing evidence of copper deficiency presenting similar to B12 deficiency. The exact mechanism for this is not well understood; it is thought that copper deficiency leads to neuropathy due to its critical involvement in several enzymes that are critical for nervous system functioning. Enzymes include peptidylglycine alpha-amidating monooxygenase for neuropeptide hormone processing and ceruloplasmin for brain iron homeostasis. Conclusions: Vitamin deficiencies are commonly seen in patients shortly after gastric bypass and continue to be possible even in compliant patients post-operatively and can lead to significant neurological dysfunction which can show improvement with vitamin repletion. Level of Evidence: Level V Poster 237: Superficial Thrombophlebitis of the Wrist Presenting as a Ganglion Cyst: A Case Report Michael Schaefer, MD (Cleveland Clinic Foundation), Ana M. Garcia, MD, Jose A. Rosa Padilla, MD Disclosures: Michael Schaefer, MD: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 46-year-old woman with history of DM type 2, HTN and bilateral carpal tunnel syndrome (CTS) presented with a 3month history of a painful, progressively growing mass over the volar aspect of her dominant right wrist. She denied any inciting event such as trauma associated. On examination a tender and mobile superficial nodule was palpated on the volar aspect of the right wrist. There was moderate limitation in the range of motion of the wrist with pain at the end range of wrist flexion. Neurovascular exam was intact. A ganglion cyst was suspected and she was referred to our clinic for ultrasound-guided cyst aspiration. Ultrasound evaluation was performed prior to the procedure showing a very small, less than 0.5cm in diameter, hyperechoic and non-compressible area within a fusiform dilation of a superficial vein. The lesion was located in the subcutaneous layer and superficial to the radial artery and correlated with the patient’s area of tenderness. Findings were consistent with a superficial vein thrombosis. No ganglion cyst was detected. Setting: Outpatient Rehabilitation Clinic. Results: The lesion persisted despite conservative management. Discussion: Ganglion cysts are the most frequent benign tumors in wrist and hand. The clinical presentation of a ganglion cyst can be similar to other etiologies such as superficial thrombophlebitis. Other lesions such as malignancies, abscesses, tendon lacerations, and foreign body reactions should be considered. Ultrasonography is an inexpensive and non-invasive method of assessing the soft tissue and can help differentiate these conditions. Conclusions: Performing an ultrasonographic assessment of the wrist is helpful to assist in the evaluation of soft tissue lesions, especially before interventional procedures. The information obtained can significantly influence the appropriate management and treatment. Superficial vein thrombosis should be considered in the differential diagnosis for soft tissue masses. Level of Evidence: Level V Poster 238: Eyrthromelalgia Case Series - Diagnostic and Treatment Challenges Neel Chandel, MD (Montefiore Medical Center, Bronx, New York, United States), Mark A. Thomas, MD Disclosures: Neel Chandel, MD: I Have No Relevant Financial Relationships To Disclose

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Abstracts / PM R 9 (2017) S131-S290

Case/Program Description: Case 1: A 53-year-old woman with previous left calf DVT 12 years ago presented with disabling burning pain with paresthesias and allodynia in left medial calf region for 2 years, initially diagnosed as chronic regional pain syndrome (RSD). The pain was associated with petechial rash in that area. Her symptoms exacerbate with physical exertion and cold weather. Exam is notable for a petechial rash from mid-calf to foot, erythema, extreme sensitivity to palpation and bilateral ankle pitting edema fluctuating between 1+ and 3+. Skin biopsy showed severe stasis dermatitis. She had minimal pain relief with pharmacological treatment with the best response resulting from a combination of minacipram and pregabalin. Case 2: A 49-year-old woman with a prior history of bariatric surgery 10 years ago, cervical radiculopathy, and depression presented with chronic severe pain in both hands that began 4 years ago without any initiating event. The pain is constant and aggravated by physical contact, activity and cold weather. She is dependent on others for ADL. The initial diagnosis was chronic RSD with associated Raynaud’s phenomenon. She failed multiple treatments including physical and occupational therapy, cognitive-behavioral therapy, dedicated desensitization training, sympathetic blocks, spinal cord stimulation. Pharmacological treatment had failed including a recent trial of pregabalin. She has been referred to interventional pain team for consideration of a pulsed RFA Stellate ganglion block. Setting: Outpatient Rehabilitation Clinic. Results: The diagnosis of erythromelalgia was made in both cases on the basis of clinical findings and inconsistent work up relating to RSD. Discussion: Erythromelalgia is a rare clinic disease and its clinical presentation is similar to RSD. Conclusions: Physiatrists who encounter chronic pain might consider this diagnosis in a patient where symptoms, findings and treatment response related to a diagnosis of RSD are atypical. Level of Evidence: Level V Poster 239: Atypical Presentation of Dystonia of Right Upper Extremity Treated with Botulinum Toxin: A Case Report Kathelynn Aviles (San Juan, San Juan, Puerto Rico), Jose R. Cumba, MD, Keryl Motta-Valencia, MD Disclosures: Kathelynn Aviles: I Have No Relevant Financial Relationships To Disclose Case/Program Description: This is a 27-year-old patient with history of right upper extremity trauma with suprascapular and brachial plexus injury who presented (3 yrs after trauma) with right hand swelling, discoloration, paresthesia, and flexed 4th and 5th digits. The patient was initially diagnosed with ulnar nerve pathology and was scheduled for an ulnar nerve decompression. However, upon evaluation by our service there were no objective findings on EDX, MRI or US to support an ulnar injury. In addition, the presence of active autonomic symptoms including bluish discoloration, swelling, and changes in temperature led to explore other etiologies. Bone scan and upper extremity Doppler ultrasound were done and reported with normal findings. Final diagnostic impression by exclusion of other diagnosis was suggestive of right hand dystonia. He was scheduled for a trial of botulinum toxin type A (Botox) injections. Procedure was performed to intrinsic and flexor muscles of 4th and 5th digits with electromyography assistance. Setting: Tertiary care hospital. Results: One week after procedure there was a reduction in the autonomic output, increased coordination for opening hand and while writing, and a decrement on intrinsic hand tone (hypothenars) at rest and during activity. Improvement of symptoms were observed on 3week follow up and sustained at 2 months follow up. Discussion: To our knowledge, this is the first reported case of hand atypical dystonia presenting as ulnar nerve pathology with marked autonomic symptoms responsive to botulinum toxin injection.

Conclusions: In a context of suspected ulnar nerve pathology not confirmed by objective studies, other etiologies such as dystonia should be considered. The use of botulinum toxin conveyed diagnostic and therapeutic advantages to successfully revert symptomatology such as correction of writing and resolution of autonomic symptoms. Level of Evidence: Level V Poster 240: Atypical Cause of Shoulder Pain in a Collegiate Softball Player: A Case Report Michael J. Slesinski, DO (MI State Univ), Mathew Saffarian, DO Disclosures: Michael Slesinski: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 20-year-old female Division I collegiate softball player. The patient presented with left shoulder pain. No injury prior to onset of pain. The left shoulder pain started 1 year ago with “catching” in the left subscapular region, which was worse with throwing activities and “overuse.” A focused physical exam of the left shoulder was normal, except there was snapping of the left posterior shoulder with abduction, which reproduced the pain in the scapulothoracic region. MRI left scapula demonstrated 8 mm circumscribed T2 hyperintense lesion within the medial aspect of the scapular body at the level of the posterior fourth rib. Components of the lesion extend beyond the ventral and dorsal cortical margins. Then, a CT scan of the left upper extremity showed a 13 mm lucent lesion within the medial scapular body, mildly expansile, with a thin rim of cortical bone surrounding the anterior and posterior margins of the lesion. Finally, a whole body bone scan was performed and was normal. The patient was referred to an orthopedic oncologist. Setting: Outpatient Academic Clinic. Results: The patient was diagnosed with left snapping scapula syndrome due to a scapular enchondroma. After discussion with an orthopedic oncologist, she decided to continue with conservative management. She continues to play softball with some pain, which is tolerable. She had two ultrasound-guided scapulothoracic bursa injections over a period of 6 months. Discussion: A medial scapular enchondroma is an atypical cause of snapping scapula syndrome. Enchondromas account for approximately 10% of all benign osseous tumors. The most common locations are hands, feet, distal femur, proximal humerus, then tibia. Enchondromas are rare in the scapula, pelvis and ribs; enchondromas in these rare areas should warrant further evaluation for chondrosarcoma. Conclusions: Scapular enchondroma is a rare cause of snapping scapula syndrome. A scapular enchondroma should be evaluated for chondrosarcoma. Level of Evidence: Level V Poster 241: Integrating Plastics and PM&R using Electromyography and Ultrasound after Free Gracilis Transfer to Forearm: A Case Report Cole R. Linville, DO, MBA (Univ of TX-UT Houston, Houston, Texas, United States), Cain R.R. Linville, MD, Faye Chiou-Tan, MD Disclosures: Cole Linville: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 26-year-old, previously healthy man status post motor vehicle accident who sustained a left shoulder injury. Previous nerve conduction study and electromyography showed left brachial panplexopathy, proximal to innervation of the serratus anterior with no motor recruitment. The patient then underwent exploration and neurolysis of left brachial plexus, harvesting of left sural nerve and nerve graft/anastomosis of left spinal accessory nerve to left lateral cord with good shoulder function but no elbow function. EMG after showed evidence of motor activity in proximal left shoulder muscles but absent distally. The patient then underwent left free