- Email: [email protected]
Poster 249: Ultrasound Guided Tarsal Tunnel Injection for Diagnosis and Treatment of Tarsal Tunnel Syndrome: A Case Report
Abstracts / PM R 9 (2017) S131-S290 isolated LCL injury is primarily due to the reported twisting injury while playing soccer in addition to the cumulative rotational stresses. Conclusions: We are reporting cases of isolated LCL injuries which are known to be rare. These two cases demonstrate that isolated LCL injuries may occur as a result of both acute and chronic stress patterns. Level of Evidence: Level V Poster 248: Dynamic Ultrasound in the Diagnosis of Retrocalcaneal Bursitis Causing Posterior Ankle Impingement with Dorsiflexion: A Case Report Julia Reilly, MD (Spaulding Rehabilitation Hospital/Harvard Medical School, Charlestown, MA, United States, Charlestown, MA, United States), Robert Diaz, MD, Minna J. Kohler, MD Disclosures: Julia Reilly: I Have No Relevant Financial Relationships To Disclose Case/Program Description: This patient presented with persistent right posterior ankle pain for 6 weeks worsened with ankle dorsiflexion. She had increased her activity level in prior months by participating in Zumba exercises. One month prior to presentation, she was clinically diagnosed with Achilles tendinopathy by an orthopedist. Symptoms did not improve with Physical Therapy and anti-inflammatory medications. Examination was notable for pain with passive ankle dorsiflexion and tenderness to palpation along her posterior ankle at the level of the Achilles tendon insertion/retrocalcaneal bursa region without visible swelling. Diagnostic ultrasound revealed moderate retrocalcaneal bursitis without Achilles tendinopathy, enthesitis, or erosions. Dynamic view of posterior ankle in dorsiflexion showed bursal impingement on the Achilles tendon, reproducing patient’s symptoms. Due to persistent pain, an ultrasound-guided retrocalcaneal bursa corticosteroid injection was performed. Her ankle was immobilized in an aircast boot for 2 weeks and repetitive ankle activity was limited after immobilization. Setting: Tertiary Rheumatology Musculoskeletal Ultrasound Clinic. Results: At 8-weeks post-injection, the patient reported significant improvement in her ankle pain and tenderness. Follow-up ultrasound revealed reduction in bursal thickening with no further impingement. Discussion: Diagnostic ultrasound with dynamic maneuvers can accurately diagnose the etiology of posterior ankle pain. Ultrasound with clinical correlation identified the pain to arise from the retrocalcaneal bursa, and dynamic views confirmed impingement and reproduced pain with dorsiflexion. Retrocalcaneal bursitis is not often considered in the differential diagnoses of posterior ankle impingement symptoms. In this case, corticosteroid injection provided targeted therapy to the bursa. Injection to the tendon is contraindicated with her previous suspected diagnosis of Achilles Tendinopathy. Conclusions: Dynamic ultrasound can improve the diagnostic accuracy of posterior ankle pain. With clinical correlation, the pain generating structure can be visibly identified, and dynamic maneuvers can confirm impingement symptoms. This case highlights how point-ofcare ultrasound can expedite diagnostic accuracy and guided treatment in posterior ankle pain. Level of Evidence: Level V Poster 249: Ultrasound Guided Tarsal Tunnel Injection for Diagnosis and Treatment of Tarsal Tunnel Syndrome: A Case Report Rohan Kapoor, MD (WA Hosp Cntr/Georgetown Univ) Disclosures: Rohan Kapoor: I Have No Relevant Financial Relationships To Disclose Case/Program Description: Our patient is a 54-year-old man who presented to clinic with bilateral foot pain. The pain started at the hallux of both feet and over time spread through the dorsal aspects. He denied any inciting event or trauma in the past. Extensive workup
S211
was completed by his Orthopedist, including EMGs, arteriogram, MRI, and bone scan, but results were unremarkable. Past treatment included a physical therapy course and had multiple lumbar epidural steroid injections preformed with no improvement. Setting: Outpatient Musculoskeletal Clinic. Results: Although EMG was negative for tarsal tunnel syndrome, strong clinical suspicion was present. Ultrasound guided tarsal tunnel injection of Lidocaine was performed with good relief of his symptoms helping our team make a diagnosis. This was followed by a corticosteroid injection. Follow up visits at 1 month proved this intervention provided greater than 80 percent improvement of his pain. Discussion: Tarsal tunnel syndrome is caused by compression of the components of the tarsal tunnel under the flexor retinaculum at the level of the ankle or below. Diagnosis is typically made with history, clinical exam, EMG studies, and imaging. In our case EMG studies and imaging were inconclusive. Clinical suspicion was high for nerve entrapment under the flexor retinaculum even with negative studies. In office ultrasound guided anesthetic injection was a valuable diagnostic tool that assisted us in coming to a diagnosis. Ultrasound guided injection in the tarsal tunnel can be of both diagnostic as well as therapeutic value. Conclusions: With strong clinical suspicion, negative EMG and imaging may not rule out tarsal tunnel syndrome. Ultrasound-guided injection to the tarsal tunnel can have both diagnostic and therapeutic value. Level of Evidence: Level V Poster 250: Congenital ACL Deficiency and Advanced Knee Osteoarthritis Gregory R. Kelley (WA Hosp Cntr/Georgetown Univ) Disclosures: Gregory Kelley: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 60-year-old man with no known orthopedic history presented to our outpatient musculoskeletal clinic with several years of bilateral knee pain made worse with weight bearing. He was mostly wheelchair bound for community distances, partly from weakness resulting from a prior stroke and partly from severe knee pain. Given bilateral ligamentous laxity on physical exam including a positive Lachman test, an MRI was ordered which, along with his severe tricompartmental arthritis, showed bilateral ACL deficiency and medial meniscus degeneration. His pain did not respond well to conservative measures such as steroid injection, viscosupplementation, or physical therapy. Setting: Musculoskeletal clinic. Results: Per patient request, the patient was referred to orthopedic surgery for consideration of bilateral knee replacement given his significant osteoarthritis, failure to respond to conservative measures, and functional limitation. Discussion: Congenital ACL deficiency has been described in orthopedic literature as a rare occurrence that can manifest as an isolated occurrence or as part of a syndrome with other structural and anatomic skeletal defects. Generally, ACL reconstruction is considered if symptomatic knee instability is present; however, there are no significant studies comparing the outcomes of surgical versus nonsurgical treatment of congenital ACL absence (partly given his rarity). It is also unclear to what degree surgical intervention in these patients may delay or halt the development of osteoarthritis. Until further studies clarify this, a reasonable management may include physical therapy to enhance stabilizing muscular forces around the knee, an exercise regimen that limits compressive knee forces and close follow-up for clinical or radiographic evidence of further knee compromise. Conclusions: While our patient was not a good candidate for reconstructive surgery, there is still debate how to best manage congenital ACL deficiency in the absence of overt clinical instability as well as its role in the development of future knee arthritis. Level of Evidence: Level V
S211
was completed by his Orthopedist, including EMGs, arteriogram, MRI, and bone scan, but results were unremarkable. Past treatment included a physical therapy course and had multiple lumbar epidural steroid injections preformed with no improvement. Setting: Outpatient Musculoskeletal Clinic. Results: Although EMG was negative for tarsal tunnel syndrome, strong clinical suspicion was present. Ultrasound guided tarsal tunnel injection of Lidocaine was performed with good relief of his symptoms helping our team make a diagnosis. This was followed by a corticosteroid injection. Follow up visits at 1 month proved this intervention provided greater than 80 percent improvement of his pain. Discussion: Tarsal tunnel syndrome is caused by compression of the components of the tarsal tunnel under the flexor retinaculum at the level of the ankle or below. Diagnosis is typically made with history, clinical exam, EMG studies, and imaging. In our case EMG studies and imaging were inconclusive. Clinical suspicion was high for nerve entrapment under the flexor retinaculum even with negative studies. In office ultrasound guided anesthetic injection was a valuable diagnostic tool that assisted us in coming to a diagnosis. Ultrasound guided injection in the tarsal tunnel can be of both diagnostic as well as therapeutic value. Conclusions: With strong clinical suspicion, negative EMG and imaging may not rule out tarsal tunnel syndrome. Ultrasound-guided injection to the tarsal tunnel can have both diagnostic and therapeutic value. Level of Evidence: Level V Poster 250: Congenital ACL Deficiency and Advanced Knee Osteoarthritis Gregory R. Kelley (WA Hosp Cntr/Georgetown Univ) Disclosures: Gregory Kelley: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 60-year-old man with no known orthopedic history presented to our outpatient musculoskeletal clinic with several years of bilateral knee pain made worse with weight bearing. He was mostly wheelchair bound for community distances, partly from weakness resulting from a prior stroke and partly from severe knee pain. Given bilateral ligamentous laxity on physical exam including a positive Lachman test, an MRI was ordered which, along with his severe tricompartmental arthritis, showed bilateral ACL deficiency and medial meniscus degeneration. His pain did not respond well to conservative measures such as steroid injection, viscosupplementation, or physical therapy. Setting: Musculoskeletal clinic. Results: Per patient request, the patient was referred to orthopedic surgery for consideration of bilateral knee replacement given his significant osteoarthritis, failure to respond to conservative measures, and functional limitation. Discussion: Congenital ACL deficiency has been described in orthopedic literature as a rare occurrence that can manifest as an isolated occurrence or as part of a syndrome with other structural and anatomic skeletal defects. Generally, ACL reconstruction is considered if symptomatic knee instability is present; however, there are no significant studies comparing the outcomes of surgical versus nonsurgical treatment of congenital ACL absence (partly given his rarity). It is also unclear to what degree surgical intervention in these patients may delay or halt the development of osteoarthritis. Until further studies clarify this, a reasonable management may include physical therapy to enhance stabilizing muscular forces around the knee, an exercise regimen that limits compressive knee forces and close follow-up for clinical or radiographic evidence of further knee compromise. Conclusions: While our patient was not a good candidate for reconstructive surgery, there is still debate how to best manage congenital ACL deficiency in the absence of overt clinical instability as well as its role in the development of future knee arthritis. Level of Evidence: Level V