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Poster 265: Multiple Sclerosis Diagnosed in an Athlete with Gait Abnormality: A Case Report
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Abstracts / PM R 9 (2017) S131-S290
scrotal swelling 4 days prior after landing from a jump. He was evaluated in the emergency department where a groin and testicular ultrasound were normal. His pain was sharp, worse with activity, rated from 0-6/10 but not increased with cough/Valsalva. Exam revealed full strength, normal and pain free passive hip range of motion, and normal neurovascular exam. Pain was reproduced with resisted adduction, supine heel lifts and palpation over the pubic bone/proximal adductor tendons. There was visible swelling in the left inguinal/pubic region. An MRI of the pelvis revealed a full-thickness tear of the left rectus abdominis/adductor longus (AL) aponeurosis with 3.5 cm AL retraction and a large hematoma extending into the left hemiscrotum. The patient was presented with the option of surgical consultation vs conservative management. He wished to return to sport this season, as he was being scouted for the NFL, and thus elected rehabilitation with Physical Therapy. Setting: Sports Medicine Center. Results: The patient was able to return to high level competition 5 weeks post injury. Discussion: Definitive guidance on the management of AL tendon avulsion is lacking. Case reports/series describe both operative and non-operative management in high level athletes. Schlegel et. al. report return to National Football League (NFL) play at 6 weeks for non-operative management vs 12 weeks for operative management. Our athlete desired to return to his season for NFL scouting reasons. He successfully returned to play at 5 weeks. Conclusions: Conservative management of acute AL avulsion in the setting of subacute athletic pubalgia can rapidly return athletes to high level sporting activities. Level of Evidence: Level V Poster 265: Multiple Sclerosis Diagnosed in an Athlete with Gait Abnormality: A Case Report Rondy M. Lazaro, MD (Virginia Commonwealth University), Katherine Dec, MD Disclosures: Rondy Lazaro: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 30-year-old woman presented with a 1.5year history of progressively worsening right leg weakness that started while training for a 10K. She demonstrated mild weakness in gait on the right with decreased forefoot clearance. Lumbar spine magnetic resonance imaging (MRI) revealed a small central L5-S1 disc protrusion. She was prescribed a course of diclofenac and physical therapy. She noted slight symptom improvement on follow-up, but physical examination showed steppage gait without foot drop, mild hip weakness with stance change, 4/5 right hip flexion strength, and no upper motor neuron signs. Because her prior imaging findings (including lumbar spine MRI and radiographs of the lumbar spine, right knee, and right hip) were inconsistent with her gait issues, and since she recalled a history of “spastic bladder,” a non-contrast brain MRI was ordered to investigate demyelination, mass, ischemia, or hydrocephalus. Setting: Academic sports medicine clinic. Results: Non-contrast brain MRI showed several scattered hyperintensities in white matter, periventricular regions, subcortical areas, and brainstem suspicious for a demyelinating process. The patient was referred to Neurology clinic. Cerebrospinal fluid analysis revealed 12 oligoclonal bands and an elevated IgG index. Contrast MRI of the brain and spine displayed several frontal lobe enhancing lesions and multiple signal intensity abnormalities in the cervical and thoracic cord without contrast enhancement, consistent with multiple sclerosis (MS). She was started on oral prednisone for her acute MS flare and natalizumab for chronic MS treatment. Discussion: MS is an immune-mediated multifocal demyelinating disease of the central nervous system demonstrated by lesion dissemination in time and space. Acute MS exacerbations are typically treated with glucocorticoids. Various disease-modifying agents are available for relapsing-remitting MS.
Conclusions: Sports medicine clinicians should consider demyelinating processes such as MS in the differential diagnosis for gait abnormality, particularly if history and physical examination do not correlate with other diagnoses or imaging findings. Level of Evidence: Level V Poster 266: Parsonage-Turner Syndrome Following Influenza Vaccination: A Case Report Anupam Sinha, MS DO (Rothman Inst, Mount Laurel, New Jersey, United States), Shivani Gupta, DO Disclosures: Anupam Sinha: I Have No Relevant Financial Relationships To Disclose Case/Program Description: An 85-year-old man presents with complaints of left shoulder weakness after having had a flu shot in the left deltoid 1 year ago. He complains of inability to move his left shoulder above the horizontal plane. He has done physical therapy for about 3 months without progress. He currently does take some herbal medications for pain relief. He denies any paresthesias. Denies weakness in the distal upper extremity. Prior to the flu vaccine, he was playing golf and staying very active physically. One week after the injection, he described acute onset of shoulder pain and weakness. Physical examination is unremarkable except for reduced active range of motion of the left shoulder, and 4 out of 5 strength in the left deltoid and left shoulder external rotators. Setting: Outpatient orthopedic practice. Results: MRI of the left shoulder shows evidence of an old rotator cuff injury. MRI of the cervical spine shows cervical spondylosis without evidence of nerve or cord impingement. Electromyography of the left upper extremity confirms the presence of left axillary nerve and suprascapular nerve injury. Discussion: We present a case of shoulder weakness due to suprascapular and axillary nerve injury following flu vaccination. Although rare, there are well documented reports of brachial neuritis or ParsonageTurner syndrome (PTS) following vaccinations. The cause is considered to be a postinfectious reaction or a reaction secondary to a hypersensitivity response. The prognosis for clinical improvement is good, although a number of patients demonstrate residual weakness and atrophy. Conclusions: Parsonage-Turner syndrome is a rare but distinct disorder with an abrupt onset of shoulder pain, followed by weakness and atrophy of the upper extremity musculature, and a slow recovery requiring months to years. We present a rare case of PTS following influenza vaccination. Clinicians should consider this diagnosis in patients with upper extremity weakness following vaccination. Level of Evidence: Level V Poster 267: Rapid Recovery from Bilateral Upper Extremity Neuralgic Amyotrophy in a Previously Healthy Male Adult: A Case Report. Tomasz K. Podobinski, DO (Univ of TX-UT Houston, Houston, Texas, United States) Disclosures: Tomasz Podobinski: I Have No Relevant Financial Relationships To Disclose Case/Program Description: This right-hand dominant man presented for evaluation of 1 month history of progressive bilateral arm pain, first and second finger numbness as well as anterior interosseous nerve and posterior interosseous nerve dysfunction. The patient described his discomfort as aching, tingling, shooting which was worse with movement. He has completed a course of methylprednisolone and gabapentin trial, but both did not provide any relief. The patient’s imaging included cervical MRI which showed mild degenerative changes, but without any disc herniation. His bilateral brachial plexus MRI did not show any masses or other abnormality. The patient had also undergone a bilateral upper extremity EMG which showed mild to moderate brachial plexopathy, involving the upper trunk, AIN and PIN in bilateral
Abstracts / PM R 9 (2017) S131-S290
scrotal swelling 4 days prior after landing from a jump. He was evaluated in the emergency department where a groin and testicular ultrasound were normal. His pain was sharp, worse with activity, rated from 0-6/10 but not increased with cough/Valsalva. Exam revealed full strength, normal and pain free passive hip range of motion, and normal neurovascular exam. Pain was reproduced with resisted adduction, supine heel lifts and palpation over the pubic bone/proximal adductor tendons. There was visible swelling in the left inguinal/pubic region. An MRI of the pelvis revealed a full-thickness tear of the left rectus abdominis/adductor longus (AL) aponeurosis with 3.5 cm AL retraction and a large hematoma extending into the left hemiscrotum. The patient was presented with the option of surgical consultation vs conservative management. He wished to return to sport this season, as he was being scouted for the NFL, and thus elected rehabilitation with Physical Therapy. Setting: Sports Medicine Center. Results: The patient was able to return to high level competition 5 weeks post injury. Discussion: Definitive guidance on the management of AL tendon avulsion is lacking. Case reports/series describe both operative and non-operative management in high level athletes. Schlegel et. al. report return to National Football League (NFL) play at 6 weeks for non-operative management vs 12 weeks for operative management. Our athlete desired to return to his season for NFL scouting reasons. He successfully returned to play at 5 weeks. Conclusions: Conservative management of acute AL avulsion in the setting of subacute athletic pubalgia can rapidly return athletes to high level sporting activities. Level of Evidence: Level V Poster 265: Multiple Sclerosis Diagnosed in an Athlete with Gait Abnormality: A Case Report Rondy M. Lazaro, MD (Virginia Commonwealth University), Katherine Dec, MD Disclosures: Rondy Lazaro: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 30-year-old woman presented with a 1.5year history of progressively worsening right leg weakness that started while training for a 10K. She demonstrated mild weakness in gait on the right with decreased forefoot clearance. Lumbar spine magnetic resonance imaging (MRI) revealed a small central L5-S1 disc protrusion. She was prescribed a course of diclofenac and physical therapy. She noted slight symptom improvement on follow-up, but physical examination showed steppage gait without foot drop, mild hip weakness with stance change, 4/5 right hip flexion strength, and no upper motor neuron signs. Because her prior imaging findings (including lumbar spine MRI and radiographs of the lumbar spine, right knee, and right hip) were inconsistent with her gait issues, and since she recalled a history of “spastic bladder,” a non-contrast brain MRI was ordered to investigate demyelination, mass, ischemia, or hydrocephalus. Setting: Academic sports medicine clinic. Results: Non-contrast brain MRI showed several scattered hyperintensities in white matter, periventricular regions, subcortical areas, and brainstem suspicious for a demyelinating process. The patient was referred to Neurology clinic. Cerebrospinal fluid analysis revealed 12 oligoclonal bands and an elevated IgG index. Contrast MRI of the brain and spine displayed several frontal lobe enhancing lesions and multiple signal intensity abnormalities in the cervical and thoracic cord without contrast enhancement, consistent with multiple sclerosis (MS). She was started on oral prednisone for her acute MS flare and natalizumab for chronic MS treatment. Discussion: MS is an immune-mediated multifocal demyelinating disease of the central nervous system demonstrated by lesion dissemination in time and space. Acute MS exacerbations are typically treated with glucocorticoids. Various disease-modifying agents are available for relapsing-remitting MS.
Conclusions: Sports medicine clinicians should consider demyelinating processes such as MS in the differential diagnosis for gait abnormality, particularly if history and physical examination do not correlate with other diagnoses or imaging findings. Level of Evidence: Level V Poster 266: Parsonage-Turner Syndrome Following Influenza Vaccination: A Case Report Anupam Sinha, MS DO (Rothman Inst, Mount Laurel, New Jersey, United States), Shivani Gupta, DO Disclosures: Anupam Sinha: I Have No Relevant Financial Relationships To Disclose Case/Program Description: An 85-year-old man presents with complaints of left shoulder weakness after having had a flu shot in the left deltoid 1 year ago. He complains of inability to move his left shoulder above the horizontal plane. He has done physical therapy for about 3 months without progress. He currently does take some herbal medications for pain relief. He denies any paresthesias. Denies weakness in the distal upper extremity. Prior to the flu vaccine, he was playing golf and staying very active physically. One week after the injection, he described acute onset of shoulder pain and weakness. Physical examination is unremarkable except for reduced active range of motion of the left shoulder, and 4 out of 5 strength in the left deltoid and left shoulder external rotators. Setting: Outpatient orthopedic practice. Results: MRI of the left shoulder shows evidence of an old rotator cuff injury. MRI of the cervical spine shows cervical spondylosis without evidence of nerve or cord impingement. Electromyography of the left upper extremity confirms the presence of left axillary nerve and suprascapular nerve injury. Discussion: We present a case of shoulder weakness due to suprascapular and axillary nerve injury following flu vaccination. Although rare, there are well documented reports of brachial neuritis or ParsonageTurner syndrome (PTS) following vaccinations. The cause is considered to be a postinfectious reaction or a reaction secondary to a hypersensitivity response. The prognosis for clinical improvement is good, although a number of patients demonstrate residual weakness and atrophy. Conclusions: Parsonage-Turner syndrome is a rare but distinct disorder with an abrupt onset of shoulder pain, followed by weakness and atrophy of the upper extremity musculature, and a slow recovery requiring months to years. We present a rare case of PTS following influenza vaccination. Clinicians should consider this diagnosis in patients with upper extremity weakness following vaccination. Level of Evidence: Level V Poster 267: Rapid Recovery from Bilateral Upper Extremity Neuralgic Amyotrophy in a Previously Healthy Male Adult: A Case Report. Tomasz K. Podobinski, DO (Univ of TX-UT Houston, Houston, Texas, United States) Disclosures: Tomasz Podobinski: I Have No Relevant Financial Relationships To Disclose Case/Program Description: This right-hand dominant man presented for evaluation of 1 month history of progressive bilateral arm pain, first and second finger numbness as well as anterior interosseous nerve and posterior interosseous nerve dysfunction. The patient described his discomfort as aching, tingling, shooting which was worse with movement. He has completed a course of methylprednisolone and gabapentin trial, but both did not provide any relief. The patient’s imaging included cervical MRI which showed mild degenerative changes, but without any disc herniation. His bilateral brachial plexus MRI did not show any masses or other abnormality. The patient had also undergone a bilateral upper extremity EMG which showed mild to moderate brachial plexopathy, involving the upper trunk, AIN and PIN in bilateral