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Poster 315 Unusual Calf Pain in a Young Athlete: A Case Report
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Abstracts / PM R 7 (2015) S83-S222
Setting: Outpatient clinic at a tertiary care university based hospital. Results or Clinical Course: Physical examination findings revealed lower extremity hyperreflexia with pathologic spread to bilateral knees and Achilles tendons. These focal neurologic signs prompted obtention of brain and cervical spine imaging, which demonstrated a right temporal lobe contusion and multiple cervical disc herniations. Discussion: This case emphasizes the importance of a thorough neurologic examination. Failure to recognize these critical signs could have resulted in premature or unsafe return to play, ultimately exposing the athlete to the risk of additional trauma. Conclusion: Concussion is primarily diagnosed clinically and therefore imaging is not routinely obtained. Thus, fastidious upper motor neuron testing should be a fundamental component of the standard neurologic examination when evaluating players suspected of having a concussion. Poster 314 Synovial Sarcoma: A Case Report Jennifer Baima, MD (University of Massachusetts Medical School, Worcester, MA, United States), Mathew Most, MD Disclosures: J. Baima, ABC-CLIO, Receipt of royalties. Case Description: Patient is a 47-year-old man with a history of hypertension, diabetes, and chronic back pain who presented to outpatient physiatry clinic with one year of right anterior knee pain of insidious onset. He had previously tried oral NSAIDs, knee brace, and physical therapy six months prior to visit. On physical exam, there was a 1-2 cm, subcutaneous midline nodular knee lesion over the right patellar tendon with no associated joint effusion, erythema, or warmth. The patient reported stable size of the lesion over the past year. On knee range of motion, extension was -5 degrees and flexion was 90 degrees with anterior knee pain. There was marked joint line tenderness at the medial and lateral joint line and especially over the midline lesion. McMurray test was positive. There was no ligamentous laxity. He had intermittent activation of right knee extension and knee flexion on the affected side with greater than anti-gravity strength. Right knee radiographs revealed mild degenerative changes only. Right knee MRI was ordered and demonstrated 2cm ovoid subcutaneous lesion on the anterior aspect of the lateral patellar tendon with underlying medial meniscal tear. Subsequent ultrasound was difficult to obtain technically due to extreme focal tenderness, but exhibited solid extra-articular soft tissue nodule. Setting: Tertiary care center. Results or Clinical Course: Differential included inflammatory lesion, giant cell tumor of tendon sheath, and glomus tumor/glomangioma. Given the small size, superficial location, significant focal tenderness, and lack of growth in one year, lesion was presumed benign. Discussion: Excisional biopsy was planned. Suspicion for glomus tumor or glomangioma was high due to severe focal tenderness and small, circumscribed size and shape. Surprisingly, histology of specimen demonstrated synovial sarcoma. Subsequent staging chest CT showed calcified lesions consistent with granulomas. Wide re-excision with gastrocnemius flap graft was performed due to positive margins and potential for recurrence with this diagnosis. Conclusion: Nodular densities on physical examination should raise concern for a wide differential including inflammatory and neoplastic causes. Synovial sarcoma may present as a small, palpable, tender nodule of stable size. Poster 315 Unusual Calf Pain in a Young Athlete: A Case Report Melissa Learned, MD (Univ. of Ark for Medical Sciences, Little Rock, AR, United States), Alexandra Rivera Vega, MD, Guillermo Escobar, MD, Roopa Ram, MD Disclosures: M. Learned: I Have No Relevant Financial Relationships To Disclose.
Case Description: A 23-year-old long distance runner with right calf pain starting 4 months after weighted calf presses. Pain was initially sharp but transitioned to achy/burning pain with associated exercise induced fatigue of the upper calf. Symptoms progressed with development of blanching, numbness and coolness in his first 3 toes when power walking. Physical examination revealed mild tenderness of right medial gastrocnemius and diminished pulse when compared to contralateral foot with no leg discoloration, coolness or sensory deficits. Of note, he was seen by 3 physicians prior to evaluation. MRI arthrogram was ordered showing an anomalous course of the medial gastrocnemius with a fibrous band causing 2cm of high-grade popliteal artery stenosis which worsened with plantar flexion (PF). Post-exercise muscle edema was present suggestive of ischemic changes. Right ankle brachial indices were normal at rest but decreased with both dorsiflexion and PF, with a great toe pressure of 0 mmHg upon PF. Of note, the left gastrocnemius had a fibrous band but no popliteal artery compression. Setting: Tertiary care hospital. Results or Clinical Course: Anticoagulation was started until fibrous band excision with right popliteal thromboendarterectomy and patch angioplasty could be done. Three weeks post-op the patient remains symptom free. Discussion: Popliteal artery entrapment syndrome (PAES) is frequently diagnosed by sports medicine specialists. The condition is either unknown or frequently overlooked by non-sport specialists, possibly because athletes are generally healthy without atherosclerosis risk factors. True incidence is unknown, however prevalence is 0.16-3.5%. Interestingly, in young patients with intermittent claudication PAES is found in 40% of the cases. Conclusion: Claudication like symptoms in a young athlete should be considered PAES until proven otherwise in order to avoid further morbidity and limb loss. More awareness of PAES will be beneficial, not only in the sports medicine field but among non-sports specialists as well.
Poster 316 The Importance of Image Guidance in Glenohumeral Joint Injection Accuracy Ryan Mattie, MD (San Jose, CA, United States), David J. Kennedy, MD Disclosures: R. Mattie: I Have No Relevant Financial Relationships To Disclose. Objective: This study compared the accuracy of blind glenohumeral joint (GHJ) injections between PM&R interventional fellows (inexperienced provider) and a PM&R attending physician with more than 5 years of post-fellowship practice (experienced provider) using either an anterior or posterior approach. Design: Retrospective analysis of prospectively collected data. Setting: Outpatient academic interventional suite. Participants: 162 patients comprising 165 glenohumeral joint injections. Interventions: All GHJ injections were initially placed via anatomic landmark guidance by either a PM&R interventional sports and spine fellow or by an attending PM&R physician. Once the fellow or attending physician felt the needle was correctly positioned in the GHJ space, contrast medium utilizing live fluoroscopy was injected to determine if intra-articular placement had been obtained. Main Outcome Measures: Analysis of accuracy rates was undertaken, specifically comparing the physician level of experience, as well as an anterior versus a posterior approach. Results or Clinical Course: The overall accuracy of a blind glenohumeral joint injection, regardless of the provider level of experience, was 45.5%. The inexperienced provider was accurate 37.6% of the time, and the experienced provider was accurate 64.6% of the time. The difference in provider accuracy based on level of experience was shown to be statistically significant at P <.05. One-hundred and fifty injections were performed using the anterior approach, with 71
Abstracts / PM R 7 (2015) S83-S222
Setting: Outpatient clinic at a tertiary care university based hospital. Results or Clinical Course: Physical examination findings revealed lower extremity hyperreflexia with pathologic spread to bilateral knees and Achilles tendons. These focal neurologic signs prompted obtention of brain and cervical spine imaging, which demonstrated a right temporal lobe contusion and multiple cervical disc herniations. Discussion: This case emphasizes the importance of a thorough neurologic examination. Failure to recognize these critical signs could have resulted in premature or unsafe return to play, ultimately exposing the athlete to the risk of additional trauma. Conclusion: Concussion is primarily diagnosed clinically and therefore imaging is not routinely obtained. Thus, fastidious upper motor neuron testing should be a fundamental component of the standard neurologic examination when evaluating players suspected of having a concussion. Poster 314 Synovial Sarcoma: A Case Report Jennifer Baima, MD (University of Massachusetts Medical School, Worcester, MA, United States), Mathew Most, MD Disclosures: J. Baima, ABC-CLIO, Receipt of royalties. Case Description: Patient is a 47-year-old man with a history of hypertension, diabetes, and chronic back pain who presented to outpatient physiatry clinic with one year of right anterior knee pain of insidious onset. He had previously tried oral NSAIDs, knee brace, and physical therapy six months prior to visit. On physical exam, there was a 1-2 cm, subcutaneous midline nodular knee lesion over the right patellar tendon with no associated joint effusion, erythema, or warmth. The patient reported stable size of the lesion over the past year. On knee range of motion, extension was -5 degrees and flexion was 90 degrees with anterior knee pain. There was marked joint line tenderness at the medial and lateral joint line and especially over the midline lesion. McMurray test was positive. There was no ligamentous laxity. He had intermittent activation of right knee extension and knee flexion on the affected side with greater than anti-gravity strength. Right knee radiographs revealed mild degenerative changes only. Right knee MRI was ordered and demonstrated 2cm ovoid subcutaneous lesion on the anterior aspect of the lateral patellar tendon with underlying medial meniscal tear. Subsequent ultrasound was difficult to obtain technically due to extreme focal tenderness, but exhibited solid extra-articular soft tissue nodule. Setting: Tertiary care center. Results or Clinical Course: Differential included inflammatory lesion, giant cell tumor of tendon sheath, and glomus tumor/glomangioma. Given the small size, superficial location, significant focal tenderness, and lack of growth in one year, lesion was presumed benign. Discussion: Excisional biopsy was planned. Suspicion for glomus tumor or glomangioma was high due to severe focal tenderness and small, circumscribed size and shape. Surprisingly, histology of specimen demonstrated synovial sarcoma. Subsequent staging chest CT showed calcified lesions consistent with granulomas. Wide re-excision with gastrocnemius flap graft was performed due to positive margins and potential for recurrence with this diagnosis. Conclusion: Nodular densities on physical examination should raise concern for a wide differential including inflammatory and neoplastic causes. Synovial sarcoma may present as a small, palpable, tender nodule of stable size. Poster 315 Unusual Calf Pain in a Young Athlete: A Case Report Melissa Learned, MD (Univ. of Ark for Medical Sciences, Little Rock, AR, United States), Alexandra Rivera Vega, MD, Guillermo Escobar, MD, Roopa Ram, MD Disclosures: M. Learned: I Have No Relevant Financial Relationships To Disclose.
Case Description: A 23-year-old long distance runner with right calf pain starting 4 months after weighted calf presses. Pain was initially sharp but transitioned to achy/burning pain with associated exercise induced fatigue of the upper calf. Symptoms progressed with development of blanching, numbness and coolness in his first 3 toes when power walking. Physical examination revealed mild tenderness of right medial gastrocnemius and diminished pulse when compared to contralateral foot with no leg discoloration, coolness or sensory deficits. Of note, he was seen by 3 physicians prior to evaluation. MRI arthrogram was ordered showing an anomalous course of the medial gastrocnemius with a fibrous band causing 2cm of high-grade popliteal artery stenosis which worsened with plantar flexion (PF). Post-exercise muscle edema was present suggestive of ischemic changes. Right ankle brachial indices were normal at rest but decreased with both dorsiflexion and PF, with a great toe pressure of 0 mmHg upon PF. Of note, the left gastrocnemius had a fibrous band but no popliteal artery compression. Setting: Tertiary care hospital. Results or Clinical Course: Anticoagulation was started until fibrous band excision with right popliteal thromboendarterectomy and patch angioplasty could be done. Three weeks post-op the patient remains symptom free. Discussion: Popliteal artery entrapment syndrome (PAES) is frequently diagnosed by sports medicine specialists. The condition is either unknown or frequently overlooked by non-sport specialists, possibly because athletes are generally healthy without atherosclerosis risk factors. True incidence is unknown, however prevalence is 0.16-3.5%. Interestingly, in young patients with intermittent claudication PAES is found in 40% of the cases. Conclusion: Claudication like symptoms in a young athlete should be considered PAES until proven otherwise in order to avoid further morbidity and limb loss. More awareness of PAES will be beneficial, not only in the sports medicine field but among non-sports specialists as well.
Poster 316 The Importance of Image Guidance in Glenohumeral Joint Injection Accuracy Ryan Mattie, MD (San Jose, CA, United States), David J. Kennedy, MD Disclosures: R. Mattie: I Have No Relevant Financial Relationships To Disclose. Objective: This study compared the accuracy of blind glenohumeral joint (GHJ) injections between PM&R interventional fellows (inexperienced provider) and a PM&R attending physician with more than 5 years of post-fellowship practice (experienced provider) using either an anterior or posterior approach. Design: Retrospective analysis of prospectively collected data. Setting: Outpatient academic interventional suite. Participants: 162 patients comprising 165 glenohumeral joint injections. Interventions: All GHJ injections were initially placed via anatomic landmark guidance by either a PM&R interventional sports and spine fellow or by an attending PM&R physician. Once the fellow or attending physician felt the needle was correctly positioned in the GHJ space, contrast medium utilizing live fluoroscopy was injected to determine if intra-articular placement had been obtained. Main Outcome Measures: Analysis of accuracy rates was undertaken, specifically comparing the physician level of experience, as well as an anterior versus a posterior approach. Results or Clinical Course: The overall accuracy of a blind glenohumeral joint injection, regardless of the provider level of experience, was 45.5%. The inexperienced provider was accurate 37.6% of the time, and the experienced provider was accurate 64.6% of the time. The difference in provider accuracy based on level of experience was shown to be statistically significant at P <.05. One-hundred and fifty injections were performed using the anterior approach, with 71