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Poster 357 Median Nerve Snapping at the Forearm in a Clarinetist: A Case Report
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Abstracts / PM R 7 (2015) S83-S222
proper gradual transition time and tried to exercise through pain until it interfered with regular daily activities which is a common problem in runners. High arches with stiffer foot landing especially on hard surfaces may predispose to PTT injuries as well. Recently, toe shoe running has been widely advertised, comparing it to barefoot running and preventing injury. It is important for musculoskeletal specialists to educate the public regarding potential injuries and multifactorial risks (patient’s anatomy, running mechanics, transition time, terrains, proprioception difference in minimalist shoes compared to barefoot) prior to considering new products and techniques. Conclusion: Transition to toe shoe running could lead to PTTD, and if not diagnosed early, with the common noncompliance in runners with activity modification, could become a serious complication.
Poster 357 Median Nerve Snapping at the Forearm in a Clarinetist: A Case Report Claire Gross, MD (Rehabilitation Institute of Chicago, Chicago, IL, United States), Aaron Gilbert, MD Disclosures: C. Gross: I Have No Relevant Financial Relationships To Disclose. Case Description: A 25-year-old man presents with a 1-year history of right upper extremity (RUE) tingling. He is a music performance and education major in college. His primary instrument is clarinet, secondary is piano, tertiary is baritone saxophone. He practices about 6 hours per day, mostly clarinet. He denies recent changes in teachers or repertoire. He notes an insidious onset of tingling in his RUE, primarily over the ulnar side of the hand and forearm, palmar and dorsal, occasionally up to the elbow and radiating to the radial side. The tingling is intermittent, most prominent after playing clarinet for about 20 minutes. He also complains of occasional neck pain after playing and morning stiffness in his right hand. On exam, no evidence of muscle wasting. 5/5 strength throughout, 2+ reflexes throughout, sensation intact to light touch and pinprick throughout. Negative Finkelstein’s, negative Tinel’s. Negative Spurling’s. Setting: Academic center outpatient clinic. Results or Clinical Course: Electrodiagnostic study without evidence of carpal tunnel syndrome or ulnar nerve entrapment. Musculoskeletal (MSK) ultrasound showed normal median and ulnar nerves. Ultrasound while playing clarinet showed the median nerve snapping over one of the superficial flexor tendons approximately 4 cm proximal to the palmar wrist crease. He completed a course of occupational therapy with focus on nerve glides, finger flexor stretching, and postural training with playing. At 2-month follow-up, patient was able to play for up to 1 hour before onset of symptoms, which were relieved with nerve glides and stretching. Discussion: This case demonstrates median nerve irritation due to mechanical snapping at the forearm in a clarinetist, diagnosed by dynamic ultrasound in the context of a normal electrodiagnostic study. Conclusion: Dynamic MSK ultrasound can be utilized to observe nerves dynamically during specific symptom-provoking maneuvers, including playing musical instruments. Identification of the site of nerve compression or irritation can allow future therapy inventions to be more specific.
Poster 358 Osteoporosis and Risk of Hip Fracture. The Role of Calcium and Vitamin D in Post-menopausal Women and Older Men Michael K. Christakos, DO (Indiana University, Indianapolis, IN, United States), Shashank J. Dave, DO Disclosures: M. K. Christakos: I Have No Relevant Financial Relationships To Disclose.
Objective: To investigate current literature for the efficacy of calcium and vitamin D in preventing hip fractures in post-menopausal women and older men. Design: PubMedÒ literature search of articles from 1966-2013 with key words: “osteoporosis,” “fracture,” “calcium,” and “vitamin D.” Only metaanalyses of randomized control trials were included. Setting: Both community and institutionalized settings. Participants: Post menopausal women and men over age 65. Interventions: Calcium alone, vitamin D alone or calcium plus vitamin D [versus placebo or no treatment]. Main Outcome Measures: Risk of hip fracture. Results or Clinical Course: 29 studies total were found with over 35,000 participants. There was no statistically significant risk reduction in hip fracture in the community dwelling participants receiving either calcium alone, vitamin D alone, or the combination of the two compared to controls. There was a small but statistically significant reduction in risk of hip fracture in institutionalized participants receiving calcium plus vitamin D supplementation. Additionally, several of these studies showed trends towards adverse outcomes in the groups containing calcium, including myocardial infarction and stroke. Conclusion: There is evidence that the use of calcium and/or vitamin D supplementation has little role in the reduction of hip or other fractures in the post menopausal and men over 65 community dwelling population. There is small but significant evidence that calcium plus vitamin D supplementation reduces the risk of hip fracture in institutionalized populations (specifically elderly women and men). Considering this evidence, providers may want to rethink recommending calcium and/or vitamin D supplementation in the community population. As for the institutionalized population, providers need to balance the modest benefit with supplementation on hip fracture reduction, especially in high risk cardiovascular disease patient populations.
Poster 359 Successful Outpatient Rehab Course in a Patient with Extensive Bilateral Quadriceps Tears without Surgical Intervention: A Case Report Gregory P. Burkard, DO (NYU, Rusk Rehab, Montauk, NY, United States), Idris Amin, MD, Brian J. Williams, DO, Josh Moosikasuwan, MD Disclosures: G. P. Burkard: I Have No Relevant Financial Relationships To Disclose. Case Description: The patient is a 62-year-old obese man who was referred to the rehabilitation clinic with bilateral (b/l) knee pain after a fall from a chair. He was unable to walk with crutches and b/l knee immobilizers, and required maximal assistance for transfers. Active knee extension of right lacked 45 degrees to neutral and the left lacked 30 degrees to neutral. Strength in knee extensors was 2/5 b/l. MRI of both knees showed complete full-thickness tears of the distal right rectus femoris and vastus intermedius tendons and near fullthickness tear of the distal left rectus femoris tendon, with retraction of up to 1.5 cm b/l. Orthopedics recommended surgery, but the patient refused due to fear of surgery and lack of guarantee of functional recovery. Setting: Outpatient musculoskeletal clinic. Results or Clinical Course: The patient completed two months of outpatient physical therapy primarily focusing on quadriceps strengthening and gait training with b/l hinged post-op knee braces and variable assistive devices. He continued to improve in strength and active range of motion as seen with multiple follow ups. Active knee extension improved to 35 degrees to neutral on right and 20 degrees to neutral on left. In addition, quadriceps strength improved to 5-/5 b/l within limited range. For household ambulation and distances up to 100ft, the patient was able to progress using b/l hinged knee braces with axillary crutches, to rolling walker to eventually lofstrand crutches.
Abstracts / PM R 7 (2015) S83-S222
proper gradual transition time and tried to exercise through pain until it interfered with regular daily activities which is a common problem in runners. High arches with stiffer foot landing especially on hard surfaces may predispose to PTT injuries as well. Recently, toe shoe running has been widely advertised, comparing it to barefoot running and preventing injury. It is important for musculoskeletal specialists to educate the public regarding potential injuries and multifactorial risks (patient’s anatomy, running mechanics, transition time, terrains, proprioception difference in minimalist shoes compared to barefoot) prior to considering new products and techniques. Conclusion: Transition to toe shoe running could lead to PTTD, and if not diagnosed early, with the common noncompliance in runners with activity modification, could become a serious complication.
Poster 357 Median Nerve Snapping at the Forearm in a Clarinetist: A Case Report Claire Gross, MD (Rehabilitation Institute of Chicago, Chicago, IL, United States), Aaron Gilbert, MD Disclosures: C. Gross: I Have No Relevant Financial Relationships To Disclose. Case Description: A 25-year-old man presents with a 1-year history of right upper extremity (RUE) tingling. He is a music performance and education major in college. His primary instrument is clarinet, secondary is piano, tertiary is baritone saxophone. He practices about 6 hours per day, mostly clarinet. He denies recent changes in teachers or repertoire. He notes an insidious onset of tingling in his RUE, primarily over the ulnar side of the hand and forearm, palmar and dorsal, occasionally up to the elbow and radiating to the radial side. The tingling is intermittent, most prominent after playing clarinet for about 20 minutes. He also complains of occasional neck pain after playing and morning stiffness in his right hand. On exam, no evidence of muscle wasting. 5/5 strength throughout, 2+ reflexes throughout, sensation intact to light touch and pinprick throughout. Negative Finkelstein’s, negative Tinel’s. Negative Spurling’s. Setting: Academic center outpatient clinic. Results or Clinical Course: Electrodiagnostic study without evidence of carpal tunnel syndrome or ulnar nerve entrapment. Musculoskeletal (MSK) ultrasound showed normal median and ulnar nerves. Ultrasound while playing clarinet showed the median nerve snapping over one of the superficial flexor tendons approximately 4 cm proximal to the palmar wrist crease. He completed a course of occupational therapy with focus on nerve glides, finger flexor stretching, and postural training with playing. At 2-month follow-up, patient was able to play for up to 1 hour before onset of symptoms, which were relieved with nerve glides and stretching. Discussion: This case demonstrates median nerve irritation due to mechanical snapping at the forearm in a clarinetist, diagnosed by dynamic ultrasound in the context of a normal electrodiagnostic study. Conclusion: Dynamic MSK ultrasound can be utilized to observe nerves dynamically during specific symptom-provoking maneuvers, including playing musical instruments. Identification of the site of nerve compression or irritation can allow future therapy inventions to be more specific.
Poster 358 Osteoporosis and Risk of Hip Fracture. The Role of Calcium and Vitamin D in Post-menopausal Women and Older Men Michael K. Christakos, DO (Indiana University, Indianapolis, IN, United States), Shashank J. Dave, DO Disclosures: M. K. Christakos: I Have No Relevant Financial Relationships To Disclose.
Objective: To investigate current literature for the efficacy of calcium and vitamin D in preventing hip fractures in post-menopausal women and older men. Design: PubMedÒ literature search of articles from 1966-2013 with key words: “osteoporosis,” “fracture,” “calcium,” and “vitamin D.” Only metaanalyses of randomized control trials were included. Setting: Both community and institutionalized settings. Participants: Post menopausal women and men over age 65. Interventions: Calcium alone, vitamin D alone or calcium plus vitamin D [versus placebo or no treatment]. Main Outcome Measures: Risk of hip fracture. Results or Clinical Course: 29 studies total were found with over 35,000 participants. There was no statistically significant risk reduction in hip fracture in the community dwelling participants receiving either calcium alone, vitamin D alone, or the combination of the two compared to controls. There was a small but statistically significant reduction in risk of hip fracture in institutionalized participants receiving calcium plus vitamin D supplementation. Additionally, several of these studies showed trends towards adverse outcomes in the groups containing calcium, including myocardial infarction and stroke. Conclusion: There is evidence that the use of calcium and/or vitamin D supplementation has little role in the reduction of hip or other fractures in the post menopausal and men over 65 community dwelling population. There is small but significant evidence that calcium plus vitamin D supplementation reduces the risk of hip fracture in institutionalized populations (specifically elderly women and men). Considering this evidence, providers may want to rethink recommending calcium and/or vitamin D supplementation in the community population. As for the institutionalized population, providers need to balance the modest benefit with supplementation on hip fracture reduction, especially in high risk cardiovascular disease patient populations.
Poster 359 Successful Outpatient Rehab Course in a Patient with Extensive Bilateral Quadriceps Tears without Surgical Intervention: A Case Report Gregory P. Burkard, DO (NYU, Rusk Rehab, Montauk, NY, United States), Idris Amin, MD, Brian J. Williams, DO, Josh Moosikasuwan, MD Disclosures: G. P. Burkard: I Have No Relevant Financial Relationships To Disclose. Case Description: The patient is a 62-year-old obese man who was referred to the rehabilitation clinic with bilateral (b/l) knee pain after a fall from a chair. He was unable to walk with crutches and b/l knee immobilizers, and required maximal assistance for transfers. Active knee extension of right lacked 45 degrees to neutral and the left lacked 30 degrees to neutral. Strength in knee extensors was 2/5 b/l. MRI of both knees showed complete full-thickness tears of the distal right rectus femoris and vastus intermedius tendons and near fullthickness tear of the distal left rectus femoris tendon, with retraction of up to 1.5 cm b/l. Orthopedics recommended surgery, but the patient refused due to fear of surgery and lack of guarantee of functional recovery. Setting: Outpatient musculoskeletal clinic. Results or Clinical Course: The patient completed two months of outpatient physical therapy primarily focusing on quadriceps strengthening and gait training with b/l hinged post-op knee braces and variable assistive devices. He continued to improve in strength and active range of motion as seen with multiple follow ups. Active knee extension improved to 35 degrees to neutral on right and 20 degrees to neutral on left. In addition, quadriceps strength improved to 5-/5 b/l within limited range. For household ambulation and distances up to 100ft, the patient was able to progress using b/l hinged knee braces with axillary crutches, to rolling walker to eventually lofstrand crutches.