Cowabunga in the Cord

Author/Presenter Full Name: Jacob Doyle, MS, DO

Katherine Bohringer, DO, CAQSM

Affiliation: Tripler Army Medical Center, Honolulu, Hawaii.

History: Pt is a 24 y/o active-duty male soldier with no significant PMH or PSH who was brought into the ER by ambulance for bilateral lower extremity weakness and numbness, one hour after surfing. Patient describes that he was pushing up on his surfboard when he immediately felt discomfort and pain in his lower back, prompting him to immediately return to shore. Initially, he was able to walk and drove himself home, but his pain rapidly progressed with endorsed bilateral leg numbness and subsequent inability to ambulate. There was no loss of bowel or bladder function. No changes in upper extremity strength or sensation. He denied head trauma, LOC, trauma, or previous back concerns. Given overt lower extremity weakness upon arrival to the ER, the patient was admitted for further evaluation.

Physical Exam: VS WNL. General: Well developed. HEENT: PEERLA Neck: supple. no JVD. Cardiac: Regular rate & rhythm. No rubs, gallops or murmurs. Lungs: clear to auscultation bilaterally. Abdomen: soft, nontender, nondistended. No hepatosplenomegaly. Good bowel sounds. Extremities: no cyanosis, clubbing, rash, edema, Brisk capillary refill. Neuro: CN II-XII intact bilaterally, speech fluent and clear. Decreased sensation below the knees b/l, 2-point discrimination and proprioception preserved. 4/5 strength in bilateral hip flexors and quadriceps. 0/5 strength with ankle dorsi/plantar flexion, as well as with extension/flexion of toes. Decreased rectal tone.

Differential Diagnosis:

1. Surfer’s Myelopathy

2. Spinal Cord Dissection

3. Epidural Abscess

4. Compressive Spondylolisthesis

5. Conversion Disorder

Test Results: Evaluation (8/27/23) CBC, CMP, Coags unremarkable. CT Head without acute intracranial pathology. Lumbar Xray's with no acute pathology or degenerative changes. MRI Thoracic and Lumbar Spine demonstrated extensive central edema with mild cord expansion and diffusion signal within the lower thoracic spine extending to conus. (09/06/23) MRA Thoracic spine showed no evidence of vascular anomalies.

Final Diagnosis: Surfer's Myelopathy.

Discussion: Surfer's Myelopathy is a rare, nontraumatic sports emergency affecting young, healthy, usually novice surfers. Presented here a case of a patient with the classic history, physical, and MRI findings of this rare condindtion. Though the exact etiology is unkown, the leading hypothesis includes spinal cord ischemia provoked by prolonged periods of hyperextension, likely due to positional vascular compression. An alternative hypothesis is congenitally altered vascular anatomy predisposing to vascular insufficiency when prone. Though this is most commonly seen in novice surfers, any sport with prolonged hyperextension of the spine may induce this pathology.

Outcome: Patient was admitted to the ICU, and Neurosurgery was consulted. He was treated with IV tencteplase and highdose steroids. A lumbar drain was placed to alleviate pressure on his spinal cord and pressors were given to assure adequate spinal perfusion. After 3 days, his sensation recovered and his lower extemity weakness began to improve. He was discharged to an inpatient rehabilitation center.

Follow-Up: On 30 Oct 2023, over 2 months after his initial injury, patient returned to Hawaii with inact sensation and 5/5 strength in his lower extemities. He continues to work with outpatient PT/OT. Unfortunately, patient has not yet returned to sports, and is currently being medically discharged from the Marine Corps.

The Hoop and the Harm—Acute Shortness of Breath After a Basketball Game

Author/Presenter Full Name: Joshua Berkowitz, MD

Jodi Schneider, MS and Jason Long, MD, MPH

Affiliation: University of North Carolina, Chapel Hill, NC.

History: 22 yo F basketball player presents for evaluation of chest pain and shortness of breath. She was in her usual state of health most of yesterday, playing 32 minutes in a game at 4:00 PM without difficulty. She denies atypical trauma during the game and felt normal until around 8:00 PM, at which time she noticed sharp pain beneath her left breast which was exacerbated by deep inspiration. She denies pain at rest or with more shallow inspiration, but developed shortness of breath overnight which became especially prominent when walking uphill this morning. She has not recently travelled long-distance and denies leg pain or swelling. She discontinued her oral contraceptive 2 months ago and does not smoke. Her father has a history of DVT in the setting of May-Thurner syndrome. She denies fever, cough, rash, dizziness, tingling, numbness or weakness. Her chest wall is not tender to touch.

Physical Exam: VS: T 97.9°, HR 90, RR 24, BP 97/64, 02 sat 98% RA, Pain 8/10 Gen: Young adult female in mild respiratory distress HEENT: Normal Neck: Normal Resp: Increased work of breathing, diminished breath sounds in the left lower and mid lung fields, rare rhonchi CV: Relative tachycardia, normal S1 and S2, no murmurs, rubs or gallops, no chest wall bruising or tenderness to palpation Ext: Well-perfused, no cyanosis, no edema, capillary refill less than 2 seconds Psych: Normal.

Differential Diagnosis:

6. Pneumothorax, spontaneous or traumatic

7. Pulmonary embolism

8. Pleural effusion, primary or secondary

9. Hemothorax

10. Pneumonia

Test Results: EKG: Normal CXR: Moderate left pleural effusion CTA Chest: No pulmonary embolism. Moderate left pleural effusion with passive atelectasis. Nonenhancement in the inferior lingular segment may represent pneumonia. Thoracentesis: 1075 mL bloody fluid Pleural fluid: Red, opaque, 3500 WBC/μL, 4,040,000 RBC/μL, Hct 36% Post-thoracentesis CTA Chest: 2.1 cm bony lesion arising from the posterior aspect of the left anterior 6th rib with imaging features most suggestive of benign exostosis (osteochondroma).

Final Diagnosis: Massive left hemothorax secondary to left 6th rib osteochondroma.

Discussion: Hemothorax is a rare complication of low energy blunt chest trauma, with no reports of hemothorax related to basketball found elsewhere in the literature. Osteochondromas comprise 20 to 50% of benign bone tumors, with 7 to 8% involving the thorax. They may be present in isolation or in the setting of hereditary multiple exostosis. Rib osteochondroma is associated with spontaneous and traumatic hemothorax, pneumothorax, pneumopericardium and diaphragm laceration. Management typically involves segmental rib resection, which requires prolonged recovery time. Isolated osteochondroma resection followed by monitoring for recurrence is a viable therapeutic alternative allowing faster return to sport.

Outcome: Patient was evaluated by thoracic surgery who recommended surgery. Nearing the end of her season and collegiate career, isolated resection of the osteochondroma was elected without segmental rib resection in hopes of allowing more rapid recovery and return to sport. The rib lesion was resected. Two areas of adjacent lung tissue were noted to be damaged and were also removed via wedge resection.

Follow-Up: VATS left 6th rib osteochondroma resection and LLL wedge resection x2. Chest tube removed, patient discharged POD 1. Stationary bike, light shooting resumed POD 4 w/gradual progression of cardiovascular and resistance training. Resumed noncontact practice POD 11, contact practice POD 18. RTP POD 20, completed the season/postseason without restriction or complication. F/u CT 6 months w/o recurrence.

A Cold Hand During a Wisconsin Summer

Author/Presenter Full Name: Adam Cordum, MD

David Bernhardt, MD and Courtney Morgan, MD

Affiliation: University of Wisconsin Madison, Department of Orthopedics, Sports Medicine Division.

History: She is a right-handed 21-year-old volleyball player and plays predominantly as a hitter. 5 days ago, she first noticed increasing discomfort of the right third finger, dorsum of the hand and wrist, and more subjective swelling, especially after hitting a volleyball during training. No reported acute traumatic event proceeding symptom onset. She previously had a metacarpal fracture of the same hand 4 years ago that healed well non-operatively and caused no persistent symptoms. She notes some weakness after hitting in the right arm that may have been ongoing since she noticed symptoms 5 days ago. No history of previous blood clots or personal history of autoimmune disease.

Physical Exam: General: Alert, no acute distress Extremities (R hand only unless otherwise stated): Positive Adson's test. Radial pulses symmetrically 2+ bilaterally. Right hand is cooler to touch than left hand, but only subtly. Negative Tinel and Phalen's tests.

Differential Diagnosis:

11. Upper Extremity DVT

12. Axillary Artery dissection

13. Acute arterial emboli

14. Thenar hammer syndrome

15. Carpal Tunnel

Test Results: CT Angiography Upper Extremity: “multifocal arterial occlusive disease involving the ulnar artery, radial artery, and interosseous branches with areas of partial distal reconstitution near the wrist. This is likely embolic in etiology, though the source of embolism is unclear on this exam.” Right upper extremity angiogram: acute occlusion of the posterior humeral circumflex artery (PHCA) about 1 cm past the takeoff with distal reconstitution, likely from quadrilateral space syndrome.

Final Diagnosis: Vascular quadrilateral space syndrome of the right upper extremity with distal embolization.

Discussion: The quadrilateral space is the space between the long head of the triceps medially, the humerus laterally, teres minor superiorly, and teres major inferiorly. In extremes of abduction and external rotation, the humeral head can compress the vascular (PHCA) and/or nervous (axillary nerve) structures in this space and lead to expected symptoms. A 2019 systematic review of PHCA pathological lesions from overhead sports found they occurred most often in volleyball players (n = 35, 72%). 1 A 2023 case study, in their literature review, found 19 cases of PHCA pathology in volleyball players, but the majority of these were aneurysms (n = 14, 78%) rather than thrombosis (n = 4, 22%) as in our case.

Outcome: The thrombus was thrombolysed with tPA and then addressed with subsequent branch ligation of the PHCA. She was placed on apixaban and aspirin 81 mg for 3 months. Initial post-operative studies were reassuring and she had immediate improvement in distal hand circulation.

Follow-Up: After 3 months of anticoagulation, upper extremity duplex US was normal, as were WBIs. She returned to hitting activities 48 hours after stopping apixaban and is doing well without new symptoms. She will continue on aspirin 81 mg daily for 1 year of total treatment time after the initial thrombus.

A Collapsed Football Athlete During a Timeout

Author/Presenter Full Name: Sanket Patel, DO

Affiliation: Geisinger Health System Danville, PA.

History: This is a 17 y/o athlete with no PMH who collapsed on the field during a timeout. An on-field assessment was initiated. The athlete was lying on the ground without any extremity movements. It was unclear if he had suffered a hit on the previous play. The team's ATC reported the athlete was having cold-like symptoms recently. He had a pulse but had prolonged respirations. Initially, patients' eyes were slightly blinking but then became unresponsive. His pupillary reflex and pain response was absent alongside no verbal/motor response. EMS was called and he was transported to the hospital. Of note, he was seen by an NP earlier in the week and diagnosed with a cold. He had a lingering headache that started few days after a hit 2 weeks ago. He played the previous week but vomited after the game. He reported feeling malaise, hot flashes, nasal congestion with a headache over the last week.

Physical Exam: General: Non-responsive, non-alert. CV: 2+ Radial and carotid pulse, tachycardic. Respiratory: Slowed respirations. Skin: warm, capillary refill was less than 2 seconds. Neuro: GCS of 3 to 4, with no pupillary reflex, nor appropriate pain response noted. MSK: No obvious bruising/deformities noted. Unable to properly assess for neck injury. Initial vitals performed by EMS were normal.

Differential Diagnosis:

16. Cerebrovascular Accident

17. Hyponatremia

18. Exertional Heat Illness

19. Cardiac Arrythmia

20. Traumatic Brain Injury

Test Results: Patient's initial labwork revealed acute kidney injury with Creatine at 2.2 and low potassium at 2.9. He had leukocytosis at 25,000. His Glucose was elevated to 244. CT revealed acute on hyperacute subdural hematoma with 1.4 leftward midline shift with subfalcine herniation, uncal herniation, and mild tonsillar herniation.

Final Diagnosis: Patient likely suffered second impact syndrome leading to dysfunctional blood autoregulation and increase in ICP with a previous subdural hematoma suffered few weeks before.

Discussion: Given his worsening symptoms with a 3 week history of lingering headache after a hit, made worse with physical activity alongside nausea/vomiting in a young pediatric patient, a CT scan was likely warranted or at least a discussion with shared-decision making was to be had based on PECARN criteria. Also, if he had suffered a mTBI/concussion initially with his headache, his persistent/worsening symptoms were also concerning. It is unclear if the athlete was showing any signs/symptoms prior to the incident or minimized his symptoms so that he can play. Although he saw a provider earlier this week, given his URI symptoms with a normal neuro exam, the viral illness was a red herring.

Outcome: He was taken to the OR for emergent decompressive hemicraniectomy. Repeat imaging noted improvement of shift but showed several ischemic areas. On Day 3, he had notable pupillary changes, head CT showed increasing ischemia in his brain and had increasing ICP. EEG did not show significant brain activity even after weaning sedation. He was taken off life support and passed away few days later.

Follow-Up: None.

Oh, Dip!

Author/Presenter Full Name: Alycia P. Heiner, DO

Keyur Desai, MD

Affiliation: Inova Children's Hospital.

History: A 14-year-old right hand dominant swimmer and diver presented with bilateral shoulder pain after swinging between 2 desks at school, in a tricep dip position. He reportedly felt his shoulders “pop” and immediately felt severe pain that caused him to fall. He presented to an outside urgent care where he was placed in a sling, given ibuprofen and cyclobenzaprine, and referred to sports medicine. No infectious symptoms were reported. Medical, surgical, and family history were negative.

Physical Exam: T: 36.8 C, HT: 155.5 cm, WT: 48.7 kg General: slouched posture, well-appearing, in no acute distress MSK: bilateral shoulders Inspection: significant ecchymosis over the bilateral proximal to mid biceps without swelling or erythema Palpation: tender to palpation about the anterior/lateral/posterior shoulder ROM: no pain or restriction with cervical or bilateral shoulder range of motion Strength: 4/5 strength throughout, pain with rotator cuff muscle activation Neurovascularly intact. Special tests: pain with Hawkins/Kennedy, Neers, and Yergason's Non-orthopedic exam unremarkable.

Differential Diagnosis:

21. Rotator cuff strain

22. Rotator cuff tear

23. Subacromial impingement

24. Avulsion fractures

25. Biceps strain

Test Results: POCUS: hyperechoic rotator cuff muscles, + fluid collection 3 view shoulder XR: humerus bone avulsions Non-contrast MRI R shoulder: signs of posterior dislocation and complete rupture of all bundles of the subscapularis tendon. Probable complete humeral avulsion of the glenohumeral ligament. Large hemarthrosis. Non-contrast MRI L shoulder: Complete rupture of all bundles of the subscapularis tendons. Humeral avulsion. Low grade supraspinatus partial thickness tear. Moderate hemarthrosis.

Final Diagnosis: Bilateral subscapularis tear with lesser tuberosity avulsions.

Discussion: Full thickness subscapularis tears are typically a result of trauma, most often from a FOOSH injury. Pediatric subscapularis tears are rare and are often associated with an avulsion of the lesser tuberosity. To our knowledge, this is the first case of bilateral rupture in the pediatric population, requiring further investigation and discussion. Subscapularis tears were previously treated non-operatively with PT. Long-term sequelae of nonoperative treatment include lesser tuberosity overgrowth, restricted ROM, inability to return to previous level of function, and chronic pain. The decision was made to proceed with surgery given age and athletic participation.

Outcome: The patient underwent open repair of the subscapularis muscles and lesser tuberosity avulsions with SwiveLock anchors via double row repair. The procedure was tolerated well.

Follow-Up: He was placed in bilateral pillow slings post op. At 2 weeks, he began a PT protocol for Bankart repair. He progressed through physical therapy without complications. Around 4 to 6 months, he returned to backstroke and freestyle. At 6 months, he was cleared to return to diving, and to start off the block for swimming. He was then eased back into butterfly. At 1 year post-op, he was fully cleared.

Elusive Effusion: A Rare Cause of Non-traumatic Knee Swelling

Author/Presenter Full Name: Jana Qiao, MD

Laura Lintner, DO

Affiliation: Wake Forest University School of Medicine, Winston-Salem, North Carolina.

History: Twenty-nine-year-old female recreational hiker who presented for evaluation of worsening, chronic left medial knee pain and swelling ongoing for 5-6 years. Pain is non-radiating, pressure-like in quality. No catching or locking of her joint, no distal paresthesias or lower extremity weakness. While utilization of knee bracing and NSAIDs have helped manage her pain, her knee effusion has continued to worsen to the point that it has started to hinder her ability to hike and carry out daily activities. She endorses a distant history of having developed pharyngitis prior to initial knee swelling, does not recall sustaining a tick bite before. She also endorses a remote history of knee injury in high school, and no history of procedure or surgeries performed on her knee. No notable personal or family history of autoimmune disease or osteoarthritis.

Physical Exam: General: In no acute distress, well-appearing, well nourished. BMI 29.4. Cardiovascular: regular rate and rhythm, well perfused extremities, non-diaphoretic, no distal edema. MSK: Left knee is diffusely swollen, prominent over the superomedial aspect of the knee with tenderness to palpation over the medial joint line, medial aspect of patella, and areas of localized swelling. ROM on flexion is decreased. Negative patellar apprehension, patellar grind, anterior drawer, posterior drawer, valgus stress test, varus stress test, McMurray test.

Differential Diagnosis:

26. Osteochondral Defect

27. Medial Meniscus Injury

28. Infectious Arthropathy

29. Autoimmune Arthropathy

30. Synovial Pathology

Test Results: X-ray: effusion, small osteophyte, medial joint space narrowing, diffuse degenerative change. US-guided aspiration: 90 cc yellow hazy synovial fluid, 4550 total nucleated cells, 2100 RBCs, no gout/pseudogout crystals, 30% neutrophils, 52% lymphocytes, fluid culture negative. MRI: joint effusion, synovitis and lipoma arborescens, seen in inflammatory or septic arthritis (mycobacterial, fungal, Lyme). Hoffa fat pad edema with patella maltracking. Chondrosis of medial patella with deep fissuring.

Final Diagnosis: Lipoma Arborescens.

Discussion: Lipoma Arborescens (LA) is a rare intra-articular hyperplastic tumor often presenting as a painless effusion caused by synovial irritation in older age, with synovectomy recommended for treatment. Studies have connected delayed intervention to arthritis progression, highlighting the importance of early identification. This unusual case in a young female with age-inconsistent degenerative changes on X-ray and worsening function, despite few OA risks, correlates with this concern and raises the question of if disease sequelae instigated LA or vice versa. Identifying alternate causes is important to avoid unnecessary surgery, illustrating the diagnostic complexity in this healthy young patient.

Outcome: Knee pain has resolved since aspiration. Patient has been referred to physical therapy for symptomatic management of suspected concurrent patellofemoral syndrome. Referred to Orthopedics for concurrent management.

Follow-Up: Patient has remained asymptomatic and has returned to daily work activities. Follow-up and ongoing surveillance for effusion recurrence and progressive symptoms are planned.

Should We CAVE on Return to Play?

Author/Presenter Full Name: Connor O'Sullivan, MD

Joseph Powers, MD, CAQSM, Torrance Laury, MD, CAQSM, and Aalok Shah, DO

Affiliation: Northside Hospital Orthopedic Institute, Lawrenceville, GA.

History: 20 y.o. M D1 football player presents to training room during summer workouts c/o headache and dizziness starting earlier the same day. Pt was participating in non-contact conditioning when sxs started. HA was moderate and the dizziness was mild. He denied any trauma or recent illness. Also denied N/V, fever, weakness, numbness or tingling. He reported a personal and Fhx of migraines. Decision was made to monitor and treat symptomatically for suspected migraine headache.

Physical Exam: Initial exam in training room; Gen: NAD; HEENT: NCAT, no JVD, PERL, EOMI; Extremities: No joint swelling; Neuro: GCS 15, Follows commands, Face symmetric, Full visual fields, Strength 5/5 throughout b/l, mildly ataxic gait, non-antalgic.

Differential Diagnosis:

31. Headache Disorder

32. Concussion

33. Heat Related Illness

34. Meningitis

35. Intracranial Hemorrhage

Test Results: Pt directed to ER 3 days later for worsening HA and development of nausea and emesis. CT Head w/o Contrast: Hyper-dense focus in the med aspect of the L cerebellar hemisphere with ∼14 cc with surrounding edema and localized mass effect. MRI Brain: Intra-parenchymal hematoma in the inf L cerebellar hemisphere extending to the L cerebellar tonsil; draining venous vessel seen superior to the hematoma in normal parenchyma; findings suggestive of cavernous malformation or AVM.

Final Diagnosis: Intra-parenchymal Hematoma secondary to Cavernous Malformation.

Discussion: Cavernous malformations (CM) are uncommon, low flow vascular malformations occurring in the CNS. Scant literature exists on recommendations for athletes with CM and RTP. One study notes hemorrhagic risk to be between 0.7 and 4.2% per pt yr, with prior hemorrhage being a predictor of future hemorrhage risk. Data for a role of physical exertion and trauma increasing hemorrhage risk is limited. We involved specialists and published literature when deciding RTP for this pt with a rare condition. In this scenario, decision was made to allow for RTP with emergent evaluation to be performed if return of HA, dizziness or nausea. Pt elected to accept these risks vs potential risks of surgery on the CM.

Outcome: Pt admitted to Neuro ICU and started on hypertonic NS and IV steroids. Decision made to not surgically intervene at that time and monitor pt. Pt’s HA continued to improve over the following 7 days. Due to stability of the bleed on repeat imaging, d/c'ed home on steroid taper as well as amlodipine to dec systolic BP. He was told to avoid strenuous activity until neurosurgical follow-up.

Follow-Up: At 2 week f/u HA and dizziness had resolved. Repeat MRI at 2 months demonstrated interval dec in size of hematoma. Case discussed with multiple neurosurgeons and lit review was performed. Decision was to have surgical resection of the lesion following football season and allow patient to participate with need for urgent imaging if sxs recurred.

A Curious Case of a Collegiate Center's Cardiac Clearance

Author/Presenter Full Name: Brendan Dempsey, MD

Arjun Kanwal, MD, Valerie Cothran, MD, and Yvette Rooks, MD

Affiliation: University of Maryland, Baltimore, Maryland.

History: A 21-year old Black Division 1 Basketball Student-athlete presents to training room for his annual PPE. He reports a past medical history of intermittent hypertension with a history of cardiac clearance to participate in sport at his previous institution. He had been diagnosed with COVID-19 infection approximately 6 months prior to his visit. Over the past year, the patient reports 4 to 5 episodes of fleeting, sharp, atypical chest discomfort with exercise. He reports exercising through this chest pain which resolves within 30 seconds. He denied any syncope, near syncope, palpitations with exertion. He denies any chest pain at rest. Of note, he reports a history of a “normal” Holter monitor test in high school for which we have no record. He has no surgical history, allergies. He is from Lagos, Nigeria. He is unaware of any cardiac family history.

Physical Exam: Height 6 foot 11 inches. Weight 240 lbs. Blood Pressure 128/80. Pulse 56. Respiratory rate 14. 98% oxygen saturations. General—well-appearing, muscular body habitus, comfortable, no acute distress HEENT—unremarkable, normal JVP, no carotid bruits Pulmonary—lungs clear to auscultation bilaterally Cardiac—The precordium is quiet. Regular rate and rhythm. S1 is normal, S2 is physiologically split. No murmur is appreciated. Diastole is quiet. Distal extremities are warm. 2+ DP pulse. Capillary refill is brisk. Chest Wall—normal without deformity or scars Abdomen—unremarkable Skin—unremarkable Extremities—unremarkable.

Differential Diagnosis:

36. Post-COVID Cardiomyopathy/Myocarditis

37. Hypertrophic Cardiomyopathy

38. Mitral or Tricuspid Valve Regurgitation

39. Anomalous Right Coronary Artery

40. Paroxysmal Atrial Fibrillation

Test Results: EKG: Sinus brady, LVH. TTE: Normal LV and RV size, systolic function, normal wall thickness. No stenosis/regurgitation. Origin of RCA off the left sinus. CTA: Common origin of the LCA and RCA. The anomalous RCA originating 1.4 cm superior to the aortic annulus and has a 1 cm intraarterial course and a short intramural course with no significant ovoid compression on diastolic phases. Stress ECHO: Negative for myocardial ischemia. Cardiac MRI:No myocardial ischemia in the RCA distribution. No LGE.

Final Diagnosis: Anomalous aortic origin of the right coronary artery (AAOCA) from the left sinus of Valsalva with an intraarterial and probable intramural course.

Discussion: AAOCA's are estimated in 0.1 to 1% of the population. The overall risk of sudden cardiac death (SCD) from AAOCA is low but thought to be highest among athletes. There is a lack of consensus on management of asymptomatic right AAOCAs. In the 2017 review of AAOCA treatment by the ACC, a conservative approach is considered reasonable without evidence of ischemia or proximal vessel narrowing. The 2015 ACC/AHA guidelines on exercise restriction states that restriction is only recommended for patients with an anomalous left coronary. For AAOCRA patients without symptoms or a positive exercise test, the decision to participate can be considered after adequate counseling.

Outcome: The cardiac findings were discussed with the athlete. Conversations included discussion of the patient's overall risk of SCD in the scenario of continuing versus stopping competitive basketball. The patient showed a strong understanding of the implications of these findings/his risk stratification. The decision was made to return to competitive basketball.

Follow-Up: The patient returned to competitive Division 1 basketball. He was marked as low risk for sudden cardiac death and was cleared to fully participate. The patient will have stress echocardiography yearly as part of his evaluation. He will be re-evaluated if any concerning cardiovascular symptoms re-present.

When Walking Funny is Not Funny

Author/Presenter Full Name: Frank Woo, MD

Nathaniel Jones, MD

Affiliation: Loyola University Medical Center, Maywood, IL.

History: Previously healthy 11 year-old boy presents to the sports medicine clinic for right leg and foot pain for 1 month. Mother initially thought patient had a hamstring strain, but it was followed by 2 weeks of right foot and ankle pain with weakness. The pain is so severe that it wakes him up at night despite taking tylenol and motrin every 3 hours. He endorses at least 2 episodes of tripping and falling due to his “foot giving out.” Per parents, he has been “walking funny.” He was evaluated at an OSH ER a week ago with normal XR of the foot and ankle. Denies injury, trauma, fever, recent illness, diarrhea, vomiting, urinary or fecal incontinence. No recent travel except for a road trip to South Dakota and Wyoming a few months ago, where he went hiking, kayaking, and paddleboarding. Denies any bug bites or ticks. Endorses decreased PO intake for the past week but no weight loss.

Physical Exam: General: no acute distress. Back: no tenderness to palpation, negative straight leg test. Right lower extremity: no effusion, muscular atrophy or tenderness noted; strength deficits include 0/5 tibialis anterior, 0/5 extensor hallucis longus, and 0/5 dorsiflexion of right foot; when foot brought into dorsiflexion, patient cannot hold foot up and has pain. Left lower extremity: normal left lower extremity exam. Neuro: decreased sensation to light touch, pinprick and temperature in the dorsal surface of the right foot extending to the lateral mid-calf. Gait: when standing, noted to have a right foot eversion and appears unstable; appears to drag right foot when ambulating.

Differential Diagnosis:

41. Lyme disease

42. Peroneal nerve compression/entrapment

43. Mononeuritis multiplex

44. Malignancy

45. Charcot-Marie-Tooth

Test Results: CBC WNL, CMP anion gap metabolic acidosis, CRP 3.4 mg/dl, ESR 50 mm, CK WNL, and UA unremarkable; XR pelvis: unremarkable, no mass seen; MRI of the entire spine with and without IV contrast: large right presacral, partially necrotic mass 4.8 cm × 6.2 cm × 5.6 cm at the anterior right S1 vertebral body with caudal extension to the coccyx and invasion of the right sacrum, right sacral neural foramina and encasement of the right internal iliac artery.

Final Diagnosis: Biopsy of the presacral mass revealed a malignant small round cell tumor, most consistent with Ewing sarcoma.

Discussion: Primary bone tumors, like Ewing sarcoma (ES), represent 6% of all childhood cancers. ES is an aggressive cancer with a 5-year survival rate of 33% if metastasis is present. The peak incidence of ES is 10 to 15 years, with slight male predominance. Since constitutional symptoms are only present in 10 to 20% of patients at diagnosis, providers should have a high degree of suspicion for malignancy in this age group, especially with neurologic symptoms. The most common locations for ES include the pelvis, axial skeleton and femur and typically present with localized pain and swelling. If the spine or sacrum are involved, symptoms and signs of nerve root or spinal cord compression are seen.

Outcome: His bone marrow showed a normocellular bone marrow with no evidence of a metastatic tumor. PET/CT showed no evidence of metastatic disease but did show prominent mesenteric lymph nodes, albeit without increased radiotracer uptake. Since this seemed to be a localized disease, he was started in a randomized control trial that included chemotherapy and radiation therapy (RT).

Follow-Up: A few months after finishing chemotherapy and RT, he complained of left scalp pain and further imaging showed a new T6 vertebral body lesion and interval growth of his presacral mass. He underwent salvage chemotherapy and RT, but after 1 month, his presacral mass was still growing. He obtained a second opinion and was briefly started on pazopanib, before ultimately deciding to pursue hospice.

When Love Makes You Limp: An Unusual Case of Ankle Pain in a High School Athlete

Author/Presenter Full Name: Grace Danby, MD

Nicole Prendergast, MD

Affiliation: Wake Forest Department of Emergency Medicine, Winston-Salem, NC.

History: An 18-year-old otherwise healthy high school football player presented to the Emergency Department (ED) for one day of progressive, nontraumatic left ankle pain. He initially noticed clicking and popping of his left ankle at football practice the previous day, but did not recall an injury. He presented to his athletic trainer who was concerned for tendonitis or ankle sprain and recommended conservative management. He noted onset of pain and swelling when he woke up the next morning, 16 hours prior to presentation. He was initially able to walk, however throughout the day had progressive worsening of pain preventing him from bearing weight. He denied fevers, paresthesias, weakness, recent viral infection, antibiotic use, sexual activity, or prior injury to the ankle. No past surgical history or medications were reported. Mom denied family history of autoimmune disease.

Physical Exam: GENERAL: non-toxic appearing, no acute distress HEENT: normocephalic atraumatic, pupils equal and reactive, extraocular muscles intact CARDIAC: regular rate and rhythm, no murmur, rub or gallop NEURO: awake and oriented x3, cranial nerves II - XII intact, cerebellar function intact, unable to assess gait SKIN: no rash FOCUSED: left ankle with visible swelling and tenderness about bilateral malleoli. Achilles tendon is tender to palpation. Negative Thompson test. No calcaneal tenderness. 2+ dorsalis pedis pulse. Normal sensorimotor function of left lower extremity. Active and passive ROM of left ankle limited by pain. No overlying erythema or laceration.

Differential Diagnosis:

46. Fracture of Ankle or Foot

47. Ankle Sprain

48. Septic Joint

49. Juvenile Idiopathic Arthritis

50. Tendonitis

Test Results: Xray L Foot and Ankle: no fracture or dislocation. Point-Of-Care Ultrasound: Tibiotalar joint effusion. No acute tendon injury. Labs: WBC 13.9, CRP 62, ESR 15, urinalysis with 500 leukocytes. STI Antigen: Positive gonorrhea and chlamydia. Synovial Fluid Analysis: purulent, 85,200 nucleated cells with 85% neutrophils, no crystals, negative gram stain. Synovial Fluid Culture: numerous WBC with no growth to date.

Final Diagnosis: Gonococcal Septic Monoarthritis of the Left Ankle.

Discussion: Gonorrhea is the second most common sexually transmitted infection in the United States. In 2021 there were 710,151 new cases with nearly half occurring in the 15 to 24 age group. Disseminated gonococcal infection (DGI) occurs in 0.5 to 3% of cases. Gonococcal arthritis is a type of DGI and usually involves the knees, ankles, wrists, and elbows. While outcomes are excellent if this condition is promptly recognized and treated, irreversible joint destruction occurs if missed. This diagnosis must be carefully considered in athletes due to the large differential of relatively benign causes of joint pain, that if anchored on prematurely, could cause a delay in diagnosis and permanent joint damage.

Outcome: The patient underwent left ankle irrigation and debridement with orthopedics and was started on IV vancomycin. Infectious disease was consulted, and antibiotics changed to IV ceftriaxone and oral doxycycline. He was discharged one week later, made weight bearing as tolerated on the left ankle and given crutches for comfort. Operative cultures and blood cultures have shown no growth to date.

Follow-Up: The patient followed up in sports medicine clinic 3 weeks after discharge. He had 0/10 ankle pain and was fully weightbearing. He had resumed light running and was working towards returning to football. He was cleared to return to football the following week under supervision of his high school athletic trainer.

Finish Line Fatigue: Weakness in a Triathlete During Mass Participation Event

Author/Presenter Full Name: Brenna Ori, DO

Affiliation: Aurora Health Care Milwaukee, Wisconsin.

History: A 19 year old male triathlete presents to the medical tent at the USA Triathlon reporting profound fatigue. The patient states he felt good during the whole race, but at the finish line noticed a sudden overwhelming sense of weakness. Other associated symptoms include mild abdominal pain and some muscle tightness. The patient reports similar incidents of these symptoms during past races though admits that his current symptoms are much more mild than they have been previously. He has required hospitalization for similar symptoms at prior events. His past medical history is significant for adrenoleukodystrophy status post bone marrow transplant 8 years ago and primary adrenal insufficiency for which he is on hydrocortisone 25 mg daily divided into 3 doses and fludrocortisone 0.1 mg daily.

Physical Exam: General: Awake, alert, and answering questions appropriately Skin: diaphoretic consistent with recent physical exertion CV: tachycardic, no murmurs Respiratory: lungs clear to auscultation Abdominal: abdomen is soft and not tender to palpation MSK: moving all 4 extremities against gravity, but is unable to stand without assistance due to weakness.

Differential Diagnosis:

51. Adrenal Crisis

52. Hyponatremia secondary to adrenal insufficiency

53. Heat-related illness

54. Muscular fatigue secondary to exertion

55. Hypoglycemia

Test Results: No testing was available due to being in the field.

Final Diagnosis: Early manifestation of an adrenal crisis and hyponatremia secondary to primary adrenal insufficiency.

Discussion: This case provides an unique example of a high level triathlete with adrenal insufficiency. High level endurance exercise has been known to commonly precipitate hyponatremia given increased fluid intake while racing. This patient is already predisposed to hyponatremia with his history of adrenal insufficiency. Most patients with primary adrenal insufficiency require stress dosing of steroids during illness. However, there are limited recommendations for stress dosing during endurance races. For this patient, his race day regimen includes: Liquid IV, fludrocortisone 0.1 mg, prednisone 5 mg, hydrocortisone 20 mg before the swim, 25 mg before the bike and 30 mg before the run, and salt tablets.

Outcome: The primary manifestations of an adrenal crisis include shock, profound weakness/fatigue, abdominal pain, and anorexia. His weakness at the finish line seems likely secondary to an early manifestation of an adrenal crisis. The patient remained stable after finishing the race and his symptoms improved dramatically with oral hydration along with salt tablet supplementation and steroid stress dosing.

Follow-Up: The patient recovered after staying in the medical tent for about an hour and was able to walk away of his own volition. In discussion with the patient several months after his race, he reports no long term effects from that race day. He acknowledges that finding the right stress dosage is still a challenge for him. However, he continues to be able to race triathlons competitively.

To the Side and Back: A Tale of Posterior Lateral Knee Pain

Author/Presenter Full Name: Christopher Omara, DO

Jonathan Stoddard, MD

Affiliation: Carl R Darnall Army Medical Center Family Medicine Residency, Fort Cavazos, TX.

History: Thirty-three year-old active duty male presents with posterior lateral left knee pain. The patient sustained an injury to the knee in May of 2020 when he landed forcefully on the left leg while exiting a military vehicle. He reports his pain is exacerbated by prolonged sitting, particularly while driving. Prior to presenting to the sports medicine clinic, the patient was treated by his primary care physician with physical therapy and NSAIDs for a presumed LCL strain with minimal improvement in his pain.

Physical Exam: Normal inspection of the knees bilaterally with no effusion. Normal range of motion and strength in flexion and extension. Pain reproduced with full flexion of the left knee. Negative and Lachman, posterior drawer and valgus and varus stress testing. Negative McMurray's. Tenderness to palpation over the posterior lateral joint line. Pain with articulation of the fibular head.

Differential Diagnosis:

56. Posterior horn lateral meniscus tear

57. Low-grade LCL injury

58. Osteoarthritis

59. Tibiofibular osteochondral defect

60. Common peroneal nerve entrapment

Test Results: Plain films of the left knee displayed mild degenerative changes but were otherwise normal. A follow-up MRI displayed a small focus of marrow edema in the fibular head at the articulation with the tibia consistent with an osteochondral lesion of the proximal tibiofibular joint. MRI was otherwise normal.

Final Diagnosis: Osteochondral defect of the proximal tibiofibular joint (PTFJ).

Discussion: The differential diagnosis for posterior lateral knee pain is wide given the anatomic complexity of this location. Most often the knee joint is suspected. However, attention should be paid to the adjacent PTFJ during the evaluation. Corticosteroid injection has demonstrated moderate improvement for refractory PTFJ pain, but given the efficacy of PRP in treatment of osteochondral defects, the patient was offered PRP injection of the PTFJ. A review of the literature found no prior case reports of PRP injection into the PTFJ for the treatment of osteochondral lesions.

Outcome: Patient was contacted 6 weeks post-injection for virtual follow-up. At that time, the patient reported decreased frequency and severity of his presenting knee pain. Patient denied any adverse effects from the PRP injection other than mild soreness for 2 to 3 days following the procedure.

Follow-Up: The patient has returned to full military duty without limitation from his left knee pain. Further follow-up is warranted to observe for long term benefit of treatment and possible need for repeat PRP injection or alternative treatment modalities in the future.

Running into Rash Decisions

Author/Presenter Full Name: Kimberly Burbank, MD

Maggie Hansell, MD and Christopher Nelson, MD

Affiliation: Atrium Health Wake Forest Baptist Family Medicine, Winston-Salem, North Carolina.

History: A 31-year-old-female runner with IBS presents to her PCP's office for a rash that occurs with exercise. She notes diffuse red and itchy welts that develop several minutes into her runs. The welts come and go along with linear red marks where she scratches. The rash subsides within an hour of exercise cessation. She denies rash with sweating or exposure to heat without exercise. She also endorses palpitations and dyspnea early in her runs. She has played multiple sports, including regular distance running throughout her lifetime, so these premature exercise-induced symptoms feel inappropriate to her. She denies chest pain or any symptoms with rest or light activity. Patient denies similar symptoms prior to the last few months, childhood asthma, or food triggers prior to symptom onset. She has had hives with naproxen once before, but no other known allergies.

Physical Exam: General: Well-appearing, cooperative, good hygiene. HEENT: Normocephalic, atraumatic. Eyes: PERRL, conjunctivae clear, EOMI. Resp: Comfortable WOB. CTAB. No wheezes or crackles. CV: RRR. Normal S1/S2, no m/g/r. No cyanosis or edema. Peripheral pulses intact. Abd: NABS, soft, nontender, nondistended. No palpable masses, no HSM. Neuro: CN II-XII grossly intact, motor and sensory grossly intact. Skin: small linear petechiae along bra line. MS: No depression, anxiety, agitation.

Differential Diagnosis:

61. Acute spontaneous urticarial reaction

62. Mast cell activation syndrome

63. Food allergy exacerbated by exercise

64. Exercise induced bronchoconstriction

65. Cardiac arrhythmia

Test Results: EKG: Sinus rhythm with sinus arrhythmia. Tryptase 2.8 (N less than 11.5). TTG IGA Ab less than 1.2. TSH 1.617. IMMAS 131 (celiac disease serology). ESR 10. WBC 5.4. HgB 13.2. MCV 93.4. Eosinophil 1%.

Final Diagnosis: Exercise-induced (cholinergic) urticaria with features of exercise induced anaphylaxis.

Discussion: Exercise induced urticaria and anaphylaxis (EIA) are important entities to recognize in the athlete population as these 2 conditions represent a continuum of symptomatology. Exercise induced anaphylaxis can quickly become life threatening with the speed at which laryngeal inflammation occurs during exercise. Although the pathophysiology of EIA is not fully understood, it is thought to involve histamine and tryptase release which leads to mast cell activation. Diagnosis of EIA is heavily based on clinical history and physical exam. However, obtaining tryptase and histamine levels during exercise can be useful as elevated levels of these markers are highly suggestive of EIA.

Outcome: PCP referred patient to an allergist and counseled her to avoid excessive exercise prior to evaluation. The allergy specialist confirmed the diagnosis and recommended maximum fexofenadine dosing. Allergy also prescribed albuterol for use prior to running and an epinephrine pen to keep on hand. The athlete reported improvement of symptoms with treatment and was able to continue distance running.

Follow-Up: Allergy and immunology released the patient back to full activity with daily maximum dose antihistamine providing adequate control of her symptoms. The athlete was instructed to carry an epinephrine pen for all cardiovascular exercise. She follows up regularly with her PCP with instruction from allergy to obtain a tryptase level for return of symptoms with exercise.

Chest Pain in a Healthy 19-Year-Old Female College Soccer Player

Author/Presenter Full Name: Swaroop Murugesh, DO

Amy Rantala, MD and Nicholas Hora, DO

Affiliation: Mayo Clinic Health System, Eau Claire, Wisconsin.

History: A healthy 19-year-old female with no prior medical history presented to the emergency department with chest pain one day after falling forward onto outstretched arms during a collegiate soccer game. On the day of presentation, she developed worsening right sided chest pain along the pectoralis muscle radiating into the right axilla. She also complained of fever, fatigue, mild shortness of breath and pre-syncopal episodes. She denied any cough, rash, wounds, headache, neck pain, abdominal pain, dysuria, diarrhea, nausea or vomiting. Patient denied IV drug use or recent dental procedures. Patient was noted to be febrile (38.7 C) and initial laboratory work up revealed positive blood cultures for gram positive cocci in 2 out of 2 bottles. Patient was admitted to the hospital for further work up and IV antibiotics.

Physical Exam: Aside from being febrile, her vitals were otherwise within normal limits. HEENT exam was normal with good dentition. Cardiovascular and respiratory exams were also normal. There was tenderness in the right upper chest, most significantly in the pectorals muscle near the insertion of the shoulder, and also along the right upper ribs towards the costochondral junction. There was no tenderness along the clavicle and no overlying skin changes, swelling, or wounds on the chest wall.

Differential Diagnosis:

66. Pectoralis Muscle strain

67. Bacterial Pneumonia

68. Endocarditis

69. Costochondritis

70. Rib Fracture

Test Results: CRP 40.2. WBC 8.4 k and ANC 7.1 k. Chest x-ray normal. CT Chest with IV contrast showed no abscess, signs of infection, or any osseous abnormalities. Blood cultures grew Methicillin-Sensitive Staphylococcus aureus. MR right shoulder negative for osteomyelitis. Ultrasound of right arm showed no fluid collection or mass. Transesophageal echocardiogram was normal. MR Chest revealed septic arthritis of sternomanubrial articulation with retrosternal fluid/edema.

Final Diagnosis: Sternal Manubrial Osteomyelitis.

Discussion: Infection of the sternomanubrial joint is uncommon. These infections occur in individuals with risk factors such as IV drug use and immunodeficiency. A young, immunocompetent female athlete developing sternomanubrial osteomyelitis after traumatic fall without a source of infection is rare. She was initially thought to have 2 separate disease processes- pectoralis muscle strain and viral illness. Blood cultures and thorough investigation to find source of infection was