Abdominal Swelling in a Volleyball Player

Primary Author/Presenter: Alexander Nguyen, MD

Kevin deWeber, MD

Affiliation: PeaceHealth Primary Care Sports Medicine Fellowship, Vancouver, WA.

Assigned #: C2022-0072

Presentation Type: Podium

History: 22 yo female D1 college volleyball player reports 2-3 weeks of atraumatic left lower quadrant abdominal pain, swelling, numbness that developed slowly over time while playing volleyball season and increased frequency spiking drills. Reported initial improvement with athletic trainer treatment with ice, electrical stimulation, kinesiotaping, ibuprofen, but worse after several rounds of scraping, cupping. She is unable to complete situp due to pain. She denies easy bruising or anticoagulation use. No family history of hemophilia or easy bleeding. No dysuria, or history of abdominal surgeries. She presents in college training room for further evaluation/treatment.

Physical Exam: Vital signs: BP 125/75, HR 80 bpm, Abd: Soft, with tenderness/induration in left lower abdomen. No guarding/rebound. Positive Carnett's sign. No hernia on exam. Pain LLQ with resisted abdominal flexion. No bruising. Remainder of exam is normal.

Differential Diagnosis:

1. Rectus Sheath Muscle Abdominal Strain 2. Athletic Pubalgia 3. Urinary Tract Infection 4. Inguinal Hernia 5. Rectus Sheath Hematoma

Test Results: Diagnostic Ultrasound in Training Room: Irregular and relatively anechoic signals within rectus muscle LLQ; no hernia noted; suspicious for rectus sheath hematoma. Formal US Abdomen complete: 1. Small focus of hemorrhage within the left rectus abdominis muscle and the location of the patient's left lower quadrant pain 2. Exam otherwise unremarkable

Final Diagnosis: Rectus Sheath Hematoma in left lower quadrant + Grade 2 Left Lower Rectus Abdominis Tear

Discussion: Rectus sheath hematoma is a rare and often missed diagnosis. However, it is more prevalent in athletes with overhead extension movements such as tennis and volleyball players, so team physicians should maintain a high index of suspicion in this population and evaluate with POC ultrasound early. Treatment for this condition should not include manual mobility adjuncts such as scraping, electrical muscle stimulation, or cupping. Physicians should work closely with their athletic training staff to ensure adequate evaluation prior to targeted, safe and effective therapies. Could manual therapies have caused the hematoma as they treated an uncomplicated abdominal wall muscle strain?

Outcome: After initial evaluation by team physician, she was told to rest, apply compression to area for few days, avoid manual therapies such as scraping, electrical stim, cupping. Patient reported marked improvement in pain, swelling after 1-2 weeks.

Follow-Up: Volleyball athlete returned to full activity and was able to return to full play at 3 weeks post-diagnosis, no further follow-up required.

The Curious Case of Shoulder Pain

Primary Author/Presenter: Dimitry Belogorodsky, DO, MS

Mitchell Cooper, MD and Faisal Al-Alim, MD

Affiliation: Lehigh Valley Health Network, Allentown, PA.

Assigned #: C2022-0085

Presentation Type: Podium

History: 33 yo RHD male presenting complaining of right shoulder pain for 5 days. He states that he was working lifting heavy rocks, did not feel any immediate pain pop or discomfort however the following day in the morning had severe pain 10/10. Was evaluated at OSH which x-ray of the cervical spine and right shoulder was obtained with no acute findings noted. He still has difficulty with raising his arm. Denies any prior surgery to the right shoulder but does have a history of possible rotator cuff injury state many years ago regarding the right shoulder. Denies any radiculopathy to the hands or finger. Denies any paresthesia to the hand or finger. Denies any clumsiness to the hand but does report of slight tightness of the right-sided neck.

Physical Exam: Cervical Neck: No spinal point tenderness | Full ROM but with stiffness to extension | Negative Spurling's bilaterally | Hypertonicity of R trapezius/levator scapulae | RIGHT Shoulder: Inspection: No erythema, no swelling/effusion, no scars noted

Differential Diagnosis:

6. Subacromial Impingement 7. Rotator Cuff Tear 8. Labral tear (SLAP) 9. Adhesive Capsulitis 10. Trapezius Spasm/Referred Neck Pain

Test Results: Xray C-spine: Unremarkable cervical spine Xray R shoulder: No acute osseous abnormality MRI: 1. Full-thickness, partial width supraspinatus tendon tear at its anterior insertion. A type II acromion is a sign of potential impingement. 2. Superior glenoid labral tear, extending anterior to posterior (SLAP). 3. Glenohumeral joint effusion. Joint Fluid& Tissue Culture: (+) for N. gonorrhea

Final Diagnosis: Right shoulder septic arthritis due to N. gonorrhea

Discussion: The incidence of septic arthritis ranges between 2-6 cases per 100,000 patient years. The overwhelming majority of cases begin with predisposing factors such as IV drug use, immunosuppression, presence of a prosthetic joint, etc. Gonococcal arthritis occurs as a disseminated infection or as a septic arthritis in young, healthy, sexually active individuals. Studies found that approximately 21% of patients diagnosed with suppurative gonococcal arthritis do not display any signs. Once diagnosed with a gram stain and culture, treatment involves IV antibiotics in combination with debridement and wash-out. Patients should be tested for other STI's and partners should tested and treated as well.

Outcome: After obtaining results and speaking with the patient as well as ID, they recommended hospital admission for initiation of IV antibiotics. Patient had PICC placed, started on IV Ceftriaxone for 3 weeks after consulting with ID. He was then discharged home to initiate PT for the rotator cuff tear and labral repair.

Follow-Up: He followed-up in the orthopedic office for 11 weeks s/p shoulder arthroscopy. Was able to return to work with no restrictions continuing to work on his shoulder ROM and rotator cuff strength.

Atraumatic Left Knee Effusion in an Athlete

Primary Author/Presenter: Jonathan Bailey, MD

Angelique Collamer, MD

Affiliation: National Capital Consortium Sports Medicine Fellowship, Bethesda, MD.

Assigned #: C2022-0133

Presentation Type: Podium

History: A 19 year old male baseball pitcher presented with a 9 day history of left knee swelling and lateral knee pain. He was conducting "suicide runs" when he heard a pop followed by pain and swelling three hours later. He reported a prior episode of left lateral knee pain and swelling 6 months ago that spontaneously resolved. He denied recent illness, prior sexually transmitted infection, fevers, chills, night sweats, erythema, dysuria, or rash. There was no improvement with rest, ice, elevation or compression. Pain was 7 of 10 in severity and he denied instability, mechanical locking, catching, or buckling. Orthopedic surgery conducted a joint aspiration and ordered a knee MRI. The MRI revealed an encapsulated nodular focus abutting the left lateral femoral condyle; the synovial fluid was non-inflammatory, synovial fluid cultures and B. burgdorferi DNA testing were negative.

Physical Exam: The left knee exam was significant for a moderate effusion without erythema. There was pain upon palpation along the lateral joint line of the left knee. The athlete had full extension of the knee but flexion was limited to 120˚s. 5 of 5 strength was noted with flexion and extension of the left knee. There was no pain or laxity with Lachman testing, anterior drawer, posterior drawer, valgus or varus testing. There was no pain with McMurray's. The remainder of the physical exam was unremarkable.

Differential Diagnosis:

11. Pigmented villonodular synovitis 12. Fibroma of the tendon sheath 13. Synovial Sarcoma 14. Reactive Arthritis 15. Nodular Fasciitis

Test Results: CBC, ESR, CMP, CRP, Uric Acid, Lyme antibodies and ANA: Negative/Normal. MRI: T2 hyperintense encapsulated nodular focus abutting the lateral femoral condyle and closely approximating the lateral collateral ligament and IT band, with reactive bone marrow edema. Large joint effusion with mild diffuse synovitis. Pathology: Consistent with benign myofibroblastic proliferation. With MRI findings, an intraarticular nodular fasciitis is favored. FISH analysis: positive for USP6 gene rearrangement.

Final Diagnosis: Intra-articular nodular fasciitis

Discussion: Nodular fasciitis is a rare, benign reactive myofibroblastic proliferation that usually occurs in subcutaneous tissues and may arise from previous trauma. Intra-articular nodular fasciitis is rarely seen and identification is necessary to avoid misdiagnosis. The differential diagnosis includes pigmented villonodular synovitis, fibroma of tendon sheath, desmoid fibromatosis, sarcoma and juxta-articular myxoma. Most patients present with a painful mass and limited range of motion. Fluorescence in-situ hybridization analysis for ubiquitin specific protease 6 is a newly recognized sensitive and specific diagnostic adjunct. Surgical excision is considered the definitive treatment modality.

Outcome: The patient underwent a left knee arthroscopy with excisional biopsy. After the procedure, he was placed in a post-operative hinged knee brace with follow up physical therapy. The specimen was sent to pathology for examination. Due to the initial pathology report, we requested a secondary in-depth evaluation which confirmed, with FISH analysis, the diagnosis of intra-articular nodular fasciitis.

Follow-Up: Six weeks after surgery, the patient was pain free at rest and pain was 2/10 with exercise. He reported 90% return to baseline athletic ability. Physical exam was normal excepting a mild left knee effusion. He was allowed to return to normal exercise as tolerated. Follow up synovial fluid aspiration was unremarkable and the patient will continue close monitoring for full resolution of symptoms.

Say It Is Not So... Sudden Weakness in the Throwing Arm of a Teenage Baseball Player

Primary Author/Presenter: Eugene Palatulan, MD

Naomi Brown, MD, Christian Belisario, DO, and Clayton Walker, MD

Affiliation: Hosp. of the University of Pennsylvania/Children's Hospital of Philadelphia, Philadelphia, PA.

Assigned #: C2022-0134

Presentation Type: Podium

History: A 15-year-old, right-hand dominant male, baseball player presented with 1-month history of weakness in his throwing arm. He first noticed losing grip strength while weightlifting and unable to hold the bar after dead lifting 120 pounds, off from his baseline. He noted intermittent tingling and numbness down both arms with neck flexion, which resolved after stretching. Overall, he is healthy and denied any constitutional symptoms or other weakness. After a benign physical exam and reassuring forearm imaging, he was initially prescribed physical therapy for trapezial and elbow flexor muscular spasm and tightness. As he was painless, he delayed the start of PT but began due to progressive weakness during winter workouts and inability to grip a baseball or operate a nail clipper. His PT also reached out with concerns of his weakness. He was seen in follow up 4 months after his initial visit.

Physical Exam: Mild atrophy of the right triceps, supraspinatus, infraspinatus and thenar eminence. No atrophy of deltoids or biceps. Normal painless range of motion of his neck, shoulders, elbows, wrists and fingers. Mild right scapular dyskinesis. No tenderness to palpation in any muscle group or palpable masses. Decreased strength of right triceps, 3+/5 and trapezius, 4/5, with fasciculations. Decreased strength of supraspinatus and infraspinatus of resisted wrist flexion 3+/5, supination, 3+/5 and pronation, 4/5. Decreased thumb strength with opposition, 3+/5 and with abduction 3+/5. Normal strength of deltoid, biceps and brachioradialis, 5/5. Sensation and reflexes were normal, equal and symmetric.

Differential Diagnosis:

16. Thoracic Outlet Syndrome 17. Amyotrophic Lateral Sclerosis 18. Hirayama's disease or Monomelic Amyotrophy 19. Cervical radiculopathy 20. Fascioscapulohumeral muscular dystrophy

Test Results: X-ray of right forearm showed no osseous abnormality. MRI of cervical spine and brachial plexus with and without contrast showed ventral displacement of posterior dural margin in flexion with repositioning in hyperextension and neutral positions. Mild symmetric spinal cord atrophy at C5-C6 without definite signal abnormality. No definite abnormality of the right brachial plexus. Electromyography revealed electrophysiologic evidence of cervical motor neuron disease or polyradiculopathy.

Final Diagnosis: Hirayama's Disease or Monomelic Amyotrophy

Discussion: Hirayama's disease, or monomelic amyotrophy, is a lower motor neuron disease and a rare clinical variant of amyotrophic lateral sclerosis. The hallmark finding of Hirayama's disease is lower motor involvement of distal muscles more commonly than proximal muscles in a single limb. There is a strong preponderance in young males than females with onset between 15 and 25 years of age. It is more common to affect the left side more than the right side, making this case presentation even more unique. Fasciculations may be present on the affected side up to 66% of cases but without sensory loss. The weakness can progress over 1 month to 5 years with a self-limiting course.

Outcome: After his follow up with worsening presentation, he was referred to neurology for consultation and diagnosis of possible neuromuscular etiology. The diagnosis of Hirayama's disease was confirmed by neurology based on the constellation of findings. He started occupational therapy for rehabilitation of his right arm and hand weakness with gradual return to baseball related activities.

Follow-Up: He continues his work with occupational therapy for rehabilitation and slow ramp up of his baseball related activities. Prognosis is guarded as he is only 2 years out of his initial symptoms of Hirayama's disease but his strength and ability to grip a baseball has improved. He hopes to participate in the upcoming winter workouts with his baseball team and eyeing a return to play in the spring.

Coughing Up a Lung

Primary Author/Presenter: Johan Latorre, MD, MS, Johan Latorre, MD, MS

Sami Rifat, MD

Affiliation: University of Michigan Primary Care Sports Medicine, Ann Arbor, MI.

Assigned #: C2022-0139

Presentation Type: Podium

History: A 22 y/o graduate student volleyball athlete with a PMH of POTS, pneumonia and asthma presented to Athletic Medicine for worsening NP cough, SOB and left-sided positional chest pain. Her chest pain was aggravated by leaning forward but not by activity. She denied fever, chills, hemoptysis, lightheadedness and palpitations. One month prior to this visit, she was diagnosed with a LUL pneumonia and was treated on a regimen of azithromycin and amoxicillin-clavulanate. Two weeks later, follow-up CXR demonstrated resolution of the pneumonia. By that time, she had returned to full activity with abatement of all symptoms except positional right-sided chest pain. Surface ECHO and EKG were normal.

Physical Exam: Vitals: BP 120/76 | Pulse 128 | SpO2 94-98% General: sitting on exam table, fatigued HENT: NCAT, MMM, no erythema in the orophyarnx. Heart: Tachycardic regular rhythm. No murmurs on auscultation. +2 radial pulses and no peripheral edema Lungs: CTAB, no dyspnea with conversation Integumentary: Warm, Dry, Pink, no open skin lesions noted in visible areas MSK: TTP diffusely at all ribs below the left breast, worst on the flank and the intercostal muscles compared to bones. No step off palpated.

Differential Diagnosis:

21. Myopericarditis 22. Relapse of pneumonia 23. Pulmonary embolism 24. Metastatic disease 25. Disorders of humoral immunity

Test Results: Relevant Tests CXR: LUL PNA D-dimer = 1.14 WBC = 19.7 CT PE: No pulmonary embolism. Obstruction of left upper lobe bronchus concerning for an endobronchial mass. Enlarged mediastinal and left supraclavicular lymph nodes. Hospital Course: She was admitted for further evaluation and the following day had a bronchoscopy that confirmed a mass that was subsequently identified as a typical carcinoid tumor. Lymph nodes were negative for mal

Final Diagnosis: Post-obstructive pneumonia secondary to typical carcinoid tumor

Discussion: Carcinoid, or neuroendocrine, tumors in the lung are rare. They comprise 1% of all lung tumors and 20-30% of all neuroendocrine tumors. Carcinoid tumors in the lung usually secrete very little hormones compared to carcinoid tumors in the intestine. They typically grow slowly and are located in the bronchus. Diagnosis is usually delayed as their presenting symptoms are very common, such as: cough, chest pain and pneumonia. Depending on their size, they can be seen on CXR, but are usually found on CT. Further imaging such as PET, CT, or MRI abdomen are usually done if the tumor is atypical, > 3 cm, or LN positive. Overall, prognosis is very good with a 5-year survival rate of 87-100%.

Outcome: Bronchoscopy was redone with further biopsies obtained at different parts of the lung and bronchus that were negative. She will undergo left upper lung resection.

Follow-Up: She will continue her conditioning and practicing with the team; she has been cleared to play once she has regained her fitness. Post-surgery, there will be no physical activity for 4-6 weeks, pending surgical approach, with gradual return to activity after that. We do not anticipate this affecting her athletic career as she has been playing without a large portion of her lung for a while.

Hip Pain After COVID-19

Primary Author/Presenter: David Nieves, MD

Amy West, MD, EdM

Affiliation: Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Department of PM&R.

Assigned #: C2022-0150

Presentation Type: Podium

History: A 51-year-old male presented to the outpatient sports medicine clinic complaining of right hip pain. He had a past medical history of hypertension, diabetes mellitus and knee osteoarthritis, for which he had received Hyaluronic Acid injections in the past and a recent history of prolonged hospitalization in March 2020 with COVID-19. He was intubated for 2 months and discharged to a rehabilitation facility in June 2020, where he stayed until September 2020. He developed right hip pain and difficulty moving his leg near the end of his stay, which worsened during his time at home. He presented to the sports medicine clinic almost two months after being discharged from rehab. Patient had been unable to walk due to the pain in his hip and did not recall any trauma to the right hip. His pain was worse with any movement of his right leg and he required the use of a wheelchair for transport.

Physical Exam: Physical examination revealed no bruising at the right hip, restriction of range of motion in all directions at the right hip (passive range of motion at the hip of 30 to 80˚s with extension and flexion and limited internal and external rotation of 10˚s and 5˚s, respectively) and positive FABER and FADIR maneuvers. In comparison, range of motion at the left hip was full and painless. There was no tenderness to palpation of the buttock, greater trochanter, or IT band and his strength was 5/5 with hip flexion, knee extension and ankle dorsiflexion and plantar flexion.

Differential Diagnosis:

26. Hip Osteoarthritis 27. Femoroacetabular impingement 28. Hip Fracture 29. Heterotopic Ossification 30. Osteonecrosis of the Femoral Head

Test Results: Right hip x-rays showed reduced space at the femoral acetabular joint with extra-articular calcifications, consistent with HO. Hip MRI demonstrated HO of the right hip with synostosis between the right greater trochanter and ischium, a stress reaction at the posterior greater trochanter and atrophy of the right thigh and hip musculature. Bone scan was also performed and it showed diffuse hyperperfusion, hyperemia and increased uptake corresponding to HO posterior to the right proximal femur.

Final Diagnosis: Pt was diagnosed with Heterotopic Ossification of his right hip and was referred to Orthopedic Surgery to discuss treatment options.

Discussion: Heterotopic ossification is the abnormal formation of mature, extra-skeletal bone in soft tissues or muscles. In its early phase, HO will cause localized, focal pain, as well as tenderness and swelling. For extra-skeletal ossification to occur, three conditions must be met: the presence of osteogenic precursor cells, an inducing agent and a permissive environment. The connection between HO and a COVID-19 infection is still undetermined, however, widespread inflammation and endothelial dysfunction may be the link between HO and severe COVID-19. Immobilization is a known risk factor of HO as well and many COVID-19 patients were non-ambulatory while intubated in the ICU, like our patient.

Outcome: Because his bone scan demonstrated active HO, he was advised to wait at least 1 year before attempting surgical resection, as immediate resection would likely result in recurrence. In September 2021, patient was cleared to undergo resection of his right hip HO. At the post-operative visit, he was able to stand and walk with rolling walker and his range of motion improved, as well as his pain.

Follow-Up: Patient will continue with physical therapy to improve his functional ability and continue to follow up with orthopedic surgery for post-operative care. He will continue to use the rolling walker with the goal of not needing an assistive device in the future.

Return to Football After Chest Pain

Primary Author/Presenter: Caitlyn Rerucha, MD, MSEd, FAAFP

Caitlyn Rerucha, MD, and Julie Creech, DO

Affiliation: National Capital Consortium Primary Care Sports Medicine Fellowship, Fort Belvoir, VA

Assigned #: C2022-0153

Presentation Type: Podium

History: A 17-year-old African American male with past medical history of Risk-Level 1 Kawasaki's Disease diagnosed at age 4 years old reports waking up this morning with diffuse sub-sternal chest pain. His chest pain has been coming and going throughout the day without relief by rest or antacid. A thorough review of systems is unremarkable including no recent illnesses, palpitations, dyspnea, or unexplained syncope. He is a lifelong multi-sport athlete excelling in football, baseball, tennis, basketball, soccer and swimming. He is currently weight training at home 4 days per week with infrequent aerobic exercise during the COVID-19 pandemic. He is a junior at a competitive high school that recently transferred in on scholarship to play football linebacker. He reports healthy immediate family members without heart disease and a maternal grandmother with heart failure that died suddenly at age 58.

Physical Exam: He is well-appearing with a muscular body habitus (height 75 inches and weight 274 lbs) in no apparent distress. His blood pressure is 117/65 mmHg and heart rate is 78 bpm. His oxygen saturation is 96% on room air. His head and neck exam are normal with jugular venous pulse of 5 cm. He has normal carotid upstrokes without bruits. Lung fields are clear to auscultation bilaterally. Chest wall and epigastrium are non-tender. Cardiac exam reveals a normally placed apical impulse. S1 and S2 sounds are present with normal intensity. There is a new 2/6 systolic ejection murmur that increases from squat to stand and with Valsalva. No S3 or S4 are heard. Pulses are equal without delay. No edema.

Differential Diagnosis:

31. Hypertrophic or dilated Cardiomyopathy 32. Myocardial ischemia/infarction or vasospasm angina 33. Mitral or tricuspid valve regurgitation 34. Myocarditis or pericarditis (COVID or other virus) 35. Innocent Still's "flow" murmur

Test Results: EKG shows T-wave inversions in V3-V6. His echocardiogram has mild concentric left-ventricular hypertrophy (14 mm, Z score 1.5). A cardiac MRI was ordered given his history of Kawasaki disease showing maximal anterior wall thickness of 27 mm, systolic anterior motion with flow acceleration through the left-ventricular outflow tract, ejection fraction 67% with no late gadolinium enhancement and normal coronary arteries. His exercise stress test is without NSVT with normal blood pressure response.

Final Diagnosis: Hypertrophic cardiomyopathy. Genetic testing revealed a pathologic variant in MYBPCS c.1224-52 G>A. His mother was also genotype positive/phenotype negative. His father and siblings were both negative

Discussion: Hypertrophic cardiomyopathy (HCM) is the most common cause of sudden cardiac death (SCD) in young athletes with increased risk in black, male football players. Echocardiogram is the gold-standard imaging modality to diagnose HCM, however, cardiac MRI findings may play an increasing role in HCM risk stratification. HCM is diagnosed by Z score > 2 in children or septal wall thickness > 15 mm in adults. This athlete's Z score on echocardiogram was not diagnostic for HCM, yet his cardiac MRI and genetic testing clearly confirm his diagnosis of familial HCM. His ESC-HCM 5-year SCD risk is low (3.31%) and the 2020 AHA/ACC Guidelines recommend that shared decision-making guide his return to play.

Outcome: The athlete's symptoms resolved same day and he remains asymptomatic. An internal cardiac defibrillator is not recommended based on ESC-HCM score < 4%. Shared decision making between the athlete, his parents, his HCM cardiology team and other stake holders (school athletic director, team physicians, athletic trainers) is to return to full participation with an emergency action plan.

Follow-Up: This case highlights individualized shared decision making rather than blanket disqualification for athletes with HCM. This athlete fully participated in the 2021 football season without symptoms or event. His emergency action plan includes BLS-trained coaches, personal AED and EMS at games. His annual HCM cardiology screening includes cardiac MRI, 2 week Holter and maximal stress echocardiogram

An Uncommon Hip Injury in a Skeletally Immature Multi-Sport Female Athlete

Primary Author/Presenter: Faustine Ramirez, MD, Faustine D. Ramirez, MD

Alan Zhang, MD, and Celina de Borja, MD

Affiliation: University of California San Francisco, San Francisco, CA.

Assigned #: C2022-0159

Presentation Type: Podium

History: A 14 year-old female soccer athlete and track sprinter presents with right hip pain for 6 weeks, which started while passing the ball during a soccer game. She denies a popping sensation. She was able to finish the game, but the pain worsened while sprinting, as the beginning of track season overlapped with her soccer season. She reports weakness that has affected her speed and kicking. The pain is antero-medial, sharp, aggravated by running and kicking. She tried resting for 2 weeks which offered improvement, but symptoms immediately recurred upon return to soccer. At the initial visit, radiographs did not show any avulsion fractures. Continued activity modifications and initiation of formal PT was recommended, which offered improvement in her pain. However, her symptoms recurred upon return to soccer where she was able to play an entire game but only at 30% of her usual performance.

Physical Exam: Inspection of the right hip and lower extremity revealed no gross deformities, swelling, bruising, or discoloration. There was tenderness to palpation over the medial aspect of the proximal quadriceps, with no palpable defect. There was no tenderness to palpation over bony prominences. She had full range of motion at the hip, with pain on passive hip flexion. On special testing, she demonstrated a positive Stinchfield test, positive Ludloff test, negative log roll test, negative FADIR test and negative Scour test. Her gait was non-antalgic but she had pain with a single leg hop, as well as pain and weakness with a single leg squat.

Differential Diagnosis:

36. Pelvic apophysitis 37. Hip flexor tendinitis 38. Quadriceps strain 39. Femoral neck stress fracture 40. Femoroacetabular impingement with labral tear

Test Results: Pelvis radiograph AP view: Normal radiograph. No avulsion fracture of the right hip. No hip dysplasia or FAI. MRI Lower Extremity without contrast: Full thickness proximal rectus femoris tear at the musculotendinous junction with retraction, begins 11.6 cm inferior to the proximal attachment, with small intramuscular hematoma or seroma. Torn portion including both full and partial thickness tear spans a total of 9.9 cm at the level of the proximal/mid femoral shaft. No acute osseous abnormality.

Final Diagnosis: Full thickness proximal rectus femoris tear

Discussion: Proximal rectus femoris tears are most often related to kicking and sprinting mechanisms. Among adults, common locations include the proximal tendon and myotendinous junction. Among adolescents, AIIS avulsions are most common, accounting for approximately 20% of acute pelvic avulsions. Tears in the muscle belly, as discovered intraoperatively in this patient, are rarely reported, as physes are inherently weaker than muscle and tendon in skeletally immature athletes. At the time of injury, our patient was simultaneously participating in competitive soccer and track seasons. Although playing multiple sports has benefits, overscheduling without adequate rest can increase the risk for injuries.

Outcome: She was referred to orthopedic sports surgery for surgical repair of a full thickness proximal rectus femoris tear using an open approach. Intraoperatively, the tear was visualized at the musculotendinous junction extending into the muscle belly, with 6 cm of retraction. The origin of the tendon at the AIIS was intact. The muscle tear was directly repaired side to side without complications.

Follow-Up: Postoperatively, she was placed in a hinged knee brace locked in extension, with use of crutches for ambulation. She started PT 1 week after surgery focused on range of motion (0-90˚s). By 6 weeks, she was off crutches and progressed to strengthening and low impact exercises (bike and elliptical). At 12 weeks, she was cleared for gradual return to high impact and sports-specific exercises.

More Than Just a Cough: Persistent RUQ Pain in a Collegiate Soccer Player

Primary Author/Presenter: Justine Ko, MD

Avinash Sridhar, MD, CAQSM, and Korin Hudson, MD, FACEP, CAQSM

Affiliation: MedStar Georgetown University Hospital & Washington Hospital Center, Washington, DC.

Assigned #: C2022-0167

Presentation Type: Podium

History: A 19 year-old male soccer player with a history of liver cancer, requiring childhood liver transplantation, presents with right upper quadrant pain. The pain started when he was diagnosed with pneumonia 4 weeks earlier and had a significant cough. The athlete reports similar RUQ pain associated with prior URIs, however these symptoms have typically resolved after 1-2 days. This time, though the pain has improved compared to initial onset, symptoms have persisted despite completion of antibiotic treatment and cessation of his cough. He describes the pain as dull, non-radiating and worse after athletic activity and with movement. He has also noticed a mass over the area that has waxed and waned with activity. The athlete denies any fever, chest pain, shortness of breath, nausea, or vomiting and denies any significant trauma. He reports ongoing compliance with all prescribed medications.

Physical Exam: Vitals signs were normal. Heart exam was normal. Lung exam revealed clear, equal breath sounds bilaterally, with normal work of breathing. There was no chest wall tenderness. The patient's abdomen was soft, non-distended, with a well-healed Mercedes abdominal incision. There was no erythema, dehiscence, or drainage noted. On palpation, he had mild tenderness around the lateral aspect of his scar. There was a palpable firm nodule, approximately 2 cm in diameter, along the lateral aspect of his incision with no pulsations or warmth. Valsalva maneuvers did not cause bulging or increased pain. There was no tenderness to palpation in all other quadrants of the abdomen and no rebound or guarding.

Differential Diagnosis:

41. External abdominal oblique strain 42. External intercostal muscle strain 43. Incisional hernia 44. Liver transplant rejection 45. Rib contusion

Test Results: Initial bedside ultrasound showed a superficial hypoechoic lesion over the area of pain. Repeat ultrasound 1 week later, performed due to increased pain after activity, revealed the same hypoechoic lesion was larger and appeared to extend to the level of the peritoneal fascia without frank fluid collection. Routine labs showed normal liver function tests and a normal white count. Formal ultrasound revealed a 0.5-cm abdominal wall defect with liver parenchyma extruding through the lesion.

Final Diagnosis: Herniation of the transplanted liver through small abdominal wall defect

Discussion: Herniation of the liver is a rare occurrence- few cases have been reported in the literature. In this patient, prior surgery from transplantation placed him at risk for an abdominal wall hernia and the increased abdominal pressure from coughing likely contributed to his presentation. While he had similar pains in the past, prolonged pain and the patient's medical history clued the team into additional workup and imaging. Herniation through the abdominal defect poses risk for incarceration and infarction of the herniated organ. Prior case reports have shown a variety of management, ranging from expectant management to liver resection and mesh repair of the defect.

Outcome: The transplant surgery team was consulted. Imaging and lab work were not suggestive of incarceration or infarction of the herniated liver. The transplant team is coordinating with the team at his home institution regarding recommendations and timing for operative repair. Extensive discussions regarding the condition have occurred among the athlete, his family, sports medicine and transplant teams.

Follow-Up: Using a shared decision making model, we reviewed the risk of further injury and considered his desire to finish the competitive season. He opted to continue playing as symptoms had not worsened despite training and competing. He is wearing a protective abdominal pad during play and will follow up regularly with the transplant surgery team with a plan for surgical repair at the end of the season.

Leg Pain in a Runner

Primary Author/Presenter: Brian Atkinson, MD

James Kramer, MD

Affiliation: Cone Sports Medicine Fellowship, Greensboro, NC.

Assigned #: C2022-0168

Presentation Type: Podium

History: 31 yo M presented with 4 days of left calf pain. No increase in activity or trauma. He was found to have achilles swelling and tenderness. CBC/CMP significant for WBC 15, glucose 232. Duplex US did not show DVT. He was discharged home with a diagnosis of achilles tendinitis and started on prednisone and CAM walker. He then presented 3 days later with continued pain. Exam showed TTP at the achilles and pain with plantarflexion. US showed soft tissue swelling in the subcutaneous tissue around the achilles tendon. He was managed with compression, NSAIDs, heel lifts and nitroglycerin patches. His pain and swelling began to worsen and he developed a small lesion on his medial ankle. Given this worsening, MRI was ordered. On the day of the MRI, he was found to have significant spread of the bullous lesion and after completing the MRI was sent urgently back to the office for evaluation.

Physical Exam: Vitals: T 98.9° | P 102 | BP 123/86 | R 16. General: Ill appearing male, NAD, alert and oriented. Left Leg: Diffuse edema and erythema of the lower leg and ankle. There are multiple large ruptured bullae with underlying necrotic tissue of the posterior lower extremity, extending distally to the medial and lateral malleoli. Warmth and tenderness to palpation. Limited ROM due to pain.

Differential Diagnosis:

46. Necrotizing Fasciitis 47. Lower Extremity Cellulitis 48. Gas Gangrene 49. Deep Venous Thrombosis 50. Achilles Tendinitis

Test Results: On arrival to the ED, labs showed WBC: 39.9, Neutrophils: 35.0, Na 118, K 3.5, Glucose 413, AG 17, Lactate 2.1, BHBA 4.81, VBG: 7.26/CO2 29/O2 28/bicarb 13, A1c: 10.6%, UA: >500 glucose/80 ketones. MRI showed a large 5.3 x 5.6 x 30.7 cm abscess within the soleus musculature and examination on arrival to the orthopedic office was consistent with necrotizing fasciitis.

Final Diagnosis: Necrotizing Fasciitis of Left Lower extremity with associated Pyomyositis; Diabetic Ketoacidosis with new diagnosis of Diabetes.

Discussion: This case illustrates the importance of maintaining a broad differential when evaluating musculoskeletal complaints in the office. Although this patient's symptoms were initially consistent with a very common entity (achilles tendonitis), he did have some early warning signs of infection with an elevated WBC count and hyperglycemia in the ED.

Outcome: He was started on IV antibiotics along with insulin drip and appropriate IV fluids for treatment of DKA. Urgent transtibial amputation was done given the extent of infection. Blood cultures showed no growth. Wound cultures were positive for MSSA and he was treated for presumed MSSA bacteremia with 6 weeks of cefazolin. He was discharged after 10 days in the hospital and 8 days of inpatient rehab.

Follow-Up: He had slow improvement in his fatigue and underwent extensive physical therapy to both regain his strength and learn to ambulate with a prosthesis. He is now followed by PM&R regarding his prosthesis. He was followed by Infectious Disease and was released after completing his 6 week course of antibiotics. He is also following with Endocrinology for his diabetes, which is well controlled.

A Real Pain in the....Armpit

Primary Author/Presenter: Matthew Endrizzi, MD

Colby Genrich, MD, Gerardo Vazquez, MD, Chenai Nettey, MD, and Justin Wright, MD

Affiliation: Texas Tech University Health Sciences Center El Paso, El Paso, TX.

Assigned #: C2022-0170

Presentation Type: Podium

History: A 17-year-old professional male soccer player, with no significant past medical history was brought to clinic by his athletic trainer after experiencing a puncture injury to the left axillae. During soccer drill called soccer tennis, in which the patient was jumping in a confined spaced, he landed awkwardly and fell onto one of the boundary poles. The patient experienced significant pain at the puncture site and complained of some numbness in the extremity. Dressing was applied to the area by the athletic trainer, which stopped the bleeding.

Physical Exam: Vitals: WNL General: Patient appearing in moderate discomfort and pain Respiratory: Normal lung sounds in all fields. Breathing comfortably on room air. Left axilla: 2 cm x 2 cm puncture wound that penetrates through the dermis along the axilla. Muscle fibers, likely the pectoralis major visible. No active bleeding, no visible soiling of wound. Neurologic: Patient with normal sensation in the distal extremities including normal function of the axillary, median and ulnar nerve.

Differential Diagnosis:

51. Penetrating trauma to the axillae 52. Brachial plexus injury 53. Vascular injury 54. Muscular/fascia injury 55. Pneumothorax

Test Results: Patient was sent to local ER where he was seen as a Level 1 Trauma. CXR showed left axillary emphysema with no cardiopulmonary abnormalities, no pneumothorax (CXR image available) CT and CTA of the chest was obtained (CT image available) which showed soft tissue emphysema in left axillary region and tracking inferiorly along anterior chest wall interposed between pectoralis major and minor without arterial injury.

Final Diagnosis: Penetrating axillae injury without neurovascular complication.

Discussion: In the case of our patient, given the mechanism of injury, there was a high risk for many more complications. Penetrating trauma to the axillae can lead to permanent severe limb dysfunction. In addition, this type of injury can be life threatening, since many of these injuries are accompanied by vascular damage and even lung injury. Immediate surgical exploration is necessary and there is consensus for simultaneous vascular and nerve repair as this can reduce the need for future procedures. In many situations a brief summary of event, medical history and a directed physical examination are sufficient to identify the level of injury, the nerves involved and the severity of the injury.

Outcome: Orthopedic Surgery was consulted. Patient went to the OR for surgical exploration with irrigation and debridement. The injury tracked under the pectoralis major without damage to the fascia posterior without tracking to any other structures. Patient was admitted to the hospital for 24 hours. He had no neurovascular abnormalities following the procedure.

Follow-Up: Patient was seen for follow up in outpatient orthopedic clinic at 1 week. He was cleared to play with application of Dermabond over the wound prior to next game which was at 2 weeks after the incident. Sutures were removed at 3 weeks and player had no residual symptoms including pain or neurovascular abnormalities.

No Ball at the Arcade—A Case of Medial Elbow Pain in a Pitcher

Primary Author/Presenter: Samuel Jacob, DO

Timothy Yu, MD, and Daanish Khan

Affiliation: Virginia Commonwealth University - St. Francis (Bon Secours), Richmond, VA.

Assigned #: C2022-0172

Presentation Type: Podium

History: 17-year-old left-hand dominant baseball player referred to the sports medicine clinic with pain and numbness radiating from the left medial epicondyle to the 4th - 5th fingers. Symptoms started three years prior following left medial epicondylar avulsion fracture secondary to pitching which was managed conservatively. He reported an EMG at that time showed “slowing of a nerve across the elbow.” The patient's pain was resistant to conservative management, so he underwent ulnar transposition surgery 2 years prior resulting in slight symptom improvement. At the time of his visit, the patient reported continued and worsening symptoms. He stated his pain was exacerbated by pitching during which he felt a lack of control over the ball. He denied any weakness in the left hand such as with writing or prolonged use. The patient was using capsaicin cream for pain control.

Physical Exam: On physical exam, the patient had normal range of motion of the bilateral upper extremities along with normal appearance, without any atrophy. There was no motor weakness including in distal ulnar innervated muscles. Sensation and reflexes were intact. Special and provocative testing was negative and the patient had a normal cervical spine exam. However, he had positive Tinel's over the ulnar nerve near the Arcade of Struthers.

Differential Diagnosis:

56. Ulnar Neuropathy 57. Medial Antebrachial Cutaneous Neuropathy 58. Cervical Radiculopathy 59. VEO Syndrome 60. Medial Epicondylitis

Test Results: X-rays of the left elbow AP, lateral and oblique were negative. 2nd EMG (1 month prior to visit) showed normal nerve conductions of the median, ulnar and radial nerves along with normal EMG of all tested muscles, including ulnar innervated muscles in the involved extremity.

Final Diagnosis: Left Ulnar Nerve neuropathy at the Arcade of Struthers

Discussion: A rare cause of ulnar neuropathy is Arcade of Struthers (AOS) entrapment. Found 3-10 cm proximal to the medial epicondyle, it is an aponeurotic band extending from the triceps to the intermuscular septum. The AOS can cause continued ulnar neuropathy even after its anterior transposition. Presentation includes pain, 4th and 5th digit paresthesia and weakness of involved muscles. EMG/NCS may show neuropraxic changes depending on severity. Failing conservative measures, treatment with surgical decompression has had good outcomes. Hydrodissection is effective for various nerve entrapments including the ulnar nerve. This is the first case to our knowledge of its use at the AOS.

Outcome: Patient underwent ultrasound-guided left ulnar nerve hydrodissection at the level of the Arcade of Struthers. The nerve was identified and hydrodissected in an out-of-plane approach, distal to proximal, using a 20 g needle and mixture of Kenalog, lidocaine and D5 (total volume approx. 13 cc). The patient tolerated the procedure without issue and reported 80% relief of symptoms.

Follow-Up: At 1 month follow-up, the patient reported resolu