Clinical Journal of Sport Medicine

Sternoclavicular Pain in a Wrestler

Kent Do, MD, DPT

All Other Authors: Carlton Covey, MD

Affiliation: Travis Sports Medicine Fellowship, Fairfield, CA.

History: A 17-year-old male presented to the emergency room with right chest pain. He landed on his right shoulder and felt a “pop” in his sternum during wrestling practice 4 weeks prior. Over the last week, he has been to the ER twice with progressively worsening pain both at rest and with movement of his right arm. Previous X-rays of the shoulder and chest were normal. His pain did not improve with regular Tylenol and Motrin dosing for a few days. Today, 1 month after his initial injury, he is presenting with a subjective fever (101°F), progressive erythema on his chest, worsening pain that now radiates to his right shoulder, and new onset shortness of breath and pleurisy.

Physical Exam: Temp: 98.5°F HR: 108 BP: 112/80 mm Hg. Palpation: Tenderness over sternoclavicular (SC) area, but no mass palpated; slight warmth to the touch over the skin at the medial sternoclavicular joint and sternal head of the pectoralis muscle, but no fluctuance ROM: full but painful shoulder ROM but pain with elevation and extension of R shoulder; L shoulder ROM reproduced R chest wall pain; no obvious SC joint subluxation with movement Strength: Full shoulder and rotator cuff strength bilaterally Neurovascular: light touch sensation intact Special Tests: pan-negative for shoulder POCUS: No collection of fluid or gross abnormality at the sternoclavicular joint.

Differential Diagnosis:

1. Sternoclavicular ligamentous sprain/subluxation
2. Muscle strain: Pectoralis major vs. subclavian
3. Pulmonary issue: small pneumothorax vs. mass
4. Fracture
5. Septic arthritis

Test Results: Labs: C-reactive protein of 18, ESR of 45, and WBC of 10.6. Imaging: CT and MRI imaging revealed concerns for septic arthritis (SA) of the R sternoclavicular joint (SCJ) with the presence of a mediastinal abscess.

Final Diagnosis: Septic arthritis with the presence of a mediastinal abscess.

Discussion: SA should be considered for rapid SCJ pain with recent trauma or illness. Joint injury may increase risk for bacterial seeding, which is prevalent with SCJ SA. Complications with septic SCJ are high, with 50% of cases leading to osteomyelitis and 20% resulting in abscess formation, underscoring the challenge of achieving an early diagnosis. The presence of fever is variable, especially with antipyretics. In cases where the onset is insidious and lacks a clear focal mechanism, laboratory tests can be helpful. An ESR > 10 mm/hour, CRP ≥ 2.0 mg/dL, and a CBC for elevated WBC necessitate advanced imaging. Intervention and antibiotics are crucial to minimizing complications and long-term sequelae.

Outcome: Patient was admitted to the pediatric intensive care unit and was started on intravenous Vancomycin and Zosyn. A retrosternal drain was placed by interventional radiology. He had the drain in place for 7 days. Cultures confirmed pan-sensitive Staph Aureus. The patient was transitioned to Cephalexin for one month.

Follow-Up: He improved without recurrence and was able to resume all physical activity and wrestling within 3 months. No long-term sequelae resulted from this injury/infection.

Monkey Bar Mishap: A Unique Scapulothoracic Injury and Presentation

Jessica Jewell, MAT

All Other Authors: Ryan Baker, MD

Affiliation: Medical Student, Washington State University Elson S. Floyd College of Medicine.

History: A 5-year-old male presented to clinic with his mother complaining of persistent shoulder girdle pain and dysfunction 2 weeks after sustaining an injury on a monkey bars. The mother notes the patient was playing on the play structure, and his right hand became wedged between 2 bars. He fell in this position, and his right arm was forced overhead into extreme abduction and traction, causing severe acute pain. Initial evaluation at the urgent care resulted in no definitive diagnosis and prompted referral for evaluation 2 weeks later with a pediatric sports medicine specialist.

Physical Exam: On observation, the patient demonstrated guarding, holding his elbow to his side, and avoiding abduction and flexion overhead. Clinical examination demonstrated no erythema, effusion, and relatively symmetric scapulothoracic motion with no definitive scapular winging. Marked tenderness was present at the level of the right inferior scapular angle when compared bilaterally with no tenderness or pain elsewhere in the shoulder girdle. While no significant strength deficits were observed, moderate decrease in forward flexion and abduction was noted due to pain on the injured side.

Differential Diagnosis:

1. Brachial plexus traction injury
2. Latissimus dorsi muscle strain
3. Scapular fracture
4. Long thoracic nerve injury
5. Glenohumeral joint subluxation

Test Results: No abnormalities were noted by radiologists or clinicians on initial AP, axillary, or lateral shoulder radiographs on the day of injury. These images underwent further review by the pediatric sports medicine specialist. An irregularity was noted at the inferior angle of the right scapula when compared contralaterally. Due to persistent symptoms 2 weeks post injury, x-rays were repeated. Periosteal reaction was noted at the inferior angle of the right scapula.

Final Diagnosis: Physical examination and radiographic imaging results were consistent with an inferior angle scapular avulsion fracture.

Discussion: This case represents the first reported pediatric case of hyper-abduction traction as the mechanism of injury for an avulsion fracture of the inferior angle of the scapula. Of the nearly 70 pediatric scapular fractures identified in literature, 16% were IASF, with a mean age of 10. Only one previous case of definitive indirect traumatic IASF in the pediatric population is described, involving an extreme shoulder extension mechanism. This case report represents a unique mechanism of injury for this rare fracture in the pediatric population. Additionally, it further reinforces the need for careful radiologic review for appropriate identification of pediatric scapular injuries.

Outcome: Due to the age of the fracture and level of symptoms upon evaluation, as well as the absence of clear scapular winging, the decision was made to manage this fracture conservatively. The patient was placed back in his sling for 2 weeks with the recommendation to practice daily elbow range of motion and was scheduled to follow up with repeat x-rays 4 weeks after his initial visit.

Follow-Up: At 6 weeks, the patient demonstrated full, pain-free range of motion, symmetric strength bilaterally, including scapular protraction, with no evidence of scapular winging. Repeat x-rays demonstrated bony callus formation at the fracture site, and evidence of resorption of the cartilage fragment. Repeat follow-up was scheduled for 12 months to confirm appropriate bony healing.

Myocardial Madness: A Collegiate Basketball Player With Arrhythmia

Matthew Waldrop, MD

All Other Authors: Neil Sparks, DO

Affiliation: Wake Forest University School of Medicine—Family Medicine Residency Winston-Salem, NC.

History: A 22-year-old college basketball player presents for a new transfer preparticipation physical evaluation. He recalls having a Marfan Syndrome evaluation with negative genetic testing and having a cardiac evaluation at his previous school but does not remember the details other than testing was “normal” and he was cleared for full participation from a cardiac standpoint. However, he was not able to participate that year due to a knee injury. He denies chest pain, shortness of breath at rest or with exertion, dizziness, palpitations, syncope, and pre-syncope. He denies a family history of arrhythmias, congenital heart disease, or sudden cardiac death. His initial screening EKG is abnormal, and he is restricted from sport pending further work-up and a review of medical records.

Physical Exam: Vitals: HR 90 bpm, BP 112/63 mm Hg, RR 12 bpm, SpO2 99%, Height: 6’9”, Weight: 253 lb 9 oz, BMI: 27.18 kg/m². Appearance: Normal. Cardiac: Regular rate, irregular rhythm. No murmurs, rubs, or gallops while supine, sitting, standing, or squatting. Brisk capillary refill present. No JVD or carotid bruits present. Pulmonary: Clear to auscultation bilaterally, no wheezes, rales, rhonchi, or crackles. Abdomen: Normoactive bowel sounds, nontender, no palpable masses or pulsating lesions. Musculoskeletal: No strength or range of motion deficits throughout the examination. Extremities: No lower extremity edema present. No sensory deficits. Equal 2+ peripheral pulses in all extremities.

Differential Diagnosis:

1. Wolff-Parkinson White Syndrome
2. Atrial Fibrillation
3. Paroxysmal Supraventricular Tachycardia
4. Frequent Premature Ventricular Contractions
5. Hypertrophic Obstructive Cardiomyopathy

Test Results: EKG shows atrial fibrillation. 3-day Holter monitor reveals 100% A-fib burden HR 58–239, averaging 110 bpm. 91 VT runs occurred which were detected within 45 seconds of being symptomatic. TTE shows a mildly dilated LV with normal wall thickness and EF 50%, mild MR, TR, PR and RV dilation. Mildly dilated IVC. CT chest with contrast reveals a severely dilated aortic sinus and ascending aorta at 5.1 cm. Cardiac MRI unremarkable. CBC, TSH, and CMP unremarkable. Marfan genetic screening is negative.

Final Diagnosis: Persistent Idiopathic Atrial Fibrillation.

Discussion: He presents in persistent atrial fibrillation with evidence of rapid ventricular response on Holter monitor with mild symptoms. His arrhythmia is idiopathic but may be related to aortic sinus dilation. No laboratory derangements suggest alternative causes. No clear explanation for aortic dilation. He is tall but does not have other marfanoid features, and genetic screening was negative. No family history of similar. No evidence of cardiomyopathy. Persistent atrial fibrillation and this degree of aortic dilation is uncommon in this population. Given his age and persistent arrhythmia, he may benefit more from cardioversion with anticoagulation, despite CHA2DS2-VASC of 0, than rate control.

Outcome: He is started on Eliquis and undergoes TEE with cardioversion 8 days after initial evaluation. Post-op EKG shows sinus bradycardia at 52 bpm. He remains asymptomatic after the procedure. He continues Eliquis 4 weeks after cardioversion. He is seen by interventional cardiology and cardiology electrophysiology. Due to the degree of aortic dilation, he is not cleared for sport.

Follow-Up: He remains asymptomatic and in normal sinus rhythm following cardioversion. He is not cleared to participate following the completion of Eliquis due to unexplained aortic dilation with high-risk feature > 40 mm diameter, disqualifying him from all competitive sports according to AHA/ACC guidelines. Annual imaging will be obtained to monitor size and he may be a surgical candidate at a later date.

Just Walk It Off

Alexander Marchek, MD

All Other Authors: Sarah Fabry, DO

Affiliation: Prisma Health Family Medicine Residency Seneca, Seneca, South Carolina.

History: A 14-year-old female volleyball player with a history of UTIs, asthma, and MRSA infections presented with tea-colored urine, myalgias, leg abscesses, left wrist pain, and bilateral flank pain to the ED from urgent care after she was found to have proteinuria and myoglobinuria. Two weeks prior, she had an undiagnosed gastroenteritis with poor appetite but has been staying well hydrated since then. She has participated in 2-a-day volleyball practices and was on a slip and slide a couple of weeks ago and has no known injury for her left elbow and wrist pain. Despite her history of MRSA abscesses, she stated that the current boils seem different. She has been compliant with Bactrim suppressive therapy and is up-to-date on vaccinations. Patient denies any fevers, chills, sick contacts, genitourinary symptoms, trauma, sexual activity, or lower extremity edema.

Physical Exam: General: well-developed, well-nourished, no acute distress, laying in bed HEENT: normocephalic, atraumatic. Oropharynx clear. External ears normal. Heart: regular rate and rhythm, systolic murmur appreciated, no rubs or gallops Chest: normal work of breathing. Clear bilaterally with no wheezes, rales, or rhonchi Abdomen: soft, diffusely tender to palpation with left worse than right Extremities: Left arm wrapped with bandage and elevated. Left thigh, knee also wrapped. Non-pitting edema present to left hand Skin: Many small pustules located on bilateral lower extremities Neuro: Normal tone. Strength and sensation grossly intact and developmentally appropriate.

Differential Diagnosis:

1. Exercise-induced Rhabdomyolysis
2. Urinary Tract Infection or Pyelonephritis
3. Autoimmune Myositis
4. Hyper-IgE syndrome/Job Syndrome
5. Granulomatosis with Polyangiitis

Test Results: Labs demonstrated MRSA bacteremia, leukocytosis, anemia, and transaminitis. Autoimmune workup was unremarkable except for elevated IgE levels. Extensive imaging workup including numerous Xrays and CT of extremities and chest, RUQ US and full-body MRI were concerning for osteomyelitis in the right femur, abscess in the right thigh, soft tissue/muscular edema around the pelvis and all extremities consistent with multifocal cellulitis/myositis, renal abscess, and multifocal pneumonia with abscesses.

Final Diagnosis: Autosomal dominant Hyper IgE syndrome with mutation in STAT3 gene resulting in multifocal MRSA disease including pyomyositis, renal abscess, skin abscesses, osteomyelitis, and pulmonary abscesses.

Discussion: This case serves as an important reminder of non-MSK diseases that can affect athletes. Rhabdomyolysis, MRSA skin infections, and UTIs are common illnesses in adolescent female athletes such as this patient. This patient’s underlying syndrome made her more prone to developing these conditions. Family history was significant for maternal acute liver and kidney failure with sepsis and death at the age of 40. Hyper IgE syndrome is a rare (fewer than 1:1,000,000) congenital immunodeficiency that is usually diagnosed early in life. For young athletes that experience recurrent infections, we should remember that congenital immunodeficiencies are a rare condition that could be the underlying cause.

Outcome: While hospitalized, the patient had multiple soft tissue I&Ds and a VATS for empyema with chest tube placement. IV antibiotics were used before the patient could be transitioned to oral Bactrim treatment dose. One month after discharge, her Bactrim was changed to a prophylactic dose until she could see Peds Immunology, and she was allowed full sports participation as tolerated.

Follow-Up: At discharge, Peds ID recommended return to light activity as tolerated (start with 10 minutes of walking per day maximum with limited activities in volleyball). Peds Orthopedics had similar recommendations, with the patient being cleared for full activity as tolerated by one month after discharge. The patient continues to see Peds ID and ortho until her first appointment with Peds Immunology.

Chronic Clavicular Pain After Nonoperative Management and Well Healed Fracture

Keenan Barr, DO

All Other Authors: Yao-Wen Eliot Hu, MD, MBA, RMSK, FAAFP, FACSM

Affiliation: Naval Hospital Camp Pendleton Family Medicine Residency, Oceanside, CA.

History: A 21-year-old male active-duty military servicemember presented with right shoulder pain that has persisted after healed clavicular fracture due to a motorcycle accident 18 months prior. His clavicle fracture was initially treated non-operatively with sling and PT but continued to have pain over the top of the clavicle. He was evaluated by orthopedics, pain management, and physical therapy who continued non-operative treatment via gabapentin, duloxetine and tizanidine. Pain management performed diagnostic injection of the lateral pectoral nerve with partial pain relief. The pain is burning and deep in the shoulder, exacerbated by his backpack strap, running, and sleeping on the right side, and occasionally radiates down the anteromedial arm to the elbow but never more distal. He denies any weakness though.

Physical Exam: Gen: no malaise, generally well-appearing Inspection: no alignment abnormalities, no bruising, no rashes, no atrophy Palpation: pain on palpation over the right supraclavicular brachial plexus, medial and lateral pectoral nerves posteromedial and mid clavicular branches ROM: flexion 180°, extension 20°, Abduction 180°, ER 90°, IR 25° Strength: deltoid 5/5, biceps 5/5, triceps 5/5, ER 5/5, IR 5/5 Neurovascular: normal Special Tests: Spurling negative, Distraction negative, Wright positive, Adson positive, Costoclavicular positive, Roo’s positive, scapular winging negative, scapular dyskinesis negative, and scapular malrotation negative.

Differential Diagnosis:

1. Neurogenic thoracic outlet syndrome
2. Brachial Plexus nerve entrapment
3. Clavicular fracture malunion/nonunion
4. Biceps tendonitis
5. AC joint osteoarthritis

Test Results: XR Clavicle (Initial): Overlapping fracture middle one-third right clavicle. XR Clavicle (10 months): Healing fracture with overlapping ends. MSK US: Scarring and enlargement of the supraclavicular brachial plexus trunks and medial/lateral pectoral nerve mid-clavicular branches with pain to sono-palpation at those sites. Slight cortical irregularity at the prior clavicle fracture site. Normal appearances of the omohyoid, 1st rib, subclavian artery, serratus anterior, and subclavius.

Final Diagnosis: Supraclavicular brachial plexus (BP) entrapment with scarring in setting of healed clavicle fracture and altered biomechanics with secondary entrapment of the lateral pectoral nerve.

Discussion: Clavicle fractures account for 2.6% of all fractures and are a common injury seen during a motor vehicle accident. Middle 1/3 fractures compose the majority of cases and are often managed conservatively. Neurovascular complications are rare, but several case reports have described thoracic outlet syndrome and BP compression after a fracture. Many of these focus on severe cases treated surgically. Few reports of hydro-dissection (HD) used for management of thoracic outlet syndrome exist. One case report described successful treatment for vascular thoracic outlet syndrome. This case represents a novel treatment for patients with chronic shoulder pain after clavicular fracture.

Outcome: The supraclavicular brachial plexus hydro-dissection achieved 100% relief of the deep radiating pain immediately after the procedure. Combined with pulsed radiofrequency ablation of the lateral pectoral nerve mid-clavicular branches, the patient experienced significant pain relief, allowing return to his baseline level of exercise and discontinuation of all pain medications.

Follow-Up: The patient was able to return to active duty. On follow-up, the patient reported 0/10 pain at rest and no need of pain medications. He endorsed periodic pain with activity associated with spasm of the right deltoid, which resolved with stretching and rehabilitation. He has returned to full activity without restrictions.

An Unusual Case of Shortness of Breath After a Bicycle Crash

Emily Speck, MD

All Other Authors: Hannah Miller, MD, Andrea Roche, DO, and Katie Dolbec, MD

Affiliation: The University of Vermont Medical Center, Burlington, Vermont.

History: The patient is a 32-year-old male with no known past medical history who presented to the medical tent for evaluation with a chief complaint of shortness of breath after falling off of his bicycle. The patient was a participant in the Lake Placid Ironman held in Lake Placid, NY. The race is composed of the following, held in sequence: 2.4 mile swim, 112 mile bicycle ride, 26.2 mile run. Our patient was entered in the professional male category. He presented to the medical tent at 10:52 am, approximately 5 hours after the start of the race. He arrived with a chief complaint of “falling over the handlebars after his hand slipped off” of his bike, which occurred shortly after beginning the bicycle portion of the race. He also reported difficulty breathing and productive cough with bloody sputum prior to evaluation. First responders obtained a finger-stick blood glucose level of 96 on scene.

Physical Exam: The patient had an initial set of vital signs that were significant for tachypnea to 22, an SpO2 of 97% on 6 liters per minute nasal cannula, normotensive. General: Alert and oriented to person, place, and event, in no apparent distress. Head: Tenderness to palpation of nasal bone, dried blood in bilateral nares. Neck: Nontender c-spine. Cleared by the physician shortly after presentation. Mouth: No blood in the oral cavity. Respiratory: Crackles and rhonchi in the left lower lobe with inspiration.

Differential Diagnosis:

1. Swimming induced pulmonary edema
2. Pulmonary contusion
3. Traumatic pneumothorax
4. Acute asthma exacerbation
5. Acute coronary syndrome

Test Results: Bedside ultrasound showed evidence of B-lines in all lung fields bilaterally with preserved left ventricular function. Brief trial off of supplemental oxygen resulted in recurrent hypoxia to 89%, requiring continued respiratory support at 6 liters per minute via nasal cannula.

Final Diagnosis: Swimming-induced pulmonary edema.

Discussion: Swimming-induced pulmonary edema (SIPE) is characterized by an acute onset cough which may be accompanied by difficulty breathing, chest tightness, and frothy red sputum. Symptoms are typically mild initially but may quickly worsen and become life threatening. The pathophysiology is thought to be the result of increased pulmonary capillary pressure resulting in pulmonary edema. The prone/supine position of swimming and central blood pooling due to cold water immersion creates the “perfect storm” of events, causing increased cardiac preload and increased pulmonary capillary pressure. Risk factors for this condition include age > 50, female sex, and underlying cardiac disease.

Outcome: The patient was sent directly to the local Emergency Department for further evaluation and for treatment of facial injuries and acute hypoxia requiring supplemental oxygen.

Follow-Up: Athletes with SIPE should not return to activity until hypoxia resolves. If prolonged supplemental oxygenation or escalation to positive pressure occurs, they may require transfer to an Emergency Department. Athletes should be aware of the increased recurrence rate of SIPE. Emphasis should be placed on early recognition of symptoms and on stopping physical activity when symptoms first occur.

Rowing Against the Current: A Collegiate Athletes Struggle With Left Leg Swelling

Grace Erickson, BS

All Other Authors: Jill Moschelli, MD, MBA

Affiliation: Michigan State University College of Human Medicine, East Lansing, MI.

History: A 19-year-old female NCAA Division 1 novice rowing athlete that presented to the training room with 2-day history of left foot and leg swelling following a bike ride. Her initial swelling persisted the day after the bike ride, and she also developed pain behind her knee that was worsening. She denied history of injury or trauma. The weekend prior to symptom onset, she spent 14 hours in a car over a 48-hour period. She denied chest pain, shortness of breath, redness, or paresthesia. She denied pain or swelling in any other location. She tried ice, elevation, and 600 mg of ibuprofen without relief. She had never had symptoms like this in the past. PMH: Secondary Amenorrhea FH: None Medications: Clindamycin 1% Topical Solution and Multivitamin Social: No tobacco, alcohol, or illicit drug use.

Physical Exam: Vitals: Temp: 36.7°C, BP: 128/69, HR: 62, RR: 20, SpO2: 100% on RA General Appearance: healthy appearing, NAD Lungs: Normal effort, Clear to auscultation B/L Cardiac: RRR, no murmurs Skin: no notable lesions or abrasions Neuro: Sensation intact to light touch LE B/L MSK: Left lower leg swelling from knee to foot. Tenderness to palpation of the popliteal fossa. Calf Circumference: (measured 12 cm from tibial tuberosity)—RIGHT: 37.5 cm and LEFT 40 cm.

Differential Diagnosis:

1. Deep Vein Thrombosis
2. Muscle Strain
3. May-Thurner Syndrome
4. Popliteal Vein Compression
5. Compartment Syndrome

Test Results: Labs: CBC, iron studies, ferritin, PT, PTT, INR, CMP, beta-HCG, Beta-2 Glycoprotein antibodies, Lupus Anticoagulant screen were negative. LE Venous Doppler: RIGHT lower extremity appears patent with no evidence of DVT. The following LEFT-sided veins showed ACUTE DEEP VENOUS THROMBOSIS (DVT): popliteal vein; prox peroneal vein; mid peroneal vein; CT Venogram: Right common iliac artery impresses upon the anterior aspect of the left common iliac vein, which may be seen in May-Thurner syndrome.

Final Diagnosis: Left Popliteal, proximal peroneal, and mid peroneal Deep Vein Thrombosis – in the setting of probable May-Thurner Syndrome.

Discussion: May-Thurner syndrome (MTS) is compression of the iliac vein against the lumbar spine by the iliac artery, and results in venous stasis and deep vein thrombosis. Mainly, this presents in women twice as much as in men. Symptoms are left leg swelling and pain. Risk factors are genetic and acquired. Acquired factors are medications, surgery, trauma, and long periods of immobility. Our athlete did have immobilization; but, it was thought that this was not enough to cause a large DVT in an otherwise healthy person. MTS was found in athletes like runners and basketball players but has not been reported in rowing athletes who are predisposed due to rowing positions that pull the knees to the chest.

Outcome: The athlete was admitted to the hospital after the positive Venous Doppler. Hematology and vascular surgery were consulted. She was started on Lovenox and is to continue this at home. Prior to discharge, she had a CT Venogram showing possible May-Thurner Syndrome. She is to follow up with the vascular surgery clinic and women’s health center. Lovenox was discontinued after a 6-week course.

Follow-Up: The athlete elected to not return to the rowing team after this diagnosis. Studies show many players with DVT are treated with anticoagulants, surgery, or a combination of the 2. Of the players in the study who were treated with anticoagulants, the average time of anticoagulant use was 4.3 months. Athletes that experienced a recurrent clotting event were placed on indefinite blood thinners.

Is It Just in My Head? A 21-Year-Old Collegiate Athlete With Radiating Arm Pain

Benjamin Rogers, MD

All Other Authors: Philip Motley, MD

Affiliation: Thomas Jefferson University, Philadelphia, PA.

History: The patient is a 21-year-old right-hand dominant collegiate shooting guard who was referred to our orthopedic clinic by her athletic trainer for evaluation of right arm pain. Her symptoms began approximately 3 months prior during an overhead weightlifting maneuver in her preseason. Her pain originated in the right shoulder with intermittent radiation posteriorly to her periscapular region and distally to her hand. Her symptoms persisted despite 2 weeks of conservative management and physical therapy. While continuing to play through the pain during her rehabilitation, her symptoms acutely worsened in the absence of inciting event or injury. At the time of her evaluation, she had been completely out of practice and competition citing progression of her symptoms to headache, nightly pain interfering with sleep, numbness, tingling, and pain refractory to oral anti-inflammatories.

Physical Exam: Well-appearing with athletic build. Normal gait. Forward posturing of the neck and bilaterally rounded shoulders. Scapular asymmetry at rest and with wall press. Painless ROM of the cervical spine without tenderness of the cervical or thoracic spinous processes. Positive Spurling’s on the right. Full and symmetric ROM of the shoulders bilaterally with flexion and abduction to 180 degrees. Painless and symmetric internal rotation to T5. Strength 5/5 with flexion, abduction, empty can, internal/external rotation. Negative Neer, Hawkins, Speed, apprehension, and load and shif test. Symmetric sensation C4-T1. Symmetric 2+ reflexes at triceps, biceps, and brachioradialis. Negative Hoffmann sign.

Differential Diagnosis:

1. Cervical radiculopathy
2. Cervical myelopathy
3. Peripheral nerve compression
4. Brachial plexopathy
5. Mass effect from brain lesion/tumor

Test Results: XR cervical spine 4 view: Normal vertebral body and disc height. No acute osseous abnormality. MRI cervical spine w/out contrast: Chiari 1.5 malformation with extensive syringomyelia of the cervical cord and partially imaged hydrocephalus of the fourth ventricle. Disc preserved in height and signal with no herniation or osteophyte complex C2-T1. MRI brain w/out contrast: Redemonstration of malformation with the obex 28 mm below the level of the foramen magnum. Elongation of the fourth ventricle.

Final Diagnosis: The patient’s formal working diagnosis after cervical spine MRI and confirmatory brain MRI was a Chiari 1.5 malformation with accompanying syringomyelia.

Discussion: Chiari malformations are congenital defects defined by caudal displacement of cerebellar structures. A Chiari 1.5 variant is a progression of the type I subtype with displacement greater than 12 mm and comorbid herniation of the brainstem. Syringomyelia is present in up to 40% of cases. Although most type I malformations are asymptomatic and incidentally found, patients can develop debilitating neurologic symptoms. MRI is the preferred diagnostic study. Symptomatic patients are referred for surgical management. Once considered an absolute contraindication to sports participation, literature is mixed on management and return to play especially in asymptomatic patients with known pathology.

Outcome: Referred to Neurosurgery. MRI brain was performed prior to consultation. She proceeded with decompression and C1 laminectomy. Postoperatively she developed gait/swallowing dysfunction and aspiration pneumonia. Repeat MRI revealed worsening compression warranting surgical revision. Post revision she developed hypotension and was started on midodrine. Discharged to outpatient physical therapy.

Follow-Up: Visits at one month post-operatively with Physiatry and Neurosurgery revealed markedly improved neurologic symptoms and function. She was gradually weaned from midodrine as her orthostasis resolved. Despite complete resolution of her symptoms and return to light aerobics at her 3-month visit, surveillance MRI revealed persistent C2-C7 syrinx. Surveillance imaging is planned at 6 months.

Blew It: Transient Diplopia in a College Running Back

Zoe Roth, DO

All Other Authors: Erin Hammer, MD

Affiliation: University of Wisconsin/Department of Family Medicine and Community Health, Madison, WI.

History: During the second quarter of a football game, a 21-year-old running back presented with right eye pain and double vision. Exam was normal and he reported his symptoms resolved so he was allowed to return to the game. Pain was absent, except for when he looked down when pain was minimal. No previous eye injuries. Did not wear contacts. He described it as looking through a foggy lens. He did use a face shield. In the locker room after the game, the patient blew his nose and had an immediate onset of swelling over the soft tissue of the right eye. Repeat examination with evidence of crepitus and mild swelling around the right eye. He was immediately instructed to go to the emergency department.

Physical Exam: General: Patient is alert, oriented, in no apparent distress. HEENT: Extraocular motions intact, Pupils equal and round and reactive to light. Fluorescein exam revealed perhaps a very small abrasion over the medial sclera of the right eye, but no corneal abrasions. Visual acuity with each eye isolated was intact, and peripheral vision was also intact. There was no tenderness over the palpable bony orbit. Examination of the superficial soft tissue structures around the right eye did not show any swelling, bruising or erythema.

Differential Diagnosis:

1. Corneal abrasion
2. Orbital fracture
3. Concussion
4. Ocular contusion
5. Lammelar laceration

Test Results: CT scan: Impression: (1) Right orbital floor blowout fracture with protrusion of the inferior rectus muscle and fat into the right maxillary sinus. CT findings are concerning for entrapment. (2) Scattered foci of blood products and air along the preorbital soft tissues and through the inferior orbital defect. No definite evidence of globe rupture or optic nerve injury. (3) The fracture parallels the infraorbital nerve. Recommend correlation for physical exam findings of V2 paresthesia.

Final Diagnosis: Right Inferior Orbital Blowout Fracture.

Discussion: Orbital blow out fractures are critical to recognize, evaluate and treat promptly. Most commonly they occur secondary to direct blunt trauma and cause serious complications (ie, diplopia, extraocular muscle entrapment, and enophthalmos). However, the presentation of symptoms can range from asymptomatic to severe symptomology, demanding a high degree of suspicion from clinicians. This case highlights the difficulty in diagnosis by examination of orbital fractures. Notably, this athlete was wearing a helmet and face shield and symptoms were mild to none. Even with thorough exam and history, we failed to timely diagnose the fracture, and the athlete did return to play.

Outcome: In the emergency department, the patient underwent a facial CT scan revealing a right inferior orbital blowout fracture. Initial imaging was concerning was entrapment. Ophthalmology was consulted who recommended no need for surgical repair and follow-up in next 48 hours for completed ophthalmic examination.

Follow-Up: The patient was seen by optometry and ophthalmology and had a dilated eye exam. Given absence of enophthalmos or diplopia in functional fields of gaze, he was managed non-operatively with avoidance of significant contact for 3 weeks and then initiation of a graduated return protocol. The athlete made a full recovery without further complications.

Oh No, My Toe

Nicholas Hora, DO

All Other Authors: Emmanouil Grigoriou, MD, Jeffery Giesking, DPM, W. Charles Huskins, MD, Christopher Reis, MD, and Benita Lin, MD

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

History: Twelve-year-old female runner and soccer player with no pertinent medical comorbidities presented to the emergency room for worsening right great toe pain, swelling and discoloration 3 days after she was diagnosed with paronychia in urgent care and placed on cefadroxil after incision and drainage with scant output. She denies drainage since then. The pain is 7/10 and causing her to limp. She enjoys pedicures but has not had one in more than 3 months. She denies trauma aside from possibly stubbing her affected toe about a month ago. She denies any systemic signs of infection such as fever, chills, nausea, vomiting, or shortness of breath. Vital signs are normal.

Physical Exam: GENERAL: Antalgic gait secondary to pain ORTHO EXAM: Pedal pulses palpable, good capillary refill, feet are warm to the touch bilaterally. Light touch sensation intact. Profound erythema and edema of the right hallux. Erythema extends to the metatarsophalangeal joint 1st interspace. No ascending lymphangitis. There is some bogginess and possible fluctuance to the proximal nail fold. No purulent drainage. Tenderness to palpation of the right great toe particularly dorsal aspect. No crepitus with palpation or manipulation. Full skin examination shows small benign-appearing scrape to the medial left ankle. No other open wounds or lesions are noted.

Differential Diagnosis:

1. Osteomyelitis with associated pathology
2. Septic Arthritis of the first IP joint
3. Seymour Fracture
4. Paronychia
5. Abscess with or without necrotizing fasciitis

Test Results: CRP = 11.4 mg/L WBC = 12.8 × 10(9)/L DX TOES RIGHT: Soft tissue swelling of the great toe surrounding a fracture of the distal phalanx. Erosion at the margins of the fracture, concerning for osteomyelitis. No soft tissue gas. MR FOOT RIGHT: Osteomyelitis of the first distal phalanx and first proximal phalangeal head and probable septic arthritis of the first IP joint. Nondisplaced Salter-Harris II fracture of the first distal phalangeal base. Multiloculated fluid collection dorsal to the first toe.

Final Diagnosis: Blastomyces osteomyelitis and septic arthritis of the 1st IP joint of the right great toe, most likely a result of open Seymour fracture with Salter II fracture of the 1st distal phalangeal base.

Discussion: In the operating room the podiatry team noted a sinus tract after avulsion of the nail plate. Incision and drainage and bone biopsy were completed. Inflammatory markers continued to rise and repeat washout with extensive debridement was done. Multiple intraoperative cultures and the bone biopsy grew Blastomyces species. Extensive infectious disease work-up was done which revealed positive urine and blood Blastomyces antigen. It was hypothesized that infection was likely related to an open Seymour fracture. Plausibly seeded via lungs, though she had no respiratory symptoms, and a normal chest x-ray.

Outcome: A multidisciplinary approach with infectious disease, orthopedics, pharmacy, and primary care was needed. She was treated with IV Amphotericin and transitioned to oral itraconazole which she will remain on for one year. She has slowly been able to resume regular activities. Some external rotational deformity of the toe and concern over nail plate growth will be addressed in the future.

Follow-Up: Heel weight bearing with crutches for 3 weeks. Then, full weight bearing with a boot until 8 weeks post-op. At 8 weeks, activity was encouraged to comfort with the exception of soccer. At 6 months she was running cross country. No complications to date, and she continues itraconazole. The distal phalanx fracture was completely consolidated on x-ray. Cleared to return to soccer by orthopedics.

Shouldering the Strain: A Cadets Unexpected Weakness Uncovered

Joshua Calderon, DO

All Other Authors: Geoff McLeod, DO

Affiliation: The Medical University of South Carolina, Charleston, South Carolina.

History: A 19-year-old, right hand dominant, female military cadet presented with acute onset of left-sided neck and shoulder pain. Symptoms occurred 24 hours prior to the office visit without provocation. Pain was described as dull, achy, and localized along the left trapezius and midline back, with radiation to the posterior shoulder. Pain was notably worsened with overhead movements and internal/external rotation of the glenohumeral joint. She expressed difficulty raising the extremity above shoulder height and significant pain while dressing and grooming. Additionally, she noted limited ability to perform push-ups, pull-ups, and bracing in company formation. She denied any history of trauma, fever, systemic symptoms, or prior musculoskeletal injuries involving the neck or shoulder. She recently completed Hell Week during which she performed hundreds of pushups throughout a 7-day period.

Physical Exam: The patient was well-appearing with normal vital signs. There was no notable muscular swelling or deformity. Palpation revealed tenderness along the left trapezius, levator scapulae, and rhomboids, with notable trigger points in these areas. Active range of motion of the left shoulder was limited in flexion and abduction by pain. External and internal rotation were preserved. Provocative testing revealed a positive Hawkins test and positive O’Brien’s test. Strength testing of the rotator cuff muscles was 4/5 and there was notable weakness in the scapular stabilizers. A subsequent sports medicine exam identified lateral scapular winging with active forward elevation and inability to shrug.

Differential Diagnosis:

1. Left shoulder impingement
2. Muscle strain
3. Rotator cuff tendinopathy
4. Scapular dyskinesis
5. Cervical radiculopathy

Test Results: X-rays of the left shoulder showed no osseous abnormality. X-rays of the left AC joint w/wo weights showed no osseous abnormality. She was referred for EMG/NCS after sports medicine evaluation which showed muscle membrane irritability in the left trapezius. Motor unit action potentials in the left trap, bicep, infraspinatus and deltoid appeared myopathic with rapid recruitment.

Final Diagnosis: Facioscapulohumeral muscular dystrophy (FSHD).

Discussion: Facioscapulohumeral muscular dystrophy (FSHD) is a genetic disorder leading to muscle degeneration and is characterized by progressive muscle weakness, particularly in the facial, and periscapular regions though usually spares the deltoid. Symptoms most commonly manifest in the second decade of life and it is the third most common muscular dystrophy. Genetic testing is essential for accurate diagnosis, especially when symptoms overlap with common athletic injuries.

Outcome: Following EMG results, a Neuromuscular specialist observed eyelid and perioral weakness, periscapular muscle atrophy, and excessive protraction, leading to a working diagnosis of FSHD. Genetic testing was recommended to confirm the diagnosis. She completed intensive physical therapy making significant improvements in range of motion, pain, and physical capability.

Follow-Up: The patient deferred genetic testing until graduation due to concerns for her ability to commission as a Naval officer. The cadet continued physical therapy with a gradual return to full military and physical activity. In the spring of 2023, the patient successfully participated in The Citadel’s freshman Recognition Day gauntlet, and maxed out her scores for the Navy Physical Fitness Test.

The Missing Factor

Mark Carrasco, MD

All Other Authors: Matthew Heath Hale, MD, Calvin Spellmon, MD, Amit Momaya, MD, Ian McKeag, MD, and Irfan M. Asif, MD

Affiliation: The University of Alabama at Birmingham, Birmingham, Alabama.

History: This is an 18-year-old M collegiate basketball player with no PMHx who presents to the training room for right lower extremity pain. Pain is described as throbbing, intermittent, localized to the right lateral thigh with no radiation. He also reports thigh swelling. Pain worsens with basketball activities and relieved at rest. He saw ortho 1 week prior for similar pain, in addition to right knee pain and swelling. This occurred after he was accidentally kneed during practice. POCUS showed fluid within the right suprapatellar pouch and 10 cc of sanguineous fluid was subsequently aspirated. He was diagnosed with a quadriceps hematoma and instructed to take indomethacin for pain control. Swelling improved a few days later at follow up. Pain has prevented him from playing any games. He had a similar episode 3 years ago which took 8 weeks to resolve. Denies paresthesia, erythema, and warmth.

Physical Exam: Right Lower Extremity: Inspection- Slight swelling over antero-lateral thigh, mild effusion in the suprapatellar pouch, no erythema, ecchymosis, or skin lesions; No tenderness to palpation along the medial or lateral knee joint lines; Range of motion is from 0 to 90 degrees limited by quad pain; Stable to varus and valgus stress testing at 0° and 30°, negative Lachman test, negative posterior drawer, negative McMurray; Extensor mechanism intact; Neurovascularly intact to the lower extremity.

Differential Diagnosis:

1. Quadriceps hematoma due to contusion
2. Quadriceps hematoma due to a bleeding disorder
3. Quadriceps hematoma due to a quad rupture
4. Traumatic myositis ossificans
5. Quadriceps hematoma due to a soft tissue tumor

Test Results: Labs: H&H 10 gm/dL/30%, PTT: 43 seconds, ESR: 45 mm/hour, Factor VIII: 125% (N: 50–186), VW antigen 83% (N: 50–249), VWF Activity 75% (N: 50–150), C Protein 116% (N: 70–140), S Protein 98% (N: 65–160); Imaging: MR Right Femur without contrast- Large intramuscular lesion centered in the right vastus intermedius spanning approximately 24.2 cm in craniocaudal dimension, likely a hematoma. Regional reactive myositis of the quadriceps. Concavity of the superior subcapital right femoral neck.

Final Diagnosis: Quadriceps hematoma due to a bleeding disorder.

Discussion: The patient denies other bleeding episodes or any family history of bleeding disorders. After a largely inconclusive work-up, we expanded our testing to include Factor XI (FXI), FIX, and fibrinogen. FXI was decreased to 43% (N: 50–150). FXI deficiency, aka hemophilia C, is a rare disorder with a prevalence of 1 in 1,000,000. It differs from hemophilia A or B by its autosomal inheritance pattern and variable bleeding tendency. Severe FXI deficiency is defined as activity level less than 20%. Patients with this disorder usually have an elevated aPTT in the setting of a normal PT. Clinical symptoms includes bleeding provoked by post-injury, epistaxis, and heavy menstrual bleeding.

Outcome: There are no factor products for FXI available in the USA. Instead this disorder is typically treated with fresh frozen plasma (FFP) prior to procedures or with injury. As an athlete there is a recurrent risk of injury, therefore the hematologist recommended FFP prior to games versus giving FFP only with injury. There is no good guidance on what to do in these cases as FXI deficiency is rare.

Follow-Up: Through shared decision making, we decided to give FFP only if an injury was sustained. Patient continued PT with symptom resolution. He played in a game 2 weeks after diagnosis. One month later, a right lower extremity MR angiogram showed no structural vascular abnormality and a resolution of the hematoma with residual fascial thickening/inflammation. He has not required FFP since diagnosis.

Syncope in the Athlete

Mitchell Peebles, DO

All Other Authors: Jill Guillete, DO and Theodore Takata, MD

Affiliation: Texas Health Harris Methodist Hospital Fort Worth, TX.

History: A 29-year-old male with no past medical history who presents for evaluation after a syncopal episode. Recently, he has been experiencing intermittent, left sided, 5/10, chest discomfort. While warming up for a soccer game he became lightheaded and lost consciousness. He only regained consciousness after a sternal rub. Family history is significant for a maternal uncle with a myocardial infarction in his thirties. With EMS, he received a 1,700 mL bolus of normal saline and 0.5 mg of Atropine for bradycardia and hypotension.

Physical Exam: Vitals Signs with EMS: 74/40, HR 60. Vital Signs in ED: 130/72, HR 77. General: no acute distress, oriented to person, place and time. Cardiovascular: Regular rate and rhythm on auscultation. No murmur, rub or gallop auscultated. Respiratory: clear to auscultation bilaterally. Neurology: strength 5/5 bilaterally in both the upper and lower extremities. No focal deficits.

Differential Diagnosis:

1. Hypertrophic obstructive cardiomyopathy (HOCM)
2. Viral myocarditis
3. Seizure disorder
4. Myocardial infarction
5. Spontaneous Coronary Artery Dissection (SCAD)

Test Results: EKG: normal sinus rhythm with ST segment changes or T-wave inversions. Rate of 72. No axis deviation. Transthoracic echocardiogram: ejection fraction of 55–60% with no wall motion abnormalities. High-Sensitivity Troponins: 99 to 1,871 to 878 to 568. Coronary Angiography: proximal dissection of the left main artery extending to the left anterior descending artery, left circumflex artery, and the ramus. Ejection fraction (EF) of 10%.

Final Diagnosis: Spontaneous Coronary Artery Dissection (SCAD) of the left main artery, left circumflex artery, and ramus artery.

Discussion: SCAD is a rare cause of myocardial infarction accounting for 0.1–4% of cases. SCAD is most commonly seen in young females, but can be seen in post-menopausal women as well. Risk factors for SCAD include being female, atherosclerosis, heavy exercise, peripartum period, and connective tissue disorders. The typical presentation is a patient with chest pain, elevated troponins, sudden cardiac death, and ventricular arrhythmias, which makes this condition difficult to distinguish from other cardiac ischemic events. Given his young age, he was sent for genetic testing as Fibromuscular Dysplasia is a possible etiology of SCAD in a young male.

Outcome: Given the results of the angiogram, and an intra-procedural EF of 10%, Cardiothoracic Surgery was consulted and performed an emergency 2 vessel coronary artery bypass graft (CABG). Prior to his CABG, the transesophageal echocardiogram (TEE) confirmed an EF of 10–15%. Post-operatively, EF was improved to 30–35%. He was referred to a specialty clinic for SCAD and for genetic testing.

Follow-Up: Given the severity of his condition, and the unknown etiology of SCAD in this patient, he was referred to a SCAD clinic where he was evaluated for and found to have evidence of Fibromuscular Dysplasia. He was also found to have a genetic mutation in the Ehlers-Danlos Syndrome family. He has since been able to run 3 miles, but not cleared for contact sports.

Eye of the Tiger—Why Cant We All Just Skate Along?

Jolie Holschen, MD, FAMSSM

Affiliation: Loyola University Hospital and Stritch School of Medicine, Chicago, IL.

History: A 27 year old professional hockey player was involved in an on ice fight during a game. He was punched in the left eye and fell face forward, striking his head on the top edge of the boards. There was no loss of consciousness. He skated off ice escorted by staff, bleeding profusely from his nose. He noted numbness around the left eye and felt a foreign body sensation in the left eye. He complained of nausea and headache. He denies neck pain, chest pain, shortness of breath, or abdominal pain. After an initial assessment, control of nasal bleeding, and laceration repair, he stood up and appeared dazed, was slow to respond to questions and became agitated, then kneeled down and started retching.

Physical Exam: 6 ft 4 inches tall, 95 kg. He was ambulatory on skates to the locker room and had good balance. Neurologic examination confirmed PERRL, EOMI, sensation intact to light touch on the bilateral face, and strength 5/5 bilateral face, arm and leg. Fluorescein stain of the cornea was negative for uptake. A complex laceration (total length 7 cm) near the corner of the left eye involved both upper and lower lids. There was left greater than right periorbital swelling and nasal deformity. Profuse bleeding came from the right nare. An abrasion was located over the mid forehead with underlying hematoma developing. Teeth were intact. The cervical spine was nontender with palpation and range of motion.

Differential Diagnosis:

1. Facial fractures- nasal and orbital
2. Concussion
3. Intracranial bleed
4. Intraabdominal injury
5. Carotid artery dissection

Test Results: CT Head shows a frontal lobe contusion with pneumocephalus and orbital fractures. CT Facial Bones shows a left orbital medial wall fracture, right nasal fracture, and frontal sinus fracture involving both the anterior and posterior walls.

Final Diagnosis: Severe traumatic brain injury, including frontal sinus fracture with pneumocephalus and frontal lobe hemorrhagic contusion. Nasal and orbital fractures with cranial nerve VI palsy. Facial lacerations.

Discussion: The initial assessment of this patient indicated a concussion and facial fractures, but his decline in the training room over a short period of time, while bleeding was addressed and the lacerations repaired, suggested a more severe injury than first realized. At this point he was transported by ambulance to the Level I trauma center. Multiple signs of severe TBI are exemplified in this case. In retrospect, the behavioral changes correlate with the frontal lobe injury found on imaging. Coaches, athletes and the public claim fighting is an integral part of the game, but it can have devastating consequences and should be banned rather than tolerated by officiants and allowed by the league.

Outcome: After evaluation in the ED, the patient was admitted to the ICU. Operative repair was performed of the nasal, orbital, and frontal sinus fractures by plastic surgery and neurosurgery. Daily headaches were problematic. He had double vision with leftward gaze due to a mild CN VI palsy. In addition, he exhibited slowness and difficulty concentrating, as well as periods of anxiety with chest pain.

Follow-Up: Neurosurgery recommended restriction from all exercise for 6 weeks, followed by no head jolting or extreme exertion due to ongoing symptoms in the subacute period after hospital discharge. A referral was made to neuro-ophthalmology. The patient returned home to recuperate and did not return to play for the rest of the season. The following year, he retired from professional ice hockey.

Odynophagia in a Collegiate Baseball Player

Haley Oosterhouse, MD

All Other Authors: Lindsay Huston, MD and Matthew Lynch, MD

Affiliation: UCSF, San Francisco, CA.

History: A 19 yo male collegiate baseball player presents to the emergency room for 2 hours of sensation that something is stuck in his throat. Approximately 4 hours prior to presentation, patient did a heavy lift, and then ate a large meal consisting of chicken and noodles which is when he first started to notice a stuck sensation in his throat and some throat pain. He does not believe there were bones in the chicken he was eating. He denies difficulty breathing or speaking, chest pain, nausea, vomiting, or fevers. No past medical history. Had Tommy-John surgery 18 months ago and is doing BFR for this. No current medications or allergies.

Physical Exam: Gen: No acute distress, not ill-appearing. HEENT: Normocephalic, atraumatic, handling secretions without issue, no visible abnormalities in the posterior oropharynx, no obvious crepitus on neck palpation. No congestion or rhinorrhea. Mucus membranes moist. PERRL, EOMI. CV: RRR, no murmurs, normal capillary refill. Pulm: Normal respiratory effort, CTAB. Abd: Soft, non-distended. Spine: Normal C-spine range of motion and neck supple, no deformity or signs of injury. Neuro: No focal deficits

Differential Diagnosis:

1. Esophageal food impaction
2. Foreign body aspiration
3. Esophagitis
4. Pharyngitis
5. Stricture

Test Results: XR neck soft tissue: Apparent moderate emphysematous changes in the pre-vertebral/retropharyngeal soft tissues. A follow-up CT scan can be obtained to further evaluate as indicated. CT neck and chest soft tissue: Moderate retropharyngeal emphysematous changes as well as moderate pneumomediastinum but no definite radiopaque foreign body seen.

Final Diagnosis: Spontaneous Pneumomediastinum (SPM) due to exertion.

Discussion: SPM is typically caused by air leaking through small alveolar ruptures, and less commonly caused by air escaping from the upper respiratory tract or GI tract. The most common predisposing condition is asthma. However, rarely an intense Valsalva maneuver or a blow to the chest wall can cause this, which is the case in intense sporting activities. The most common presenting features of SPM include chest pain, dyspnea, cough, neck pain, odynophagia and dysphagia. Physical exam can show subcutaneous crepitus on neck/chest palpation or Hamman sign on cardiac auscultation. The diagnosis is confirmed with frontal and lateral chest radiographs which show lucent streaks of gas in the mediastinum.

Outcome: The patient was admitted to the hospital, given a dose of empiric Unasyn, started on IV fluids and kept NPO. He remained stable throughout hospitalization, and a CT with PO gastrograffin was done showing no contrast extravasation or evidence of esophageal perforation. He was slowly advanced to regular PO intake and able to be discharged approximately 24 hours after admission.

Follow-Up: On follow up, he continued to feel well with no residual odynophagia, and was tolerating a regular diet without difficulty. He was advanced back to light physical activity including light catch, swinging, and stationary biking. He followed up with CT surgery 10 days after discharge, with X-ray showing no residual pneumomediastinum. He was cleared for advancement to full baseball participation.

A New Bike, A New Pain?

Tyler Dejong, MD

All Other Authors: Bradley Changstrom, MD

Affiliation: University of Colorado, Aurora, CO.

History: A 13 y/o healthy M who was brought to Sports clinic after developing left posterior shoulder pain. Ten days before presentation to clinic, he got a new mountain bike and rode it heavily for 3 days. A few days later, he developed mild vague shoulder discomfort on the L side into his scapula and L posterior shoulder. He described the pain as burning and sharp. The following day pain was getting worse, and that he now noticed the pain with deep breathing and laying down. He fevered the same day and was given NSAIDs with improvement in pain and fevers. The following 2 days, he was unable to attend school due to persistent symptoms. A massage therapist diagnosed him with a slipping rib and he had a manipulation with transient improvement. On the day of his visit, he had fever, shoulder pain and vomiting. His mother reports that they recently returned from the Paris Olympics 12 days ago.

Physical Exam: VS: HR 110, BP 107/61, SPO2 94% T: 38.2 Physical Exam: Constitutional: Non ill appearing child, Non Toxic, Conversant. HENT: No pharyngeal erythema, exudate, mucositis. Tonsils WNL. CV: Tachycardic, 2+ pulses, No friction rub. Pulmonary: Normal effort, no tachypnea, no stridor, wheezing, rhonchi, or rales. Chest: Chest wall is non tender. Abdominal: Flat, non tender abdomen, no peritoneal signs. MSK: Mild TTP over scapular body. L medial scapular winging with overhead reach. Pain improves with leaning forward and worsens when lying flat. No vertebral body TTP. Negative provocative shoulder testing.

Differential Diagnosis:

1. Pericarditis
2. Osteomyelitis
3. Long thoracic nerve palsy
4. Slipping rib syndrome
5. Occult trauma

Test Results: Patient was referred to ED and had the following workup: CBC: WBCs 12.5 w/ CMP: AST 67 ALT 50 CRP: greater than 27 Sed rate: 22 D-Dimer: 2.82 RPP: Rhinovirus positive. XR: Negative scapular radiograph. MRI: Osteomyelitis centered at the head of the left third rib with surrounding abscess, either abutting or extending into the adjacent lung parenchyma. Adjacent lung consolidation is also present. Stranding is also present extending into the mediastinum concerning for mediastinitis.

Final Diagnosis: Left 3rd rib costo-vertebral osteomyelitis and abscess with associated mediastinitis.

Discussion: The patient was admitted on ceftaroline and had MRI of his chest showing L 3rd rib osteomyelitis w/ mediastinitis. 2 days after admission he had IR place a left posterior mediastinal drain. Although our concern for pericarditis in clinic was high, his pain source and systemic symptoms were from soft tissue and bone infection. He needed multiple advanced imaging studies, frequent lab draws, and cultures from an IR procedure to make the diagnosis. Costal and vertebral osteomyelitis are a semi-rare occurrence in children but present with systemic symptoms. A high level of suspicion is needed to ensure this diagnosis is not missed in the clinic setting.

Outcome: This patient had the drain removed 2 days after 13 cc of purulent fluid was irrigated from the abscess cavity. He was then discharged on oral keflex and pain control with ID and PCP follow up. His inflammatory markers continued to down trend after source control with drain placement and he stayed in the hospital for 6 days.

Follow-Up: The patient completed 6 weeks of keflex. He was able to return to all activities shortly after he was discharged from the hospital. He has had outpatient follow up with ID and his pediatrician and is doing well overall.

Insidious Ulnar Sided Forearm Pain in Softball Pitcher and Bowler

Hamilton Newhart, MD

All Other Authors: Andrew Cunningham, MD

Affiliation: Henry Ford Hospital, Detroit, MI.

History: A 16-year-old right hand dominant female softball pitcher and bowler presented as new patient for evaluation of right ulnar sided forearm pain. She says her pain began insidiously with softball pitching about 1 month prior to the visit. About 8 months prior she had similar pain during bowling season that had resolved. The patient was pitching in a tournament and noticed moderate pain in the ulnar forearm after pitching. The location of pain was at the ulnar side forearm about 8–10 cm distal to the medial elbow joint line. She says she was able to continue pitching during that weekend, but the pain had persisted over the prior 4 weeks. She had taken a 2 week break from softball prior to the visit which had helped her with pain symptoms. She denies any numbness, tingling or weakness in her hand. She denied fatigue, irregular menstruation, weight loss, depression or anxiety.

Physical Exam: General: alert, oriented, conversant. Right elbow/Forearm: Skin intact, no lesions or abnormalities. No significant swelling noted. Tenderness to palpation over mid-proximal ulnar diaphysis at medial border. Wrist/elbow range of motion: Normal and symmetrical. Sensation intact to light touch in median, radial and ulnar nerve distributions in the hand. Motor units intact in AIN, PIN and ulnar nerve distributions in the hand. No pain with resisted wrist extension. Mild pain with resisted wrist flexion. No pain with resisted supination. Mild pain with resisted pronation. Grip strength: symmetric bilaterally. Negative varus and valgus stress testing of the elbow. Negative Milking maneuver.

Differential Diagnosis:

1. Proximal forearm flexor/pronator tendinopathy
2. Ulnar diaphysial stress injury
3. Medial epicondylitis/avulsion
4. Pronator syndrome
5. Medial antebrachial cutaneous nerve pathology

Test Results: XR right forearm: Questionable periosteal reaction of the mid-shaft ulnar diaphysis noted in clinic prompting workup with advanced imaging. MRI of right forearm without contrast: T2 weighted images show high signal of the mid-shaft ulna involving the cortex, bone marrow and periosteum. T1 weighted images in the same region demonstrated hypointense signal consistent with marrow replacement. No clear fracture line was seen. This is consistent with a bone stress injury to the ulna.

Final Diagnosis: Bone stress injury of the mid-shaft ulna without evidence of fracture.

Discussion: Ulnar diaphyseal stress injuries are rare and often misdiagnosed as flexor tendinitis initially. There is a paucity of literature on the topic, but ulnar stress injuries have been reported in active athletes that perform significant pronation/supination and rotational motions. In softball, the windmill pitch motion causes the revolving force of the radius to exert high forces on the ulna which is relatively immobile. The middle third of the ulna has the smallest diameter and thinnest cortex of the bone making the most likely location. Notably, there are no pitch count regulations in softball. Clinicians should consider ulnar stress injuries in throwing athletes with forearm pain.

Outcome: We treated our patient with a course of strict rest including no pitching, weightlifting, repetitive forearm pronation/supination. At 4 weeks she continued to have mild tenderness to palpation of the ulna which was resolved at the 7-week follow-up visit. The patient was then transitioned to physical therapy to begin gradual return to throw program.

Follow-Up: Our patient has been cleared to start a gradual return to throw program with the goal to return to previous form over the next several months. We strongly encouraged her to continue to address general strength and throwing biomechanics in order to prevent future occurrence and injury. She was screened for signs of relative energy deficiency in sport (RED-S) and had no worrisome components.

In Depth Diagnosis: A Case of Exertional Associated Collapse

Reggie Taylor, DO, MA

All Other Authors: Brian Merrigan, MD

Affiliation: National Capital Consortium Sports Medicine Program Fort Belvoir, VA.

History: A 19-year-old male active-duty service member presented to the emergency department after 2 exertional syncope events. Patient reported loss of consciousness 1 mile into a run with no prodromal symptoms. He regained consciousness and endorsed feeling lightheaded but was able to resume his run. A half mile later he felt his legs and upper body go weak and give out. He lost consciousness again, this time hitting the back of his head. Patient went directly to the ER following the second collapse. Denies chest pain preceding collapse. ROS: (−) Confusion, vomiting, tongue biting, jerking, SOB, palpitations (+) Blurry vision after 2nd collapse. Past medical history: Narcolepsy and ADHD, Not on medication. Family history: Diabetes type 2 Maternal cousin with sudden unexplained death in 20’s Two paternal cousins with sudden unexplained death in their 20’s and 30’s.

Physical Exam: General: Alert and oriented, well nourished, no acute distress. Eye: EOM Intact, PERRLA, normal conjunctiva. HENT: Normocephalic, atraumatic. Lungs: non-labored respiration, symmetric bilateral chest wall expansion, CTAB. Heart: No peripheral edema, well perfused, regular rate and rhythm, no murmurs appreciated. Skin: Skin is warm, dry and pink, no rashes or lesions. Neurologic: Awake, alert, and oriented, Cranial Nerves II–XII intact, no focal deficits. Psychiatric: Cooperative, appropriate mood and affect.

Differential Diagnosis:

1. Structural Cardiac Abnormality
2. Symptomatic Coronary Anomaly
3. Cardiac Channelopathy
4. Exertional heat Injury
5. Seizure disorder

Test Results: Troponin: 0.15, 0.16, 0.10. EKG: Sinus Bradycardia, early repolarization and RSR’ pattern. CT Heart: Long segment of myocardial bridging 2.04 mm deep and 44.6 mm in length starting in the mLAD just distal to the 1st diagonal branch extending to the distal LAD. Treadmill Stress Test – Reproduction of chest pain and EKG with global ST changes. Cardiac catheterization: Significant myocardial bridging of mLAD and when stressed had elevated index of microvascular resistance and left coronary flow.

Final Diagnosis: Symptomatic Myocardial Bridging of the Left Anterior Descending Artery.

Discussion: Myocardial bridging (MB) is a rare cause of exertional chest pain and syncope. The prevalence of MB is estimated to be 25%, however the vast majority of these patients are asymptomatic. Symptomatic patients typically present with anginal symptoms. Diagnosis is best made with coronary angiography. Conservative management includes beta blockers while surgical management includes CABG or myocardial unroofing. Asymptomatic athletes with MB and normal stress testing should not be restricted from sport. Symptomatic athletes who undergo surgical intervention should be restricted to low intensity sports for 6 months after the procedure. If asymptomatic for 6 months, they may return to full sport.

Outcome: After initial presentation, patient was restricted to light activity. He presented to the ED twice more with chest pain brought on by minimal exertion. Medical management was attempted but he was unable to tolerate beta blockers due to a low resting heart rate. He eventually underwent a successful surgical unroofing of his LAD by cardiothoracic surgery.

Follow-Up: Patient is currently in cardiac rehab and doing well post-operatively. If the patient is able to return to symptom free exercise with normal stress testing, he would like to return as an active duty service member.

Rebounding From Breathlessness: A Case of Dyspnea in a Collegiate Womens Basketball Player

Clarinda Hougen, MD

All Other Authors: Lacey Knowles, MD

Affiliation: Cedars-Sinai Kerlan-Jobe Institute, Los Angeles, California.

History: Patient DH is a 22 y.o. female collegiate women’s basketball player with no significant medical history who presented to her team physician with a complaint of dyspnea on exertion. Her dyspnea had started several years ago, limiting her ability to play basketball at full capacity, and was felt by a previous provider to be vocal cord dysfunction versus gastrointestinal reflux. That provider recommended speech therapy, which was provided through her undergraduate institution, but did not resolve her symptoms. She continued treatment of dyspnea and wheezing with budesonide but did not note any improvement. About one year later, she presented to a pulmonologist, for further evaluation.

Physical Exam: Gen: Conversant, NAD. HEENT: NCAT, normal eyelids, conjunctivae, EOMI, PERRL; Normal oropharynx. Neck: Supple, no LAD, no thyroid masses. CV: RRR, normal S1, S2, no murmurs. Pulm: Breathing comfortably on RA, CTAB. Abd: Soft, NTND, no gross organomegaly. Ext: No edema, clubbing, or cyanosis. Skin: No rashes. Neuro: AAOx3, CNII-XII grossly intact, normal speech. Psych: Normal mood and affect.

Differential Diagnosis:

1. Asthma/Allergies
2. Vocal cord dysfunction
3. Anemia
4. Congenital heart condition
5. Cardiac arrhythmia, e.g. SVT

Test Results: Two-view chest X-ray: Right-sided aortic arch noted. Allergy panel: multiple positives. PFTs: normal except low DLCO. H/H: 12.3/38.2. TTE: Normal. CT angiogram chest: Mild tracheal narrowing with vascular ring and right aortic arch. CT chest no contrast: Right aortic arch with aberrant left subclavian artery arising from diverticulum of Kommerell, compatible with vascular ring. Mild focal tracheal stenosis and tracheomalacia at the level of the vascular ring.

Final Diagnosis: Right-sided aortic arch with aberrant left subclavian artery resulting in tracheomalacia secondary to vascular ring.

Discussion: Right aortic arch is an uncommon pathology affecting 0.01–0.1% of the population. The most commonly observed vascular branching patterns are mirror-image branching (50%) and aberrant left subclavian artery creating a fourth vascular branch (40%). Type 2 anomalies cause development of a vascular ring due to the attachment points of the ligamentum arteriosum, resulting in a tracheal or esophageal stricture. Right aortic arch can be associated with other congenital defects like DiGeorge syndrome or truncus arteriosus. If additional defects are not present, the cardiovascular exam is normal. Vascular rings may require surgical intervention if associated with dyspnea or dysphagia.

Outcome: Patient underwent successful surgery for division of the vascular ring and translocation of the aberrant left subclavian artery.

Follow-Up: At her 2-week postoperative follow-up, the patient was noted to be recovering well and walking without shortness of breath. Three months after surgery, she continues to participate in cardiac rehabilitation but has not yet returned to basketball.

Friday Night Frights: A Tackle Gone Wrong

Caleb Curry, DO

All Other Authors: Jennifer Mitchell, MD, FAAFP, FAMSSM

Affiliation: Texas Tech Primary Care Sports Medicine Fellowship, University of Texas Tech Health Sciences Cent.

History: 18 yo M high school tailback was tackled and thrown down on crown of his helmet, did not lose consciousness. He continued to play but was not acting right, so was asked to leave the field by officials, then started walking toward the endzone when he collapsed. He reported numbness and weakness of his right extremities, so c-spine was stabilized and helmet and shoulder pads removed. He was taken by EMS to the ED under spinal precautions. In the ED he still had R-sided numbness, paresis, neck and upper back pain, and headache, which prompted imaging and neurosurgery consult. Imaging showed no abnormality, but due to persistent deficits he was admitted to the ICU for monitoring and additional evaluation. ROS: R-sided neck/upper back pain, RUE weakness and numbness, RLE paralysis and numbness, headache, no bowel/bladder symptoms. PMH: multiple concussions. PSH: appendectomy, R labral repair.

Physical Exam: In the ED: T 37°C, HR 118, RR 18, BP 163/86, SpO2 95%. General: awake, alert, answers questions appropriately. Neuro: CN II-XII intact, reflexes 2+ bilaterally, mental status intact. Motor: Normal muscle bulk and tone; Right pronator drift. Strength: 5/5 except as follows; 4/5 right deltoid, biceps, triceps, wrist flexion/extension, interossei, abdominals, iliopsoas, quads, hamstrings, glutei, ant/post tibial, peroneal, gastroc. Sensory: Diminished sensation to light touch and differentiation of sharp and dull in right shoulder, right hand, and right upper and lower leg; Normal sensation in chest/abdomen; Full sensation in the right foot; Preserved proprioception in bilateral LEs.

Differential Diagnosis:

1. Cervical cord neurapraxia
2. Cervical spine fracture/dislocation
3. Intracranial hemorrhage/Traumatic brain injury
4. Spinal cord injury w/out radiographic abnormality
5. Spinal cord hemisection

Test Results: Labs: Cr 1.4, BUN 22, CMP otherwise WNL, H/H 15.9/44.0, WBC 13.92, Plt 288. CT Head, C-spine, T-spine: No acute fracture or abnormalities, canal stenosis, or hemorrhage; Thoracic kyphosis from known butterfly vertebrae at T8. MRI Brain, C-spine, T-spine: Normal, unremarkable imaging, with anomalous T8 vertebral body. CTA Head/Neck: Normal CTA; No focal stenosis, large vessel occlusion, or dissection. XR C-spine: Normal alignment in lateral plane; No subluxation with flexion or extension.

Final Diagnosis: Spinal Cord Injury Without Radiographic Abnormality (SCIWORA).

Discussion: Athletes’ long-term health is most important when managing transient hemiplegia. There are few formal guidelines for management of CCN and SCIWORA. It is well established that CCN resolves in 48 hours and resolution of SCIWORA varies, some having residual deficits. Deficits that resolve can be managed with an individualized approach, but persistent deficits should never be cleared for contact/collision sports. Clearance may be allowed after a first SCIWORA with complete resolution if there’s no other red flags. Guidelines recommend lifetime restriction following a second CCN event. This case highlights the continued knowledge gaps regarding SCIWORA even with increasing accessibility of MRI.

Outcome: Admitted to ICU for neuro checks and imaging. BP normalized, though was on pressors from day 1–3 for MAP goal >85, MAPs in low 80s. Day 2 strength improved globally though not back to baseline. Day 3 still reported heaviness in feet with unsteady gait. Day 4 was back to baseline with symmetric strength, 5/5 globally, on exam without unsteadiness. Discharged home to follow-up with PCP for concerns.

Follow-Up: Trauma team discharge instructions: “avoid contact sports for 6 months” and “see PCP for problems.” His parents didn’t know what to do, so went to orthopedist, was sent to PT and PCSM team. Given injury and medical history, will not be cleared for contact/collision sports, but if remains symptom free will be cleared to run track in the spring but not for high-risk events like hurdles and jumping.

Acute Back Pain and Lower Extremity Weakness During the Squat in a Teenage Powerlifter

Flynn McGuire, MD, MS

All Other Authors: Kristen Saad, MD MS, Akbar Nabi, DO, Michael Green, DO, and Aaron Provance, MD

Affiliation: University of Utah, Salt Lake City, Utah.

History: A previously healthy 15-year-old female was performing a high bar smith machine back squat at 2.04 times bodyweight when she experienced sudden-onset mid-back pain and fell forward to the floor and had immediate loss of lower extremity sensation and strength. The barbell did not land on her. She had been powerlifting 2–3 times a week and the week prior had squatted 1.95 times her bodyweight without incident. She had no prior history of musculoskeletal injuries but did experience mild intermittent mid-back pain. Pre-injury risk factors were reviewed and negative for female athlete triad, irregular menses, or significant thyroid or parathyroid disorders.

Physical Exam: On initial examination, the patient was noted to be uncomfortable but not in distress with a cervical collar in place. She was alert and oriented and following commands with pupils there were equal, round, and reactive to light. There were no abrasions, contusions, or tenderness of the clavicles, ribs, or sternum. The abdomen showed no abrasions, contusions, or distention, with no pain upon palpation, but there was a loss of sensation below the umbilicus. The pelvis was stable to rocking. There was a step off deformity noted at approximately T10 and the patient was unable to move her lower extremities, but upper extremities had normal motion, strength, and sensation.

Differential Diagnosis:

1. Acute Spondylolysis with listhesis
2. Acute vertebral disc herniation
3. Acute compression fracture
4. Acute muscle tear
5. Apophyseal ring fracture

Test Results: Imaging revealed unstable T11 vertebral body compression fracture complicated by anterolisthesis of T10 and T11 resulting in >50% spinal cord compression, cord edema from T9–T11, and intramedullary hemorrhage.

Final Diagnosis: Spinal cord injury (SCI) was graded as a T10 AIS B by ASIA exam performed 2.5 weeks post-event but improved to T11 AIS B by ASIA exam 1-month post-injury.

Discussion: Compression fractures are rare and typically associated with high-velocity mechanisms. The patient sustained a significant injury while engaging in a common strength activity without clear training history, endocrinologic, iatrogenic, malignant, or dietary factors that can predispose to weakened bone density. There was pre-morbid intermittent back pain which may have been indicative of underlying spondylolysis, however this cannot be confirmed due to lack of pre-morbid imaging. To our knowledge, there are no cases of squatting-related spine fractures complicated by SCI in the literature. Limitations of this case include a lack of pre-morbid imaging and no DEXA scan to assess bone density.

Outcome: She subsequently underwent emergent T11 laminectomy, superior facetectomies, and posterior spinal instrumentation and fusion from T8-L2. Following acute inpatient stay significant for spinal shock, patient was admitted to inpatient rehabilitation for therapeutic optimization, wheelchair and equipment training, management of spasticity, neurogenic bowel, and neurogenic bladder.

Follow-Up: The patient was discharged to home about 1.5 months post-injury where she continues with outpatient physical and occupational therapy. This peculiar presentation should prompt discussion of the safety of heavy weight resistance training in adolescents.

Dare to Huff: A Bone Altering Journey

Joshua Manuel, MD

All Other Authors: Yara Gonzales, MD

Affiliation: JPS Health Network, Fort Worth, TX.

History: A 27-year-old left-handed male mechanic with past medical history of recurrent diverticulitis, obesity, and MDD presents for evaluation of bilateral hand pain, swelling, and finger deformities that have been progressively worsening for the past 6 months. Symptoms started symmetrically, but now worse on the right, and now causing inability to perform daily tasks at work. He denies any history of hand trauma. Hand x-rays were obtained which showed diffuse, multifocal periosteal reactions of the tubular bones of bilateral hands and forearms. He denies any weight loss, hemoptysis, SOB, CP, pale stools, heat intolerance, cold intolerance, IV drug use, or alcohol use. He does endorse prior marijuana use, previous 7.5 pack year smoking history, and current smokeless tobacco use.

Physical Exam: Inspection of both hands reveals multiple firm, palpable nodules located over the dorsal, radial, and ulnar aspects of all fingers bilaterally. The nodules are non-erythematous, non-painful, non-mobile, and have no overlying skin changes. Range of motion of the left hand is maintained, though he does have tightness with fist formation. Range of motion of the right hand is limited in flexion of the phalanges and he is unable to fully make a fist or completely close his hand. He has normal and symmetric sensation in the median, ulnar, and radial nerve distributions bilaterally, normal grip strength, wrist extension, and wrist flexion bilaterally, and all ligaments are intact bilaterally.

Differential Diagnosis:

1. Early Onset Osteoarthritis
2. Rheumatologic Arthritis
3. Tophaceous Gout
4. Primary vs Secondary Hypertrophic Osteoarthropathy
5. Thyroid Acropachy

Test Results: CBC with mild normocytic anemia, normal WBC and Plt. CMP notable for an elevated Alk Phos at 260 (Liver ALP-82, Bone ALP-179). TSH, Free T4, and Total T3 normal. Uric acid mildly elevated at 7.7. ESR and CRP normal. ANA, RF, and CCP are all within normal limits. EGD with negative H Pylori and celiac disease biopsies. Colonoscopy with diverticulosis, no evidence of inflammatory disease. Normal echocardiogram. CT chest with contrast with no pulmonary nodules, but shows diffuse osseous sclerosis.

Final Diagnosis: Diffuse Skeletal Fluorosis Secondary to Difluoroethane Abuse.

Discussion: This is a case of non-endemic skeletal fluorosis that was caused by chronic abuse of compressed air cleaners, which contain 1,1-difluoroethane (DFE). DFE is abused by directly inhaling, “huffing,” and is widely abused for its euphoric effects. Skeletal Fluorosis develops from long-term exposure of high levels of fluoride and is endemic in some areas of India, Asia, and Africa where the drinking water has high levels of fluoride. Skeletal fluorosis causes a variety of non-specific findings, including osteosclerosis, bone thickening, periosteal bone formation, and ossification of tendons, ligaments, and muscles. Fluoride is deposited in the bone with a half-life of 7 years, making improvement.

Outcome: After significant workup, we still didn’t have a cause. At a later visit, my patient endorsed a 7-year history of inhalant abuse in which he “huffed” 4–8 cans of air duster daily from age 18–25 yo. With this new information, we obtained a DEXA scan with a T-score of +9.7 at the lumbar spine and a serum fluoride level which resulted at 1.1 mg/L (0.05), confirming the diagnosis of skeletal fluorosis.

Follow-Up: Three years after his last use of inhalants, his hand stiffness is improving with daily exercises and anti-inflammatory medications, and he has been able to fully return to work. He is on supplemental vitamin D and calcium to ensure adequate stores for bone remodeling. He will continue to need close monitoring for development of renal disease, nephrolithiasis, nerve compressions, and fractures.

From Shoulder Press to Spinal Cord Injury

Logan Maag, MD

Affiliation: OhioHealth, Columbus, Ohio.

History: Twenty-four year old male with no significant past medical history, presents with acute onset cervical neck pain progressing to upper extremity paresthesias, upper extremity weakness with distal greater than proximal, lower extremity weakness with left greater than right, and urinary retention after performing a shoulder press with free weights in a gym. He first reported hearing a pop in his cervical neck and felt a “squishing” sensation while overhead pressing 145 pounds, prior to the onset of symptoms. Within minutes he began having severe bilateral shoulder pain radiating straight to his back and neck and into his arms. This progressed to bilateral arm paresthesias and arm weakness. He was able to ambulate into the emergency room but shortly after arrival he began having paresthesias and weakness of bilateral legs.

Physical Exam: He was alert and oriented to person, place, and time. Appropriately distressed. Regular rate and rhythm with normal breath sounds. Extremities well perfused with no skin changes. Strength testing revealed greatly diminished strength in bilateral upper extremity with distal grip strength weaker than proximal upper extremity muscles. His left lower extremity was flaccid. His right lower extremity had less than anti-gravity strength in hip flexion, knee extension, and foot plantarflexion and dorsiflexion. Pinprick and light touch sensation was absent distal to a C7 level. Vibration sensation and proprioception were intact in all extremities.

Differential Diagnosis:

1. Spinal Cord Infarction
2. Vertebral Artery Dissection
3. Cerebrovascular Accident
4. Syringomyelia
5. Myasthenia Gravis

Test Results: MRI C/T spine, MRA C spine, and CTA revealed cervical cord myelopathy with acute edema and T2 signal hyperintensity from C4–5 to T1. No evidence of hematoma, disc, or other compressive disease. Lab workup unremarkable with mildly low serum copper. Negative homocysteine, hypercoagulable panel, cardiolipin Ab IgG/A/M, prothrombin gene, B2 glycoprotein. Normal lipid panel, ESR, CRP, vitamin B12, zinc. Echocardiogram with mild LA enlargement and no shunt or valve abnormalities.

Final Diagnosis: Spinal Cord Infarction due to Fibrocartilaginous Embolism.

Discussion: Fibrocartilaginous embolism may represent around 5.5% of spinal cord infarctions. Literature states that 5000 to 8000 cases of spontaneous spinal cord infarction occur per year with most cases involving the cervical cord, and fewer involve the lower medulla or upper thoracic cord. If the cervical spine is involved, fatality rates are typically high. Typically, there is preceding neck injury, often minor such as lifting, causing neck pain and intervertebral disc herniation. The pathogenesis is hypothesized that axial loading forces on the spinal column and disc, may cause disc material to eject into the vasculature and spread retrograde to spinal cord blood vessels.

Outcome: Using the International Standards for Neurological Classification of Spinal Cord Injury, he was found to have a C5 AIS C Incomplete spinal cord injury. He was initially treated with IV Decadron, and a foley was placed for urinary retention. He was discharged to inpatient rehabilitation, where he progressed rapidly and significantly with his functional gains, including use of robotic gait device.

Follow-Up: Ultimately discharged home as modified independent in all activities of daily living except minimal assist in lower body dressing and ambulating with a left ankle foot orthosis and walker. He is voiding spontaneously. Repeat exam revealed C4 AIS D incomplete level of spinal cord injury.

Launched from the Saddle

Charles Baugh, MD

Affiliation: JPS Sports Medicine Fellowship, Fort Worth, Texas.

History: Forty-eight-year-old male, competitive runner, presented to clinic for right hip pain. 4 weeks prior to arrival he had a fall while riding his bicycle. He was riding on a trail, when his handlebars caught a bystander’s backpack, and he was launched over the front of his handles onto his right hip. Immediately felt pain in his right hip. He was evaluated in the Emergency Department where X-rays were negative. Diagnosed as muscle strain. Followed up 1 week after injury at outside office with continued pain. Repeat x-rays of his right hip were negative. Continued to treat as Muscle Strain. At presentation to our clinic, he reported persistent right hip pain. Originated at anterior groin and radiated posterior to buttock. Reports pain as severe, sharp. Having to use a cane to walk. He has radiation of pain down right leg, weakness, and saddle anesthesia of right testicle and groin. Denies back pain.

Physical Exam: Right Hip: No gross deformity, pelvis is level, no leg length discrepancy ROM: Full with hip flexion, extension, and External Rotation. Internal Rotation Limited. Pain with maximal flexion Strength: 5/5 with hip flexion, extension, abduction, and adduction Palpation: Tenderness to palpation at iliopsoas. Nontender over greater trochanter and posteriorly Special tests: Piriformis: Negative FABER: Positive FADIR Positive Back: No deformity, non-tender. Normal ROM in flexion, extension, lateral rotation. SLR negative GU: Equal, no swelling. Severe Tenderness to palpation at right external inguinal ring without bulging or swelling. Decreased sensation over right testicle.

Differential Diagnosis:

1. Right Hip Labral Tear
2. Right Hip Osteoarthritis
3. Iliopsoas Tear
4. Sacroilitis
5. Right Hip Fracture

Test Results: Xray Right Hip: No acute fractures. No evidence of joint space narrowing MRI Hip/Pelvis: (1) Acute Nondisplaced fracture of the proximal right superior pubic ramus. (2) Acute Mildly comminuted, non-displaced fracture of the right inferior pubic ramus. (3) Surrounding muscular edema and soft tissue edema involving the obturator and pudendal nerves. (4) Nondisplaced fracture involving the superior endplate of the S3 vertebral body as well as patchy edema in right inferior sacral ala.

Final Diagnosis: Multi-focal non-displaced pelvic fracture involving right Pubic Ramus and Sacral fracture with associated pudendal neuropathy.

Discussion: Typically pubic ramus fractures are seen in complex pelvic fractures from high energy traumas. Isolated pubic ramus fractures are usually seen in insufficiency fractures or low energy traumas in an aging population. For our patient, he presented 4 weeks after trauma after a bike fall with continued pain, difficulty bearing weight, and neuropathy. Unusual for an otherwise high functioning male running marathons competitively. His initial evaluation should have been considered a modified trauma and evaluated as such with CT scan. Consider advanced imaging for athletes in high energy traumas when complaining of continued pain despite normal radiographs.

Outcome: Made non-weightbearing for 4–6 weeks at time of diagnosis. Pain controlled with tramadol. Cleared for full weight bearing and physical therapy at 6 weeks. Significant improvement with physical therapy, able to walk without pain. At 6 weeks he was transitioned to running on Alter G treadmill. 3 months post diagnosis cleared for running.

Follow-Up: Patient has competed in 5-kilometer race, 3 months after full clearance at sub-7-minute pace without pain. He is planning to run his first marathon after injury in January 2025.

Shoulder Pain and Swelling in a 24 Year Old Female

Wesley Baker, DO

Affiliation: The Ohio State University, Columbus, Ohio.

History: A 24 year old female was referred to our Sports medicine department for left shoulder pain and swelling. The symptoms started approximately 4 months prior to her first visit. There was no injury or trauma associated with the onset of symptoms. Her initial evaluation by her primary care physician resulted in a diagnosis of rotator cuff strain. The initial treatment consisted of physical therapy and NSAIDs. There was no improvement following initial treatment. Shoulder symptoms progressed over the 4 months including worsening weakness and limited shoulder range of motion affecting her ability to work and perform ADLs. The patient also complained of increasing swelling in the posterior shoulder. No other symptoms reported and she had no other additional past medical history.

Physical Exam: General: Well appearing 24 year old female in no acute distress Left Shoulder Examination: Inspection: Prominence of posterior shoulder compared to contralateral side, no erythema or ecchymosis – visible swelling or mass in the posterior shoulder/scapular region Palpation: Firm, fixed mass located over posterior shoulder approximately 8 cm wide which was tender to palpation ROM: limited active and passive in all planes of motion Strength: 3/5 external rotation, 3/5 supraspinatus, 5/5 abduction, 5/5 internal rotation, 5/5 subscapularis, 5/5 biceps Sensation: normal.

Differential Diagnosis:

1. Soft tissue mass – benign vs malignant
2. Osseous mass of scapula – benign vs malignant
3. Cystic mass – subcutaneous
4. Intraarticular glenohumeral cyst vs mass
5. Atypical infectious process

Test Results: Xray left shoulder—extraosseous mineralizing soft tissue mass superficial to left scapula MRI left shoulder—Large expansile aggressive mass centered within the left scapula measuring 5.8 × 7.6 × 7.4 cm. Multiple septated cystic cavities are present throughout the lesion with dependent fluid/fluid leveling. Prominent infiltration of the surrounding rotator cuff musculature. CT guided biopsy left shoulder mass—osteoclast-like giant cell rich neoplasm with metaplastic bone formation.

Final Diagnosis: Primary Aneurysmal Bone Cyst with Giant Cell neoplastic features concerning for malignancy.

Discussion: An aneurysmal bone cyst (ABC) is a benign but aggressive bone lesion with blood-filled cystic spaces that can cause bone destruction. The cause is unclear but may involve vascular malformations or trauma. Primary ABCs are rare, comprising about 1% of bone tumors, and mostly occur in children and young adults aged 10–20, with a slight female predominance, often affecting long bones and vertebrae. Genomic analysis confirmed this case as a primary ABC. Treatment options include curettage with bone grafting, resection, arterial embolization, or sclerotherapy. Recurrence rate is about 20%. The shoulder mass was initially missed; a thorough exam could have expedited care.

Outcome: The patient initially opted for sclerotherapy. After completing 3 rounds of doxycycline injections, the mass continued to grow, and her symptoms progressed. Plans were made for resection of the scapula with either endoprosthetic or allograft reconstruction. Additional imaging (MRI, CT) is scheduled to begin the pre-operative planning and design process.

Follow-Up: Orthopedic Oncology notes that the post-operative expectations would be limited with respect to shoulder forward elevation. The patient is currently attending physical therapy to maintain function. They will follow up with the Orthopedic Oncology after additional follow up imaging to schedule surgery.

A Case of Persistent Thigh Swelling in a High School Football Player

Abby Wolfe, MD

All Other Authors: Natalie Ronshaugen, MD and Elizabeth LaBombard, MAEd

Affiliation: University of Nebraska Medical Center, Omaha, NE.

History: A 15-year-old previously healthy male sustained a helmet injury to his left thigh when tackled during football. Three days after the injury, he was seen for pain and swelling of the thigh secondary to a hematoma that developed. A left open quadricep hematoma evacuation, irrigation and debridement was performed after which his pain improved. He was started on an iron supplement for anemia secondary to blood loss. Two days after the procedure, he returned with continued swelling of the leg, lightheadedness and fatigue. He was transferred to a regional hospital for further evaluation and treatment.

Physical Exam: On exam, the patient had left thigh swelling with mild tenderness to palpation and an overlying incision from his prior hematoma drainage. The dressing was clean, dry and intact. His thigh compartments were firm but compressible, however, in the emergency department he was noted to have tension in the anterior thigh compartment. Sensation was intact throughout the lower extremity and pulses were 2+. He was able to tolerate passive range of motion of the knee without significant pain or difficulty.

Differential Diagnosis:

1. Muscular hematoma
2. Pseudoaneurysm
3. Compartment syndrome
4. Blood loss anemia
5. Deep vein thrombosis

Test Results: His initial hemoglobin was 7.0 (g/dL). Ultrasound with doppler of the hematoma demonstrated a hypoechoic structure closely approximating the left femoral vasculature with suggestion of to and fro flow. Computed tomography (CT) scan of the thigh revealed a pseudoaneurysm with active bleeding. An embolization arteriogram showed the pseudoaneurysm was located in a branch of the left profunda femoris artery.

Final Diagnosis: The patient was diagnosed with a profunda femoris artery pseudoaneurysm with active bleeding, causing blood loss anemia and his symptoms of fatigue and lightheadedness.

Discussion: Profunda femoris artery pseudoaneurysms are a rare complication that can occur following trauma, femoral fracture, or orthopedic procedures. The incidence rate is between 1–6%. Typical presentation includes thigh swelling with hematoma but can be nonspecific including hip pain or unexplained anemia (1). They are diagnosed using doppler ultrasound or CT angiogram, with CT being more accurate. Treatment is typically endovascular repair. Without treatment, potential complications include thrombosis, neurovascular compression, deep vein thrombosis or rupture (2). Given the possible complications, it is important to be able to recognize despite its rare and oftentimes nonspecific presentation.

Outcome: Our patient was monitored in the hospital following endovascular embolization for signs of developing compartment syndrome or worsening anemia, neither of which developed. On post operative day one he was discharged with crutches for ambulatory support with a plan to trend hemoglobin and undergo physical therapy outpatient.

Follow-Up: Five days after discharge, his thigh remained swollen and tender with limited flexion of his knee. He continued to have fatigue and lightheadedness secondary to anemia. Ten days after discharge, his hemoglobin was improved, and he felt well enough to resume school and begin physical therapy. He will sit out for the remainder of the football season while awaiting full recovery.

The Finger Trap: A Hidden Dual Fracture in a College Baseball Player

Lee Friedman, BS

All Other Authors: Pritom Karmaker, BS and Kristopher Paultre, MD

Affiliation: University of Miami Miller School of Medicine, Miami, FL.

History: A 20-year-old male college baseball player presented with pain and visible deformity in his left fifth digit. The injury occurred during batting practice where his finger became pinned between a pitch traveling at game speed (87–95 mph) and his bat in the middle of his swing. After the patient’s batting glove was removed there was an obvious deformity and pain on the distal aspect of the finger. The patient was unable to extend or flex his finger and had significant swelling at the time of injury. At initial injury patient reported not having reduced sensation at the tip of his digit. Patient’s finger was initially assessed by the team’s Athletic Trainer on the sideline before being bandaged and iced on route to further imaging.

Physical Exam: The patient appeared well-developed and well-nourished. He was alert, cooperative, and communicative in significant pain. Vital signs included elevated blood pressure and a BMI of 26.39, with other metrics unremarkable. Left Hand: Tenderness noted at the left fifth digit’s distal interphalangeal (DIP) joint with moderate edema and erythema. The patient could make a full fist but was unable to fully extend the injured finger. Grip strength was reduced secondary to pain. The skin examination showed some bruising at nail-bed with erythema towards the distal aspect of digit. There was significant deformity with the Distal interphalangeal joint remaining in a flexed position.

Differential Diagnosis:

1. Fracture of the left fifth digit distal phalanx
2. Fracture of the left fifth digit middle phalanx
3. Extensor digiti minimi tendon injury/avulsion
4. Bone contusion of left fifth digit
5. Left fifth digit DIP joint dislocation

Test Results: X-ray: Revealed fractures of both the distal and middle phalanges at the DIP joint of the left fifth digit. MRI: Demonstrated intra-articular comminuted fractures of the distal phalanx base and middle phalanx head, acute full-thickness rupture of the extensor digiti minimi tendon, acute tear of the DIP joint capsule, radial collateral ligament and palmar plate injuries, flexor digitorum profundus/superficialis tendon strains, and A4/A5 pulley sprains.

Final Diagnosis: Closed displaced fractures of both the distal and middle phalanges of the left fifth digit, confirmed by X-ray. Avulsion injury of the extensor digiti minimi tendon, confirmed during surgery.

Discussion: This case illustrates the complexity of phalangeal fractures and the overlapping symptoms with soft tissue injuries that can complicate diagnosis. The patient’s inability to extend the finger, coupled with localized tenderness, led to imaging that confirmed dual fractures and a ruptured extensor tendon. The MRI findings highlighted the severity of the injury, including comminuted fractures of the distal and middle phalanges. Surgical intervention with open reduction and internal fixation (ORIF) was deemed necessary to ensure proper realignment and repair of the structures.

Outcome: The patient underwent surgery for closed displaced fractures of the distal and middle phalanges. During the procedure, a complete avulsion of the extensor digiti minimi tendon was identified. The fractures were stabilized with wires and the tendon was repaired with sutures. The surgery proceeded without complications. Postoperatively, patient was advised on rehabilitation to restore full function.

Follow-Up: During the season, the patient was placed on an intense occupational and physical therapy regiment. He continued to have a minor flexion deformity consistent with mallet finger (due to extensor lag) and post traumatic osteoarthritis. Though he had a continued deformity, he returned to full participation 3 months post-injury.

Calling Timeout for a Heart on a Fast Break

Corey Spector, DO

All Other Authors: Ben Reisz, ATC, Ankit Shah, MD, and Korin Hudson, MD

Affiliation: MedStar—Georgetown/National Rehabilitation Hospital, Washington, DC.

History: Eighteen-year-old male NCAA Division 1 athlete who recently moved from overseas presented for cardiac evaluation after experiencing episodes of shortness of breath during practice that resolved with coughing. During his pre-participation screening history, he denied significant past medical history. He was a multisport athlete in high school and denied any history of syncope, chest discomfort, dizziness, lightheadedness, or palpitations during exercise. He had no known family history of cardiovascular disease. During pre-participation screening, ECG demonstrated normal sinus rhythm without concerning morphologic changes. Due to the symptoms experienced during practice, additional testing was performed. In retrospect, he acknowledged having similar sensations during exercise previously, terminated by coughing, but not realizing it was abnormal and always just felt that he was working hard.

Physical Exam: Vital Signs: Blood Pressure 139/62, Heart Rate 65 beats per minute, SpO2 99%, Respiratory Rate 14 General: No acute distress Neck: No JVD. Cardiovascular: Regular rate and rhythm, no murmur, gallop, or rub. No pectus deformity. Lungs: No respiratory distress. Lungs clear to auscultation with no wheezing or crackles. Pulse check: Femoral and distal pulses 2 plus without bruit Musculoskeletal: No gross deformity of extremities. Full range of motion. No swelling. Skin: Warm, dry, pink Neurologic: Sensation intact to light touch. No focal motor deficits.

Differential Diagnosis:

1. Atypical AV nodal reentrant tachycardia (AVNRT)
2. Accessory pathway-mediated tachycardia (WPW)
3. Hypertrophic cardiomyopathy (HCM)
4. Arrhythmogenic right ventricular cardiomyopathy
5. Pulmonary embolism

Test Results: Stress echo: 20 seconds of narrow complex tachycardia (NCT), 250 bpm, no symptoms or ischemic changes on ECG; salvos 3–5 wide complex beats during recovery 4-day Zio patch: 2 episodes of NCT, at 188 bpm; no symptoms Cardiac MRI: EF 60%, no evidence of ARVC or HCM CT angiogram: Normal coronaries, no anomalous vessels, ventricles normal size Repeat stress test: Sprint testing reproduced dyspnea and NCT at 262 bpm; Arrhythmia terminated with coughing EP study: Atypical AVNRT with slow-slow conduction.

Final Diagnosis: Atypical AV nodal reentrant tachycardia (slow-slow) confirmed by electrophysiology study, with successful ablation of the reentry circuit.

Discussion: While sudden cardiac death is the leading cause of death in NCAA student athletes, pre-participation exams demonstrate limited sensitivity in cardiac screening. This case highlights the limitations of the history and physical exam alone, given the patient had exertional symptoms without realizing they were abnormal. A systematic review and meta-analysis of over 47,000 athletes demonstrated ECG screening has superior efficacy in detecting cardiovascular conditions with 94% sensitivity, while history and physical exam alone are 20% and 9% respectively. ECG screening also had a lower false positive rate of 6%, providing strong evidence for its inclusion in pre-participation screening protocols.

Outcome: Given his rapid SVT with symptoms, the patient underwent successful catheter ablation of the reentry circuit using 3D mapping (CARTO). Procedure confirmed atypical AVNRT with cycle length 500–551 ms. Post-ablation testing showed no inducible tachycardia, even with isoproterenol challenge. No complications occurred during the procedure.

Follow-Up: Post-procedure instructions included avoidance of vigorous activity for 2 weeks. Gradual return to basketball activities began after cardiologist clearance at 2 weeks, leading to full return to sport activity.

Out of the Pocket, Out of Place: The Quarterback’s Wrist Injury

Bernard Holtman, DO

All Other Authors: Paul Klawitter, MD, PhD and Peter Christiano, MD

Affiliation: SUNY Upstate Medical University. Syracuse, NY.

History: A D1 collegiate quarterback had a fall on outstretched right hand while in game. After the fall he had immediate pain over the right wrist and distal radius. He complained of severe pain and claimed he could not move the right wrist. He also developed symptoms consistent with a median nerve injury with decreased sensation over the 1st through 3rd digits. The athlete was taken to the training room and C-arm x-rays were performed.

Physical Exam: Right wrist was exquisitely tender to palpation, greatest over the carpal bones. No obvious deformity. Significant limitations in active ROM in flexion and extension of the wrist. 2+ radial pulses. Brisk capillary refill. Some reported decreased sensation over the 1st through 3rd digits.

Differential Diagnosis:

1. Distal radius fracture
2. Scaphoid fracture
3. Perilunate dislocation
4. Contusion
5. TFCC tear

Test Results: C-Arm x-rays revealed a perilunate dislocation. The patient was taken to the local ER where imaging also revealed a trans-scaphoid fracture. Attempt was made at closed reduction under sedation, however was unsuccessful and was then taken to the OR.

Final Diagnosis: Right trans-scphoid perilunate fracture dislocation complicated by carpal tunnel syndrome.

Discussion: High enery injuries to the wrist can include a number of complex fractures, radiocarpal dislocations, perilunate dislocations, intracarpal dislocations or a combination of these as demonstrated in this case. These injuries are often associated with compression or contusion of the median nerve. Mechanism of injury can give us a clue to the type of injury, but the majority are confirmed by plain radiographs. Immediate action should be taken to alleviate any neurovascular compromise. Often these complicated injuries will require surgery, which may result in significant stiffness. Functional motion can be achieved with 70% of the maximal ROM, but must be individualized to the athlete and sport.

Outcome: The player was taken to the OR for ORIF. Hematoma was noted to be compressing the carpal tunnel, which was released. Scaphoid fracture was fixated with K wires and compression screw. He also required fixation of the lunotriquetral joint. He remained in a cast for 12 weeks. Following cast removal he had pins removed and began a rehab program to restore ROM.

Follow-Up: The athlete completed a rigorous physical therapy regimen program to restore range of motion and begin throwing a football again. He did have some residual loss of motion primarily in flexion/extension but returned to function and was able to begin a throwing program in the off season. He returned to play at the beginning of the next season about 9 months after the original injury.

When a Sore Throat Becomes Life Threatening

Travis Kinane, DO

All Other Authors: Elizabeth Rothe, MD

Affiliation: Maine-Dartmouth Augusta, Maine.

History: An 18-year-old female Division III hockey player with no significant past medical history presented to the emergency department (ED) with a 2-day history of sore throat, cough, and fever. Initial workup, including COVID-19, mononucleosis, influenza, and strep tests, was negative. She was discharged with a diagnosis of viral pharyngitis. Five days later, she returned to her primary care provider with worsening symptoms, including new nausea, shortness of breath, and chest pain radiating to both arms. During this visit, she was noted to be hypoxic with an oxygen saturation of 87%. Due to her chest pain and low oxygen saturation, she was referred to the ED for further evaluation. Her medications include an oral combination contraceptive, and she has no family history of sudden cardiac death, coagulopathies or clotting disorders.

Physical Exam: Vitals at presentation to ED on October 15, 2024: BP—140/63, Pulse—151, Temp—102.2, RR—60, O2 Sat 87% General: Awake, alert, oriented, mildly distressed HEENT: dry mucus membrane, erythematous oral pharynx, adenopathy of the neck left worse than right Cardiac: sinus tachycardia, no murmurs, rubs or gallops Pulmonary: Tachypnea, mildly diminished lung sounds in the bases bilaterally.

Differential Diagnosis:

1. Pulmonary Embolism
2. Pneumonia
3. Peritonsillar abscess
4. Sepsis
5. Mononucleosis

Test Results: 10/15-CXR-Increased interstitial markings in the setting of hypo inflation. 10/16-CT angiogram Pulm- Diffuse multifocal consolidations concerning for multifocal pneumonia with at least mild interstitial pulmonary edema.10/17-Venous Doppler Neck- Occlusive thrombus within the L internal jugular vein 10/23- CT Angio Neck- Occlusive thrombus within L internal jugular vein from C3 level down to the thoracic inlet, involving a 9 cm long segment, compared to the reported 3.1 cm in previous US on 10/17.

Final Diagnosis: Lemierres’s Syndrome and multifocal pneumonia.

Discussion: Lemierre’s syndrome is often underdiagnosed or diagnosed late, contributing to a mortality rate of 5–18%. It typically affects young, healthy adults who initially present with unilateral sore throat and fever, which may progress to pleuritic chest pain. The diagnosis is characterized by a recent history of oropharyngeal infection, internal jugular vein thrombosis, and the isolation of anaerobic bacteria.

Outcome: Our athlete was hospitalized for 12 days and, upon discharge, was started on oral antibiotics, prednisone, and anticoagulation. She began a gradual return-to-play protocol 3 weeks after symptom onset per cardiology guidelines following any thrombus.

Follow-Up: She will initially engage in low- to moderate-intensity exercises, with plans to progress to non-contact activities while on anticoagulation. She will remain on Eliquis for 3–6 months to manage her internal jugular vein thrombosis and contact sports (hockey) will be restricted during this period to reduce bleeding risk.

The Hidden Cost of Muscle Mass

Joseph White, MD, MS

All Other Authors: Omar G. Jarrett, MD, Juan G. Jimenez-Garcia, MD, Juan R. Santos Rivera, MD, and Guillermo Izquierdo-Pretel, MD

Affiliation: Florida International University, Herbert Wertheim College of Medicine, Miami, Florida.

History: The patient is a 37-year-old male bodybuilder and weightlifter who presented to the ED with worsening shortness of breath, diaphoresis, and abdominal pain. His medical history includes obstructive sleep apnea (managed with CPAP), anabolic steroid use, benzodiazepine use, stimulant use disorder, hypertension, and bilateral quadriceps rupture. Initial imaging revealed a right pleural effusion and a left bronchogenic mass. Due to acute respiratory distress and abnormal imaging findings, he was admitted to the ICU.

Physical Exam: Vital signs are within normal limits except for tachypnea at 30. In no acute distress and tired appearance. HEENT: Normocephalic, atraumatic, and anicteric. Lungs: Coarse with noisy respirations bilaterally, no accessory muscle use. Heart: Regular rate and rhythm, no murmurs, or gallops. Extremities: Full range of motion, mild generalized muscle tenderness. Motor strength 5/5 in upper and lower extremities. Neurological: Alert and oriented with no focal deficits.

Differential Diagnosis:

1. Anabolic Steroid-Induced Pulmonary Pseudotumor
2. Lung Carcinoma
3. Lymphoma
4. Pneumonia
5. Inflammatory Myofibroblastic Tumor (IMT)

Test Results: Labwork was notable for elevated D-dimer 5.47, potassium 5, BUN/Cr 19/1.35 (high creatinine reflecting muscle mass), hemoglobin 8.6, WBC 15.7 and platelets 687. EKG demonstrated rightward axis and incomplete right bundle branch block. Echo found normal LV wall motion, moderate concentric LV hypertrophy, and mild to moderate dilation of the RV. Chest X-ray was noticeable for right pleural effusion. CTA chest with contrast demonstrated 5.6 cm × 5.4 mass causing severe narrowing of left upper lobe.

Final Diagnosis: Anabolic Steroid-Induced Pulmonary Pseudotumor.

Discussion:

Androgen use has become a major public health concern due to the transition of use from strictly sports to a much wider spectrum of the population. Millions of Americans have used anabolic-androgenic steroids to increase muscle mass, whether for sports performance or cosmetic purposes. The potential side effects of anabolic steroid abuse are significant. It is known to cause liver damage, cardiovascular issues, and cancers like liver and prostate cancer. Androgen receptors (ARs), are present in many tissues, such as adipose tissue. Their presence in respiratory epithelial cells has also been linked to abnormal cell growth, highlighting a potential role in pathologic changes in the patient.

Outcome: The patient was initially hospitalized in the ICU, then the medicine floor, with length of stay of 11 days. He had resolution of his shortness of breath and reduction of the bronchogenic mass. The patient remained on 50 mg of ethacrynic acid for diuresis, chosen over furosemide due to the patient’s sulfa allergy. Education was given regarding anabolic steroid use as well as stimulant use.

Follow-Up: He was discharged home with plans for close follow-up with pulmonology and clearance to resume normal physical activity.

Even Amateur Athletes Can Have Drip

Keith DellaGrotta, MD

Affiliation: Georgetown University/MedStar Washington, DC.

History: A 29-year-old otherwise healthy male presented to sports medicine clinic for evaluation of a head injury. Two weeks earlier, he sustained a blunt head injury while playing softball, where he collided with another player. He denied loss of consciousness but quickly developed a headache and 2 episodes of vomiting. A head CT was obtained at a local ER on the day of the injury, which was negative. At the time of his first clinic visit, the patient reported persistent headaches, difficulty focusing gaze, neck pain, and difficulty sleeping. He was started on amitriptyline for headaches and was referred for physical and vision therapy. At the 2-month follow-up, he reported improvement in visual symptoms and cervicalgia, but his headaches were not better and were limiting his ability to return to work. The headaches improved when lying flat and consuming caffeine.

Physical Exam: General: well appearing in no distress HEENT: normocephalic, atraumatic, extraocular movements intact, moist mucous membranes Heart: Normal rate Lungs: No labored breathing Abdomen: No distension Skin: No apparent rash Musculoskeletal: cervical paraspinal muscle tenderness bilaterally, no midline vertebral tenderness, full range of motion of spine and all 4 extremities without pain Neurologic: alert and oriented, cranial nerves II–XII intact, full strength and sensation in all 4 extremities No symptoms with vestibular-ocular motor screening Normal balance including Romberg, tandem, and single-leg stance Psychiatry: Normal mood and affect.

Differential Diagnosis:

1. Post-Concussion Syndrome
2. Migraine
3. Delayed Intracranial Hemorrhage
4. Intracranial Hypotension
5. Depression

Test Results: Two months S/P injury Repeat CT Head: (1) Mixed density acute on subacute subdural hematomas along bilateral convexities. (2) Diffuse effacement of the suprasellar cistern, decrease in mammilo-pontine distance and prepontine cistern. MR Brain and C-/L-Spine: Spinal longitudinal extradural collection spanning the ventral aspect of C2-T3 causing moderate effacement of the thecal sac. Abnormal T2/STIR hyperintense fluid in the posterior C1-C2 interspinous region. Consistent with CSF leak.

Final Diagnosis: Intracranial hypotension from post-concussive CSF leak complicated by subdural hematoma.

Discussion: While the majority (at least 70%) of concussion symptoms improve by 2 weeks after injury, up to 15% of patients can have symptoms beyond 3 months. Risk factors for prolonged symptoms include prior concussion, female sex, and psychiatric diagnoses. Symptoms beyond 3 months, with no other cause, indicate post-concussive syndrome, but other pathologies should be considered. Only a few cases of CSF leak after a concussion have been reported in the literature. None of these had a concomitant subdural hematoma. We hypothesize that volume loss from the CSF leak caused rupture of the bridging veins. CSF leak is essential to consider in persistent postural headaches after a concussion.

Outcome: The patient was admitted to the neurosurgical service. He initially underwent a fluoroscopic-guided autologous blood patch, which was unsuccessful. He eventually underwent open surgery to repair the tear in his dura, with subsequent resolution of his symptoms. On repeat imaging, there were no signs of persistent CSF leak, and the subdural hematoma resorbed.

Follow-Up: He was able to make a full recovery and return to his prior activity level.

Can’t Shrug This Shoulder Pain—Not Your Typical Overuse Injury

Karen Reynolds, MD, PT, DPT

All Other Authors: Jordan Hilgefort, MD, MBA, Justin Chu, MD, Ruk Yakkanti, DO, and Brittney Richardson, MD

Affiliation: University of Louisville School of Medicine, Louisville, KY.

History: The patient is a 21-year-old collegiate swimmer with PMH notable for prior left shoulder instability and dislocation who presented with right shoulder pain, worse during backstroke, overhead movement, and turning to the right to breathe on freestyle. His pain felt “deep” inside the shoulder, but he also experienced anterior pain while reaching overhead. He had been doing rehab and avoiding overhead exercises, but his pain persisted. His initial evaluation was suggestive of biceps tendinopathy vs labral tear given a positive O’Brien’s test. Initial imaging was obtained and reviewed by his Sports Medicine and Orthopedics team physicians and the patient was cleared to swim. Approximately 6 weeks later, he returns with right shoulder pain now accompanied by swelling, with intermittent numbness in his bicep that improves with cupping.

Physical Exam: Temp 98.2 HR 72 RR 16 BP 160/77 Sat 100% on RA General: Swelling of right shoulder and chest with apparent venous distention present; left shoulder examination notable for chronic hypertrophic scar. No gross deformities, no ecchymosis, erythema, or abrasions. Normal active and passive range of motion of bilateral arms and shoulders. Neurovascularly intact, 5/5 strength bilaterally. Negative Jobe’s, Resisted Internal & External rotation, Drop arm, Speed’s, Yergason’s, Neer’s, Hawkins, Apprehension/Relocation, Jerk, Load and shift, Sulcus sign, Crossbody adduction. Positive O’Brien’s & TTP over the bicipital groove.

Differential Diagnosis:

1. Biceps Tendinopathy
2. Glenohumeral Labral Tear
3. Paget-Schroetter Syndrome
4. Parsonage-Turner Syndrome
5. Rotator Cuff Arthropathy

Test Results: X-ray Right Shoulder: unremarkable. MRA Right Shoulder: Anterior superior labral defect at 11:00–3:00 is suspicious for a possible superior glenoid labral tear. No rotator cuff tear. US Veins Duplex R UE: Occlusive DVT from the R subclavian vein to the distal R brachial vein. Peri-operative RUE Venogram: Complete occlusion of the R brachial, axillary, & subclavian veins. Large collateral from brachial to basilic vein, which appears to drain the majority of the RUE. Patent SVC & R IJ.

Final Diagnosis: Venous thoracic outlet syndrome (involving the right brachial, axillary, & subclavian veins) secondary to Paget-Schroetter Syndrome.

Discussion: Thoracic outlet syndrome (TOS) involves compression of neurovascular structures as they pass through one of 3 distinct regions of the neck and chest. Paget-Schroetter syndrome (PSS) is a specific type of venous TOS, known as effort thrombosis. The subclavian vein passes between the clavicle & 1st rib making it vulnerable to a “nutcracker effect,” & thrombosis is induced due to repetitive compression with arm movements. Features include pain, swelling, discoloration, & formation of collateral circulation. Management consists of anticoagulation, thrombolysis, & surgical decompression, typically via 1st rib resection, anterior scalenectomy, or resection of the costoclavicular ligament.

Outcome: Underwent EKOS catheter-directed thrombolysis and venoplasty of R subclavian vein. D/c on 3 months of anticoagulation; continued to require anti-HTN meds. Approx 3 months later, again complained of R arm pain and mild swelling. Found to have chronic R axillary DVT and subacute subclavian DVT. CT surgery performed first rib resection to more definitively decompress subclavian; symptoms resolved.

Follow-Up: Following recovery from first rib resection, pt reported resolution of pain and swelling and was able to return to full training and competition without restrictions. He did not require ongoing anti-coagulation and is now normotensive without medication. Long-term success rates following surgical decompression of first rib/anterior scalene/costoclavicular ligament are reported to be 95–100%.

Chest Pain, Syncope, and the Hidden Struggle in an Athletes Heart

Sixtus Akinlosotu, MD

All Other Authors: Vatsal Gandhi, DO, MBA, MPH

Affiliation: UPMC Shadyside, Pittsburgh, PA.

History: The patient is 19 y/o male without significant past medical history who has had a 2 year history of episodic chest pain, shortness of breath, and lightheadedness during peak exertion. He most recently had a syncopal event at college soccer practice as witnessed by teammates and trainers. His symptoms over the years have occurred while playing soccer and at physically strenuous times (fitness, sprints at the end of a game). They last for a couple of minutes and are relieved when he is resting. This is the first time he has lost consciousness. Sport physicals have been normal to date so his symptoms were deemed secondary to physical exertion and related to poor fitness. He has no family history of significant cardiac disease, such as heart attacks or sudden cardiac death.

Physical Exam: Vitals: BP 124/73, HR 74, SPO2 98%, WT 196 lbs, HT 72 inches. GEN: well appearing, no acute distress. HEENT: moist mucous membranes, no oropharyngeal lesions, anicteric sclera, no conjunctival pallor. CV: Normal s1 and s2, no murmur, rubs or gallops, JVP 5 cm, no carotid bruits. Pulm: Clear to auscultation bilaterally. Skin: No obvious skin lesions. MSK: No obvious deformities. Extremities: Warm, well-perfused, brisk capillary refill. No clubbing, cyanosis or edema.

Differential Diagnosis:

1. Structural cardiac disease (HOCM, MVP)
2. Arrhythmia (WPW, Long QT, Brugada)
3. Coronary disease (Myocardial bridge, ARCA)
4. Vasovagal syncope
5. Anemia

Test Results: EKG: Normal except for ST segment elevation in V1-V3 with T wave inversions. CBC/CMP: normal Stress test: Normalization of anterior ST-T wave changes with exercise. Lightheadedness during max exertion. No other EKG changes or symptoms. ECHO: Normal CCTA: 3 cm myocardial bridge in the proximal to mid LAD as well as obtuse marginal vascular territory.

Final Diagnosis: Myocardial bridge.

Discussion: Myocardial bridging is a common congenital coronary artery anomaly where a segment of a coronary artery tunnels through the myocardium. The prevalence of MB is unknown, but thought to be present to some extent in about 1 in 3 adults. Patients with such an anomaly are often asymptomatic but others may present with angina, ACS, arrhythmia, syncope, or sudden cardiac death. Beta blockers are considered the mainstay of therapy for symptomatic patients given their ability to allow for decreased compression of coronary arteries through their negative inotropic and chronotropic effects. Invasive options for more refractory cases include PCI and myotomy.

Outcome: The patient started metoprolol with resolution of majority of his symptoms. He still, however, had episodes of syncope, particularly when not taking his medication. Sometimes, this occurred even at rest.

Follow-Up: EP was consulted and 30-day event monitoring was unremarkable. He was cleared for return to play but had an implantable loop recorder inserted to clarify if there is underlying arrhythmia unrelated to his myocardial bridging. He will have periodic follow-up with both cardiology and electrophysiology. He was advised to remain on metoprolol indefinitely.

More Than Just in Your Head—Persistent Headache in a Young Female After Low Impact Head Collision

Edward Cho, MD

All Other Authors: Mikhail Carlow, MBBS and Dean Padavan, MD

Affiliation: Atlantic Sports Health, Morristown, NJ.

History: A 21-year-old female presented to our office for concussion evaluation after a low-impact head collision during dance 10 days prior. She initially had headache and dizziness that resolved within 24 hours and denied loss of consciousness, vision changes, or amnesia. She remained asymptomatic until Day 5 when her headache returned, now constant and radiating from the left temple to the neck, with dizziness, photophobia, and tinnitus. She went to the ED on Day 9, where CT head without contrast was negative and symptoms improved with IV fluids and pain medication. She was referred to neurology and sports medicine for concussion evaluation. At our evaluation, she reported a left temporal headache that worsened with bright lights and position changes, woke her up at night, and affected her school performance. Daily medications included Zoloft 50 mg and combined oral contraceptives.

Physical Exam: Vitals: BP 106/72, HR 78, SpO2 99%. Constitutional: Well appearing, no acute distress. Eyes: Pupils round, equal, and reactive to light bilaterally; fundoscopic exam normal. HENT: No abnormalities noted. Cardiopulmonary: Normal rate, regular rhythm, normal heart and lung sounds. Musculoskeletal: Full neck range of motion, taut left trapezius, left cervical paraspinal tenderness. Neurologic: No focal cranial nerve deficits; sensation, coordination, strength, and reflexes intact. Special tests: Negative Kernig and Brudzinski. Concussion testing: VOMS negative, SAC 28/30, PCSS 42; patient feels 50% her normal self.

Differential Diagnosis:

1. Concussion
2. Migraine
3. Cervicogenic headache
4. Cluster headache
5. Intracranial thrombus

Test Results: MR brain w wo contrast and MRA head wo contrast: Left transverse sinus thrombosis and pansinusitis. CBC, CMP, ESR, and CRP normal. Hypercoagulability workup (Factor V Leiden, antithrombin III, Lupus anticoagulant, cardiolipin, beta-2 glycoprotein, ANA, RF, protein C, protein S) negative.

Final Diagnosis: left transverse sinus thromboses.

Discussion: Concussions are defined as mBTI with no neuroimaging abnormalities. Concussions may be diagnosed on the basis of negative CT alone, as imaging such as MR is more difficult to obtain. Thus, knowing when to suspect non-concussion etiologies is crucial for patients such as ours, in whom an erroneous diagnosis of concussion may have been potentially fatal. Cerebral sinus venous thromboses have an incidence of 5 per million, but our patient had several of the most common risk factors, including female sex, oral contraceptives, sinusitis, and head injury. Headache is the most common symptom, typically diffuse and worsened with recumbency or Valsalva. Diagnosis is usually made with CT or MR.

Outcome: Upon receiving her MR results, we advised the patient go to the ED immediately. She was started on IV heparin and evaluated by neurosurgery and neurology, who recommended no acute neurosurgical intervention, but to transition to Eliquis 5 mg BID and avoid estrogen containing birth control indefinitely. Her symptoms have since resolved.

Follow-Up: Repeat MR/MRV at 3 months showed improved but persisting left transverse sinus thrombosis. She remains on Eliquis 5 mg BID and is following with hematology outpatient. She will need repeat imaging to monitor her thrombosis and determine safe discontinuation of anticoagulation. While on anticoagulation, she is cleared to participate in non-contact activities only.

Don’t Jump to Conclusions—Neck Pain After a High Ropes Course Mishap

Brendan George, MD

All Other Authors: Timothy Thomsen, MD

Affiliation: University of Iowa, Department of Family Medicine, Iowa City, Iowa.

History: A 23-year-old female presents to Sports Medicine clinic with right neck and shoulder pain. Testing a new high-ropes course for her work, she leapt from an elevated platform toward a grab-bar. She missed the bar and after falling about 6 feet, the safety harness rope became stuck under her helmet, causing the helmet chin strap to strangulate her. Coworkers recalled her seemingly briefly losing consciousness with her arms flapping outstretched to her side; recorded video of the event support this. After being lowered to the ground, she felt comfortable continuing the course. She eventually sought evaluation the following week, where she reported pain from the base of her skull into her upper posterior shoulder, as well as dizziness whenever she turned left. She denied any vision changes, hearing difficulties/tinnitus, gait ataxia, or any numbness, tingling, or weakness of her extremities.

Physical Exam: General: Alert, no acute distress HEENT: Abrasion and ecchymosis under the left mandible. Full neck ROM. Tenderness to palpation at the base of the skull, but no midline cervical tenderness. Extremities: Shoulder exam unremarkable, with normal ROM, strength, and sensation. Special testing, including empty can, O’Brien’s, and Neer’s negative Neuro: Alert, oriented ×3. Cranial nerves II–XII intact. Gait normal. Sensation normal in all dermatomes. Dizziness elicited with left lateral gaze.

Differential Diagnosis:

1. Cervical vertebral body fracture
2. Clay shoveler’s (spinous process) fracture
3. Trapezius muscle injury
4. Vertebral artery dissection
5. Concussion with loss of consciousness

Test Results: X-ray cervical spine: loss of normal lordosis, but no anterolisthesis or fractures noted MRI/MRA Neck/Spine: Long segment linear filling defect involving the right V2 segment vertebral artery, concerning for vertebral dissection.

Final Diagnosis: Vertebral artery dissection.

Discussion: Vertebral artery dissections most commonly occur in the setting of trauma, often mild in nature. Even seemingly benign activities such as amusement park rides, swimming, or high-ropes courses hold potential for arterial dissection. Initial symptoms can include ipsilateral head/neck pain (60–90% of cases), pulsatile tinnitus, Horner syndrome, cranial neuropathies (most commonly CN XII and IX), and dizziness/vertigo. Clinicians should have a high degree of suspicion for arterial dissection in patients with acute head or neck pain and/or other neurologic symptoms in the setting of trauma or sporting activity. Diagnosis is confirmed with MRI brain and neck and MRA head/neck.

Outcome: Patient was sent to the ER based on the imaging finding and was evaluated by neurology. As MRI brain showed no infarct at that time and her NIHSS score was 0 without exam deficits, they recommended daily aspirin 81 mg until outpatient follow up. She was restricted from activities that would significantly increase blood pressure, such as weightlifting and underwater diving.

Follow-Up: CTA head/neck ∼2 months post-injury showed resolution of previous vertebral artery filling defect. At a 3 month follow up with neurology, she had returned to her neurologic baseline and was cleared for all normal work duties, including her previous role as a lifeguard. Neurology recommended lifelong low-dose aspirin use and advised avoiding high-risk contact sports and chiropractic manipulation.

Return to Sport Following Sudden Cardiac Arrest

Kelly Moeder, MD

All Other Authors: Abby Bertholf, MD

Affiliation: Via Christi Sports Medicine Fellowship Wichita, KS.

History: The patient is a 20-year-old male basketball player presenting for cardiac clearance after it was brought to the athletic trainer’s attention by the strength coach that the patient was unable to do sit-ups because of his “implant.” Our medical staff was unaware the patient had any cardiac history as none was mentioned on his intake form or to the physician evaluating him at PPE’s. Upon further discussion the patient disclosed he’d had a defibrillator placed in high school after collapsing during a basketball game, requiring chest compressions and defibrillation. He followed up with a cardiologist who had cleared him to return to basketball following ICD placement. Patient also stated he collapsed a second time following device placement and remembers the device firing. Our medical team decided to hold him from activity until further information could be obtained from his cardiologist.

Physical Exam: The patient had an unremarkable physical exam that day in the training room and during his preparticipation physical exam the month prior. General: well appearing, no acute distress HEENT: normocephalic, atraumatic CV: Regular rate and rhythm, no murmurs, rubs, or gallops Pulmonary: No increased work of breathing, lungs clear to auscultation bilaterally Abdomen: soft, non-distended, ICD palpable in LUQ Extremities: warm, well perfused, no edema or cyanosis.

Differential Diagnosis:

1. Hypertrophic cardiomyopathy
2. Coronary Artery Anomaly
3. Congenital Long QT Syndrome
4. Commotio Cordis
5. Brugada Syndrome

Test Results: Normal labs on several occasions including CBC, CMP, Mag Echo – mild septal hypertrophy w/max septal wall thickness of 13 mm, prominent apical LV myocardial trabeculations. No ventricular outflow tract obstruction. EF 69%. Stress Test—normal ECG—normal Holter study—unremarkable Genetic testing—3 maternal variants of uncertain significance in the OBSCN gene No episodes of V-fib or non-sustained V-tach on patient’s device over the last 2 years.

Final Diagnosis: The root cause of the patient’s ventricular fibrillation leading to sudden cardiac arrest is LV noncompaction cardiomyopathy (with prominent LV apical trabeculations) and mild cardiac hypertrophy.

Discussion: Our team found this case controversial given the conflicting stances of the patient’s cardiologist, who currently follows over 600 athletes with sudden death associated cardiac conditions and fully supported the patient continuing to play collegiate basketball, and the 36th Bethesda Guidelines which state “the presence of an ICD (for primary or secondary prevention of sudden death) should disqualify athletes from most competitive sports.” This case highlights the need for more information, data and discussion surrounding athletes with sudden death associated cardiac conditions returning to competitive sport in order to aid the sports medicine provider in navigating clearance decisions.

Outcome: Since his second collapse about one year following ICD placement, the patient has played over 1,000 minutes of competitive JuCo basketball with no events or abnormal rhythms recorded on his device. After discussions with the patient’s cardiologist, our medical team cleared the patient to return to basketball given compliance with his metoprolol and rules to protect his ICD/prevent misfiring.

Follow-Up: The patient returned to full sports participation on 10/25/24 after signing an agreement with the university and our sports medicine team. We developed an EAP for the patient as well as trained coaches, teammates and roommates on the use of an AED. His cardiologist recommended follow up in his office for testing each pre and post-season moving forward.

Jumping to Conclusions

Laura Shaffer, MD, MBS

Affiliation: Nemours Children’s Health Sports Medicine.

History: A 10-year-old female gymnast presents to clinic with acute left shoulder and neck pain after falling on a trampoline 3 days ago. Patient presented to the emergency department on the day of injury with complaint of severe left shoulder and neck pain and difficulty breathing. Patient was discharged after imaging from the ED and advised to have sports medicine follow up. In clinic 3 days later, patient reports difficulty with ambulating secondary to pain in her neck and shoulder region with any movement. Pain is reported as 9/10. Patient’s parents deny any head trauma. No numbness or tingling. No prior injury. No significant surgical or medical history. Patient’s pain is uncontrolled with Hydrocodone from ED.

Physical Exam: Vitals show patient is slightly tachypneic and tachycardic. She is well-developed and appears in mild acute distress. Normal affect. Tearful. Pulm Exam: Lungs are clear to auscultation and breath sounds present bilaterally. Msk Exam: Patient with positive tenderness to palpation about the left clavicle. Limited active and passive range of motion of the left shoulder and arm secondary to pain. Sensation is intact to light touch throughout left upper extremity. Hand and fingers are warm and well perfused. Palpable radial pulse and intact capillary refill. Associated swelling of the left hand.

Differential Diagnosis:

1. Displaced Left Clavicle Shaft Fracture
2. Left Sterno-clavicular Dislocation
3. Displaced Left Medial Clavicle Physeal Fracture
4. Left Pneumothorax
5. Left Proximal Humerus Fracture

Test Results: In ED: Left Forearm, Humerus, Shoulder, Chest, and Pelvis Xrays revealed no acute fracture or dislocation. CT C-Spine revealed medial aspect of left clavicle with posterior positioning in relation to sternum with adjacent osseous fragment. Inpatient 3 days later: CTA, MRI, and US revealed physeal fracture of the medial left clavicle with posterior displacement of the distal fracture fragment from the manubrium by more than one full shaft width, with small osseous fragment. Patent great vessels.

Final Diagnosis: Displaced Left Medial Clavicle Physeal Fracture (Posterior Sterno-Clavicular Pseudo-dislocation).

Discussion: Medial clavicle physeal fractures (Sternoclavicular Pseudo-dislocations) are rare but serious traumatic injuries. The posterior displacement of the lateral aspect of the clavicle puts the mediastinal structures in close proximity at risk. Symptoms include dyspnea, dysphagia, tachypnea, diminution of distal pulses or paresthesias depending on the associated structure compressed or injured. Displaced medial clavicle physeal fractures are often misdiagnosed as posterior sternoclavicular dislocations due to the medial clavicle being the last physis to close around 20–25 years of age. It is difficult to visualize the fracture dislocation on AP Xrays; therefore, CT scan is the study of choice.

Outcome: When the patient presented to sports medicine clinic 2 days after injury tachypneic, in mild acute distress, and using a wheel chair due to pain with ambulating, she was emergently admitted to the PICU for pain control, CTA/MRI, and surgical management. Patient underwent an open reduction with suture fixation of the left clavicle. Thoracic surgery was present.

Follow-Up: Patient’s post-operative course was uneventful. She used a sling for immobilization for 3 weeks. From 3 to 6 weeks, full shoulder passive range of motion was achieved. From 6 to 12 weeks, active shoulder range of motion was achieved. At 12 weeks, patient was released to full activities including gymnastics.

Searching for a Javelin in a Haystack: Uncommon Cause of Chest Wall Pain in a Division 1 Heptathlete

Kersten Schwanz, MD

All Other Authors: Kelly McInnis, DO

Affiliation: Spaulding/MGB/HMS, Boston, MA.

History: Twenty-one F RHD Division 1 heptathlete presented with 1 year of diffuse chronic R-sided posterior rib/mid thoracic chest wall pain. Initially intermittent during spring competition season and improved over summer break when she took a period off throwing. Upon return to campus and resuming throwing, pain returned and persisted. Only associated with throwing javelin at speed and otherwise difficult to recreate; no other activities are bothersome. This movement produced sharp, vague pain through posterior aspect of R chest wall/ribs with a diffuse ache radiating into R flank. No improvement with soft tissue mobilization and has never been able of find a specific area that recreates her pain. No shortness of breath or palpitations. Pertinent history of iron deficiency on oral supplementation and prior grade 3 bone stress reaction of R os navicularis 6 months prior to development of chest wall pain.

Physical Exam: Inspection: Slight R scapula medial border winging. Palpation: NT through R chest wall musculature, ribs, scapula, thoracic and lumbar spine. ROM: Mild discomfort with R rotation of thoracic spine; otherwise, range of motion is symmetric and nonpainful for thoracic/lumbar spine and shoulders. Strength: 5/5, nonpainful through shoulder ER, IR, abduction and with isolation of latissimus, serratus anterior, subscapularis. Sensation: Intact to LT. Special: Wall push-up neg. Functional: Index discomfort near R T6–8 level between paravertebral and scapular lines during multisegmental rotation with R trunk rotation, R hip extension, and R shoulder abducted, fully extended, recreating throwing stance.

Differential Diagnosis:

1. Bone stress injury (BSI)-Posterior rib, scapula
2. Musculotendinous-serratus ant, lat dorsi, intercos
3. Neurogenic-Thoracic radic, intercostal neuritis
4. Thoracolumbar myofascial pain
5. Lung/visceral

Test Results: XR Right Ribs: no fracture or osseous abnormality MRI Chest Wall: Marrow edema of the right inferior scapula at the attachment site of latissimus dorsi, compatible with grade 2 stress response. Lab Studies: Vit D (81), CBC (wnl; Hgb 13.3, Hct 40.4), CMP (wnl), iron studies (Fe 158, TIBC 322, transferrin % sat 49 H), ferritin (43 wnl).

Final Diagnosis: Right scapula (inferior angle) bone stress injury.

Discussion: There are limited case reports of scapula BSIs in throwing athletes. The latissimus dorsi, serratus anterior, teres major, and rhomboid major muscles all insert on the inferior angle of the scapula, making this a potential region of high stress when coordinating rotational force transference from hips through acceleration phase of the throwing motion. Upon further discussion with athlete, she feels her previous right foot BSI changed how she applies pressure thorough her R leg. Based on the biomechanics of the javelin throw, this change may have limited her R hip extension and caused more rotational stress to her R shoulder and back for force generation when throwing.

Outcome: Rehabilitation has focused on a break from throwing during the off-season. Ongoing therapeutic exercise includes biomechanical focus on periscapular stabilization and hip girdle with specific focus on interplay of latissimus, subscapularis, and serratus. Conservative measures also include lengthening and mobilization of thoracolumbar fascia. Metabolic work up largely negative. No signs of REDs.

Follow-Up: Currently tolerating all track and field activity aside from throwing. Multidisciplinary plan for return to throwing progression includes incorporation of full kinetic chain multisegmental rotational/derotational exercises, oscillatory exercises in scapular throwing stance, and potential graded reintroduction of full speed throws with lower weight javelins to aid in graduated advancement.

Neck Stiffness in a Collegiate Swimmer: Uncovering a Hidden Threat in the Training Room

Christian Kaschak, DO

All Other Authors: Jeffrey Bytomski, DO

Affiliation: Duke University Durham, North Carolina.

History: An 18-year-old collegiate swimmer presented to the training room for mononucleosis follow-up after abstaining from sport for 3 weeks. Nine days ago, she developed persistent fatigue, poor appetite, and a sore throat. New symptoms include neck pain and stiffness. Labs and imaging were offered, but she deferred. The following day, she developed meningismus and was seen in the ED, where labs revealed a leukocytosis and anemia. After 2 ED visits without imaging, she followed up with her PCP who urged her to return to the ED. At her third ED visit, CT revealed internal jugular vein thrombi, prevertebral fluid collections, and apical airspace opacities. IV antibiotics and anticoagulation were initiated and she was transferred to ICU. She underwent multiple surgeries for thrombi and spinal abscesses. Her condition improved after a week and she was subsequently discharged to recover at home.

Physical Exam: The patient is an alert, nontoxic, but uncomfortable-appearing female. The oropharynx is without tonsillar swelling or exudates. The neck has moderately tender and significantly enlarged anterior cervical lymphadenopathy bilaterally. Active range of motion of the neck is limited in rotation (45 degrees), flexion (40°), extension (30°), and side bending (20°). Muscle strength and sensation are grossly full and intact in bilateral upper and lower extremities. No midline cervical spinal tenderness to palpation. Negative Kernig’s and Brudzinski’s.

Differential Diagnosis:

1. Mononucleosis sequelae
2. Cervical Spasm
3. Lemierre’s Syndrome
4. Retropharyngeal Abscess
5. Meningitis

Test Results: CBC: WBC 12.2; Hgb 8.5. CRP: 373.1 mg/L. ESR: 108 mm/hour. EBV Titers: +EBV Ab/VCA IgM. Blood Culture: Growth of Streptococcus. CT Neck: Multilocular fluid collections within the prevertebral space and along the right cervical lymph chain. Occlusive thrombus within RIJ and nonocclusive thrombus on the LIJ. Patchy airspaces in bilateral apices. MRI Brain and Spine: Severe pansinusitis, extensive paraspinal soft tissue edema. Enhancement within the posterior upper thoracic spinal canal from C7-T3.

Final Diagnosis: Lemierre’s Syndrome following Epstein-Barr Virus Infection.

Discussion: Lemierre’s Syndrome (LS) is an internal jugular vein (IJV)septic thrombophlebitis and is a rare (3.6–14.4 cases/million) cause of neck pain. It is seen most often in otherwise healthy adults. LS is caused by a primary infection (typically pharyngitis) and local invasion of the pharyngeal space and IJV with an interval of 1–3 weeks. The most common bacteria isolated is the anaerobe, Fusobacterium necrophorum. Several cases reported LS after an EBV infection, as in this case. Pulmonary complications like septic emboli, noted in this patient, are common. Prompt diagnosis and management with antimicrobials and occasionally surgery are imperative in this life-threatening condition.

Outcome: After multiple surgeries, antibiotics, and anticoagulation, the patient was discharged home. She will continue anticoagulation with Rivaroxaban and intravenous antibiotics (Meropenem) through her PICC line.

Follow-Up: She will follow up with vascular surgery and have a repeat jugular vein ultrasound performed to evaluate for any residual clot burden. If negative, we anticipate sports clearance and resumption of activity in the swimming pool in mid-January. She medically withdrew from the Fall semester, but plans to return for the Spring semester.

Teenage Girl Knee-ding Some Stability

Anna Bergquist, MD

All Other Authors: Rebecca Peebles, DO, CAQSM, FAAFP and Justin Bartley, MD, FAAOS, FAANA

Affiliation: University of Texas at Tyler, Tyler, Texas.

History: Fifteen-year-old RHD female with past medical history of autosomal dominant multiple synostosis, anemia, anxiety, and migraines presents for bilateral knee pain. Patient reports the pain as 7/10; present for years but worsening recently due to increasing activity while “showing livestock with FFA.” Patient describes the pain as aching, dull, continuous, and agonizing; subjective instability present while walking on uneven terrain. Pain is exacerbated by activity, knee flexion and extension, cold temperatures, and prolonged sitting or standing. Patient has restriction with squatting, kneeling, pivoting, running, jumping, and cutting. Patient denies previous patellar dislocations or patellar instability. Also denies history of trauma or injuries. Additional positive review of symptoms includes fatigue, back pain, joint swelling, muscle aches and weakness, swollen lymph nodes and anxiety.

Physical Exam: General appearance: no acute distress HEENT: Oropharynx clear Neck: Supple Cardiovascular/Pulmonary: Regular rate and rhythm. Lungs are clear to auscultation bilaterally with no audible wheezing Musculoskeletal: Bilateral knees: Positive medial and lateral joint line tenderness. Positive Lachman and Posterior drawer. Negative patellofemoral grind and crepitus, patellar apprehension, McMurray’s, varus and valgus stress in full extension and 30-degree flexion. Reciprocal heel to toe gait, neutral knee alignment, no effusion. Straight leg raise: 5/5 strength. Sensation to light touch intact in all peripheral nerve distributions. Skin intact. Leg warm, well perfused with good capillary refill.

Differential Diagnosis:

1. Cruciate ligament tear
2. Agenesis of cruciate ligaments
3. Patellar instability
4. Patellofemoral pain syndrome
5. Patellar or quadriceps tendinopathy

Test Results: Bilateral knee X ray: There is no evidence of fracture or dislocation. There is no significant narrowing or osteophytosis of the medial, lateral, or patellofemoral joint space. There is underlying trochlear dysplasia as well as lack of tibial eminence associated with an underlying congenital absence of the ACL and PCL. MRI: Demonstrates macerated medial and lateral meniscus tearing without focal, longitudinal tearing. MCL and LCL are intact, but ACL and PCL are absent.

Final Diagnosis: Congenital absence of the bilateral anterior and posterior cruciate ligaments.

Discussion: Congenital absence of a cruciate ligament is a rare pathology with a prevalence of 0.017 per 1000 live births, with the absence of both the ACL and PCL even more rare. These anomalies occur during the seventh to tenth week of gestation when the knee is developing. This condition is often associated with other knee deformities, such as hypoplasia of the lateral femoral condyle, tibial intercondylar spines, absent or abnormal meniscus, congenital femur shortening, defects in the fibular head, or patellar dislocation Reconstruction of the ligaments are often recommended in cases of severe knee instability or pain. Most patients will need knee replacement at some point in their lifetime.

Outcome: First ACL and PCL reconstruction of right knee performed on October 29, 2024. Plan to perform surgery on left side after recovery from first reconstruction.

Follow-Up: Crutches to be used in first 7–10 days post operative. Increase weight bearing as tolerated with utilization of knee brace. Initiate physical therapy thereafter. Follow up with surgeon at regular intervals including 1–2 weeks, 1 month, 3 months, 6 months, and a year post operative. Return to activity based on grade 3 MCL average return to sport, 6 to 8 weeks post operative. Repeat x-ray and MRI as needed.

The Case of the Distracting Cervical Spine Injury

Alex Hanna, MD

All Other Authors: Ian McKeag, MD, MS, Irfan Asif, MD, and Brandon Sadler, LAT, ATC

Affiliation: The University of Alabama at Birmingham.

History: A healthy 17-year-old male defensive high school football player sustained a blindside crackback block by an offensive blocker during a competition. He was hit in the right side of the torso and driven to the ground, landing on his head and neck. There was no loss of consciousness. He reported midline cervical spine tenderness, pain in the right side of his chest and flank, paresthesias of both hands and feet and was briefly unable to move his lower extremities. He denied any shortness of breath. He underwent spine boarding by the sideline medical team and was transferred to the local children’s hospital via EMS with concern for cervical spine injury and possible chest trauma.

Physical Exam: General: Awake, alert, and fully oriented. Lying prone on the field. Neck: No gross deformity. Tender to palpation to the lower midline cervical spine. Chest & Abdomen: Tender to palpation throughout the right side of the lower anterior chest and right flank. No overlying bruising or skin changes. Neuro: Following commands. Spontaneous movement in the bilateral upper and lower extremities present. Grossly diminished sensation to light touch in the bilateral feet and ankles.

Differential Diagnosis:

1. Cervical spine fracture
2. Cervical cord neurapraxia
3. Rib fractures
4. Chest or abdominal wall contusion
5. Liver or kidney injury

Test Results: CBC: elevated WBC to 13.26 and normal Hgb of 14.3 CMP: elevated ALT to 128.5 and AST to 112 CT abdomen/pelvis with IV contrast: (1) Grade III hepatic injury as indicated by 9 cm laceration of the right lobe. No evidence of extravasation. (2) Small focus of air adjacent to the cartilaginous portions of the anterior right 7th and 8th ribs, likely secondary to direct trauma to this area and may represent the sequela of nondisplaced fractures. Tiny pneumothorax is not excluded.

Final Diagnosis: Grade III liver laceration with transaminitis and fractures of the right 7th and 8th ribs.

Discussion: When determining the need for spine boarding, we often refer to injuries that may distract from a potential cervical spine injury. That script was reversed in this case, however, as concern for cervical spine injury distracted from an ultimate diagnosis of rib fractures and a high-grade traumatic liver bleed. This highlights the need to consider other severe injuries in a cervical spine evaluation while triaging on-field trauma. Sideline protocols or checklists may benefit from addition of rapid, focused assessment of the chest and abdomen for blunt trauma, especially when appropriate as indicated by the mechanism of injury.

Outcome: In the ED, the cervical spine was cleared and work-up was pursued as above. He was admitted for inpatient observation, and his vitals and clinical condition remained stable throughout 2 days. Pain was treated with oral NSAIDs and IV morphine as needed. It was recommended that he follow up after discharge with his PCP, but no further follow-up or return-to-play recommendations were provided.

Follow-Up: In outpatient follow-up 3 days later, vitals were stable and pain overall improved. Labs were rechecked with a normal CBC, LFTs, and INR. Repeat CT imaging was ordered for 4–6 weeks out to assess for stability of the liver, though full healing can take 3–4 months. Hemodynamic, laboratory, and imaging stability should ultimately guide decisions regarding return to athletics from liver laceration.

The Price of Paradise

Bijan Origel, DO

All Other Authors: Rabiah Fresco, MD, Crystal Estrada, MD, Jeff Ijadi, MD, Jesse Cheung, MD, and Jay Shah, DO

Affiliation: Pomona Valley Hospital Medical Center, Pomona, California.

History: Sixteen year old male with no significant PMH presented to ED for bilateral lower extremity numbness and weakness. The patient was on vacation in Maui, where he took a one hour surfing lesson from 8–9 am. This was the patient’s first time surfing and denied any wipe outs, or trauma. After completing his lesson, he was able to walk back to the hotel and shower without difficulty. Shortly after 9 am, patient started experiencing some limping, leg weakness, and lower back pain. By 11 am, patient lost the ability to void or stool, move his legs, or walk. Later that day, family had to fly to Oahu and patient required wheelchair assistance during transport as he could not walk. After landing in Oahu, patient spent the remainder of the day resting in the hotel. The following morning, patient noted no improvement of symptoms and decided to go to the hospital.

Physical Exam: General: Appears Comfortable, NAD HEENT:NC/AT, no rhinorrhea, MM dry, PERRL, EOMI, No nystagmus, no photophobia Neck: Normal ROM. CV: RRR, Intact distal pulses, No Murmur heard. Lungs: Effort normal, breath sounds CTA. Abdomen: Soft, Non-tender, Distended. No rebound/ guarding or masses. MSK: Back without any external signs of trauma. There is no point tenderness to palpation. Neuro: Awake, alert, oriented. Language intact. No dysarthria. Cranial nerves CN2–12 intact. Sensation intact to all extremities. Motor: Bulk/tone is normal. Power is 5/5 in BUE. BLE with flaccid paralysis. He is able to barely move his toes on his left foot only. Skin: Warm and dry. Not Diaphoretic. No pallor.

Differential Diagnosis:

1. Surfer’s Myelopathy
2. Transverse Myelitis
3. Guillain-Barre Syndrome
4. Cauda Equina
5. Acute Spinal Cord Ischemia Syndrome

Test Results: CBC Notable for WBC-10.07, Neutrophil-72.1, and Abs Neutrophil-7.26. BMP and all other components of CBC were within normal limits. MRI thoracic/Lumbar spine without IV contrast: Abnormal T2 hyperintense signal in the central spinal cord extending from T7 to conus with mild expansion. MRI cervical spine without IV contrast: Unremarkable.

Final Diagnosis: The patient was found to have Surfer’s Myelopathy.

Discussion: Surfer’s Myelopathy is a rare non-traumatic spinal cord injury associated with first time surfers. The most common symptoms include back pain, sensory loss, paraplegia, lower extremity weakness, and urinary retention. The exact cause of surfer’s myelopathy is still unknown. However, it is commonly believed that prolonged hyperextension leads to vascular damage in the distal portion of spinal cord. It is theorized that first time surfers are more likely to be in this prolonged hyperextended state than experienced surfers. Therefore, it is important to educate first time surfers proper maneuvering techniques to prevent prolonged hyperextension. There is no standardized treatment.

Outcome: Patient was admitted in the hospital for 7 days, where he received IV fluids for permissive HTN, 5 days of aspirin, physical therapy, and a Foley catheter was placed for urinary retention. Upon completion of hospitalization, patient still required Foley catheter and was unable to walk without assistance. Patient was then discharged back to California to an inpatient rehab facility.

Follow-Up: A year later, patient is able to ambulate with no assistance. Patient still experiences numbness and weakness of right lower extremity and has right foot drop. Patient saw urologist for neurogenic bladder and was eventually able to have Foley removed. Patient continues to receive physical therapy to strengthen right lower extremity.

Poor Perfusion or Elevated Pressures? An Exertional Lower Limb Pain Conundrum

Ana Capati, MD

All Other Authors: Michael Bolton, MD, Soren Estvold, MD, MPH, CAQSM, and Alexander Knobloch, MD, CAQSM, FAAFP

Affiliation: David Grant Medical Center, Travis Air Force Base, Fairfield, California.

History: A 35-year-old active duty U.S. Air Force male presented to clinic with a 6-year history of right lower extremity pain and tightness while running and walking. Localized to his posterior lower leg, he described a tightening and burning pain that starts a few minutes into his runs or with prolonged walking, resolving within a few minutes after he stops. There was no preceding increase in activity level and no history of trauma to his lower leg, though he did sustain a left ankle injury around the time of symptom onset. He denies numbness, tingling, weakness, or skin changes of the lower leg, ankle, or foot before, during, or after exertion. He has had no sustained relief with physical therapy. He otherwise had no cardiovascular or metabolic disease history nor significant family history, and he did not use tobacco products.

Physical Exam: He was healthy appearing, in no acute distress, with a non-antalgic gait. Subtle atrophy of the right calf was noted. There was no ecchymosis, skin lesion or discoloration, deformity, pes planus, or pes cavus. His lower extremities were warm and well-perfused, without edema. There was no bony or soft tissue tenderness. Ankle and knee ranges of motion were normal. Strength was full at the ankle and foot, and sensation to light touch was intact and symmetric bilaterally. Posterior tibial and dorsalis pedis pulses were 2+ and symmetric. Pain was not reproduced with walking on toes in the exam room or repeated standing heel raises.

Differential Diagnosis:

1. Popliteal Artery Entrapment Syndrome
2. Chronic Exertional Compartment Syndrome
3. Medial Tibial Stress Syndrome
4. Tibial Nerve Entrapment (Soleal Sling Syndrome)
5. Peripheral Artery Disease

Test Results: Right Lower Leg: Compartment Pressure Testing: Anterior/Lateral Pre-Exercise: 21/25 mm Hg; 1-minute Post- Exercise: 33/33 mm Hg MRI: Congenital lateralized take-off of gastrocnemius medial head with unusual popliteal vessel course and mass effect. Arterial Duplex Ultrasound: Mid and distal popliteal artery possibly occluded at rest, retrograde flow with dorsiflexion, anterograde flow with plantarflexion. CT Angiogram: Popliteal artery complete occlusion distal to the takeoff of the Geniculate arteries.

Final Diagnosis: Popliteal Artery Entrapment Syndrome with Concurrent Chronic Exertional Compartment Syndrome.

Discussion: Exertional lower limb pain diagnosis can be challenging due to overlapping presentations. Popliteal artery entrapment syndrome (PAES) is a rare cause, resulting from an aberrant relationship between the artery and the gastrocnemius medial head or popliteus. Patients often present with complaints of foot and leg claudication symptoms, along with numbness, paresthesias, or discoloration. Few reports exist of patients with PAES and concurrently elevated compartment pressures seen in chronic exertional compartment syndrome (CECS). This case is the first to report a rare example of a type 2 PAES initially treated as a pressure- confirmed CECS with 2 rounds of intramuscular botulinum toxin.

Outcome: Following his compartment pressure testing, 2 courses of intramuscular botulinum toxin injections were performed for CECS treatment, 3 months apart and in conjunction with physical therapy. He had minimal symptom alleviation, leading to a widened diagnostic evaluation for PAES with advanced imaging. Results were consistent with this diagnosis and the patient was referred to Vascular Surgery.

Follow-Up: The patient underwent a right popliteal artery bypass and gastrocnemius release, with resolution of his right lower extremity symptoms. Because of similar but less severe findings of entrapment on the contralateral side during his diagnostic evaluation, he underwent a left gastrocnemius release 5 months after his first surgery and has begun a gradual return to activity.

A Pain in the Neck

Matthew Usevitch, MD

All Other Authors: Nicole Thomas, DO, Gina Bertelli, DO, Jana Qiao, MD, Sarah Nullmeyer, MD, and Christopher Miles, MD

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

History: A 23-year-old collegiate tennis player with a history of ADHD and a recent hospitalization for sepsis and myocarditis presents to the Emergency Room with malaise and left-sided neck pain. Since discharge 3 days prior, he has had intermittent fevers to 102 F, left neck and facial pain, trismus, and acute onset dyspnea with pleuritic chest pain. He denies voice changes, dysphagia, confusion, weakness, numbness, or focal neurologic deficits. Chart review reveals the patient was admitted for presumed viral myocarditis complicated by acute heart failure (EF 20–25%) and Strep dysgalactiae bacteremia. He was discharged on metoprolol, losartan, and furosemide for his heart failure and oral cefpodoxime for his bacteremia. He reports adherence with his regimen since discharge though notably was switched to Augmentin due to new growth of Fusobacterium necrophorum on his blood cultures.

Physical Exam: On arrival, patient is febrile to 102.4 F, tachycardic to 134 bpm, tachypneic to 27 bpm, normotensive, and requiring 2 L of oxygen to maintain SpO2 greater than 90%. He is ill-appearing with dry mucous membranes. He has left-sided tender anterior cervical and submandibular lymphadenopathy. There is no peritonsillar edema, exudate, or oropharyngeal erythema. Heart sounds are tachycardic with regular rhythm and no murmurs or rubs. He has increased work of breathing with supraclavicular retractions but no focal findings on auscultation. His abdomen is tender but without rebound, guarding, hepatosplenomegaly, or masses. He has no peripheral edema or skin changes. His neurological exam is intact.

Differential Diagnosis:

1. Lemierre Syndrome (LS)
2. Pulmonary Embolism
3. Meningitis
4. Retropharyngeal abscess
5. Infectious Endocarditis

Test Results: CBC was notable for new WBC of 24,500. CMP showed a stable transaminitis and troponins were down-trending from recent admission. EKG showed sinus tachycardia. Chest x-ray demonstrated cardiomegaly with mild interstitial edema and small bilateral pleural effusions. CT angiogram of the chest showed findings concerning for multifocal septic emboli. Admitting team requested a CT angiogram of the neck which demonstrated a left internal jugular vein filling defect extending from the level of C1 to C6.

Final Diagnosis: This patient was ultimately diagnosed with septic thrombophlebitis of the left internal jugular vein, also known as Lemierre syndrome (LS), complicated by septic pulmonary emboli.

Discussion: Lemierre syndrome is a rare but serious condition stemming from either a primary F. necrophorum oropharyngeal infection or a secondary infection after an initial viral or bacterial insult. In this case, the athlete could have sustained either a primary or secondary infection though a secondary infection is favored given prolonged symptoms prior to his first hospitalization and return of positive coxsackievirus titers during that admission. LS should be considered in any young adult who develops fevers, neck pain, and trismus after an upper respiratory infection. Early diagnosis and treatment are imperative to decreasing metastatic and local complications as well as fatality.

Outcome: The patient was promptly started on broad-spectrum IV antibiotics when LS was suspected. Once confirmed, Infectious Disease and Vascular surgery were consulted for treatment recommendations. The patient was treated with 6 weeks of continuous penicillin G for antibiotics and 3 months of apixaban for anticoagulation. He tolerated the treatment well with near-full resolution of symptoms.

Follow-Up: Return to activity after LS should be guided by a patient’s resolution of symptoms and treatment duration. The athlete in this case underwent a slow return to activity after recovery from his acute illnesses. This athlete’s LS did not slow his return to play as his heart failure recovery was longer than his recovery from LS. He ultimately returned to competition 7 months after his illness.

Elbow Pain With a Pharyngeal Source

Joseph Werner, MD

All Other Authors: Cassandra Ward, DO and Jolie Holschen, MD

Affiliation: Loyola University Medical Center, Maywood, IL.

History: The patient is a 23-year-old female with no significant PMHx who presents to ED with a chief complaint of right elbow pain. Patient states that she started having right elbow pain approximately 6 days ago. Patient is a right-handed tennis player. It has progressively worsened over the past 6 days despite refraining from physical activity. Pain occurs with all movements. Today, patient noted that it was 10 out of 10 in severity and came to the ED for further evaluation. Denies any falls or trauma. Has never had pain like this in the past. Other than the elbow pain, patient states she is doing well, denies any other areas of pain or any other symptoms.

Physical Exam: Patient holding right elbow in 90 degrees flexion, refuses to move elbow Diffuse swelling noted to the posterior elbow. No skin changes noted Tenderness to palpation diffusely throughout the posterior elbow 5/5 strength noted to the right shoulder, wrist, hand Compartments soft Strong right radial pulse with brisk cap refill to all fingers Intact sensation throughout entire right upper extremity.

Differential Diagnosis:

1. Olecranon Bursitis
2. Septic Arthritis
3. Radial Head Fracture
4. Lateral Epicondylitis
5. Elbow Dislocation

Test Results: Elbow XR: large joint effusion, occult radial head fracture is suspected. CT Elbow: Right elbow joint effusion. No acute fracture detected, however occult radial head fracture is still possible. ESR 66. CRP 63. GC Chlamydia Urine test Negative. Synovial WBC 84300. Synovial Culture Positive for Neisseria Gonorrhea. Rectal Culture Negative. Pharyngeal Culture Positive for Neisseria Gonorrhea.

Final Diagnosis: Septic Arthritis Secondary to Disseminated Gonorrhea Infection.

Discussion: This case highlights the importance of considering sexually transmitted infections as a cause of joint pain, and specifically septic arthritis, in all sexually active athletes. In addition, it can be present even without the “typical” symptoms of genital infection, as the throat can also serve as an asymptomatic source of infection. Lastly, the patient presentation should play a large role in radiology interpretation, as an occult fracture should have been apparent at this stage of the injury process.

Outcome: The patient was discharged from the hospital with a peripherally inserted central catheter placed and started on a 2-week course of ceftriaxone.

Follow-Up: The patient sat out all sports related activity until the completion of her course of antibiotics. After endorsing complete resolution of her symptoms on follow up, patient was cleared for all activity.

Severe Exercise-induced Headaches After All Workouts

Kyle Kener, MD

All Other Authors: Mo Mortazavi, MD

Affiliation: Banner Health/University of Arizona, Tucson, AZ.

History: A healthy 37-year-old male with a history of childhood meningitis presents with chronic exercise intolerance and post-exertional headaches occurring for 1–3 hours after physical activity. Associated symptoms include dizziness, lightheadedness, and postural instability. Symptoms are strongly exercise-dependent, varying by intensity, modality, and duration of activity. The patient had a negative workup by neurology, including a prior negative MRI and symptoms are not alleviated by migraine medications. Evaluation by ENT and cardiology yielded no significant findings. The patient denies a history of emesis, nighttime awakenings from headaches, deterioration, altered mental status, focal neurologic deficits, seizures, photophobia, and phonophobia.

Physical Exam: General: No acute distress, well-appearing. Skin: No rashes. HEENT: EOMI, PERRLA, no scleral icterus, no nares patent, no discharge. Neck: Nontender over cervical spine, full range of motion with no end-range stiffness. CV: RRR, brisk pulses.

Differential Diagnosis:

1. Autonomic Dysfunction
2. Migraines
3. Carotid Dissection
4. Brain Mass
5. Spinal Fluid Leak

Test Results: Labs: CBC, CMP, TSH, Testosterone, FSH, LH, Prolactin, Iron, Ferritin, and Cortisol were all within normal limits. A 48 hours flat test was positive. MRI head w/ and w/o contrast: Interval development of areas of decreased signal on gradient echo images along the cerebellar folia, brainstem, and bilateral cerebral hemispheres likely reflecting superficial siderosis. This likely reflects sequelae of prior subarachnoid hemorrhage. Incidental left hemisphere developmental venous anomaly.

Final Diagnosis: Exertional and orthostatic headaches secondary to chronic spinal leak and resultant superficial siderosis.

Discussion: This case underscores the need for thorough evaluation in patients with persistent headaches, especially when typical causes have been ruled out. While headaches are common and often due to benign or primary etiologies, chronic symptoms that are unresponsive to standard treatments, like this patient’s exercise-dependent orthostatic headaches, warrant further investigation. Exertional and orthostatic triggers with associated dizzines suggest less common pathologies beyond primary headache disorders. A comprehensive approach ensures potential underlying pathologies are not overlooked and new imaging may be warranted even if prior imaging was normal.

Outcome: The patient was referred to interventional radiology for diagnostic/therapeautic blood patch. Location of the leak was unknown at time of procedure as it was likely small. After one blood patch, symptoms greatly improved/resolved and patient was able to return to normal activities without further exercise induced or orthoastic headaches.

Follow-Up: The patient returned to regular exercise in a gradual stepwise fashion over the course of a few weeks status post blood patch proceedure with no further exertional or orthostatic headaches. No further interventions were needed.

If It Aint Broken, Dont Fix It…but Should We?: Wrist Pain in a Baseball Player

William Cates, DO

All Other Authors: Mark Stovak, MD, Tony Islas, MD, Daniel Harrington, MD, and Chris Dolan, MD

Affiliation: University of Nevada, Reno, Primary Care Sports Medicine Fellowship. Reno, NV.

History: A 20-year-old, right-hand dominant, male collegiate baseball catcher presented to the physician staff in the training room complaining of left wrist pain. Symptoms began 1.5 weeks prior to evaluation as a dull ache made worse with batting. The intensity of the ache grew steadily to the point that the athlete was unable to participate in batting practice without pain. Batting practice was the main evoking activity for the pain. Symptoms were not elicited with unweighted movement of the wrist, catching, or weightlifting. He denied symptoms of paresthesias in the hand or fingers, grip strength weakness, prior injury to the hand or wrist, neck pain, or any specific trauma.

Physical Exam: Focused exam of the left wrist and hand: Full active range of motion of the wrist with flexion, extension, ulnar deviation, radial deviation, forearm supination and pronation Full active flexion and extension of all fingers Normal strength of wrist and fingers Mildly uncomfortable during ulnar deviation of the wrist Mild tenderness to palpation with deep pressure over the hamate Nontender over the pisiform and the remaining carpal and metacarpal bones Nontender at the distal radius and ulna Distal 2-point discrimination of the fourth and fifth digits intact Brisk capillary refill Negative Tinnel’s sign at the carpal tunnel and cubital tunnel, Durken’s test, lift off test, fovea sign

Differential Diagnosis:

1. Fracture to the hook of the hamate
2. Triangular fibrocartilage complex tear
3. Ulnar nerve entrapment at Guyon’s canal
4. Flexor carpi ulnaris tendinopathy
5. Ulnarcarpal ligament sprain

Test Results: X-ray Left Wrist: PA, LAT, Oblique, Carpal tunnel and lateral view with thumb abducted and radially deviated (1). Triquetrolunate coalition; (2) Normal alignment of carpal bones; (3) Normal ulnar variance; (4) No fractures. MRI Left Wrist: (1) Bone marrow edema in the hook of the hamate, consistent with stress fracture; (2) No definite complete tear of the TFCC but there is small amount of fluid in the distal radioulnar joint. CT Left Wrist: (1) No fracture lines correlating to hamate marrow edema seen on MRI.

Final Diagnosis: Left hook of hamate stress reaction without fracture.

Discussion: The treatment of choice for hook of hamate fractures in baseball players is excision of the hook. Return-to-sport rates range from 80 to 100% in around 50 days. This athlete, however, did not present with a fracture but a stress reaction. Non-operative treatments for hook of hamate reactions can have a high recurrence and malunion rate, eventually leading to surgical intervention. Indeed, in one case series all 4 baseball players with a hook of hamate stress reaction progressed to overt fracture when treated non-operatively. After eventual excision, all returned to sport. As such, an aggressive surgical treatment plan for elite athletes results in definitive care.

Outcome: After being evaluated by the orthopedic hand surgeon, the athlete was initially treated conservatively with 2 weeks of wrist splinting and upper extremity rest until he was pain free. He then progressed through a rehab program and returned to batting, though symptoms redeveloped. A fracture line could be seen on follow up radiographs. He then underwent a hook of hamate excision.

Follow-Up: This athlete had an unremarkable postoperative experience. After the incision healed, he began rehabilitation focusing on wrist mobility and strength and gradually returned to catching and hitting without pain. He has fully returned to sport.

This Shoulder Pain Makes Me Nerveous

Chioma Nwasike, MD

All Other Authors: Thomas Chu, DO, CAQSM and Steven Collina, MD, CAQSM

Affiliation: UPMC, Harrisburg, PA.

History: A 14-year-old male lacrosse player presented to the sports medicine clinic 3 weeks after an acute injury. He had sustained blunt trauma to his left shoulder while being checked with a lacrosse stick. In addition to left shoulder pain, he also endorsed brief upper extremity numbness and tingling immediately after the trauma. Following the incident, he was initially seen at a non-orthopedic urgent care and diagnosed with an AC sprain. He was treated with home exercises, NSAIDs and a sling, however continued to have pain with pushing/pulling activities. Interestingly, he noticed a lump on the top of his shoulder after a few weeks.

Physical Exam: Focused MSK exam: Inspection of the left shoulder revealed severe supraspinatus and infraspinatus atrophy. There was no focal bony or soft tissue tenderness to palpation. Passive range of motion was full, but there was weakness of supraspinatus and infraspinatus. Scapula winging was present with wall push-ups. Instability testing was unremarkable, along with O’Brien’s. Otherwise neurovascularly intact.

Differential Diagnosis:

1. GH subluxation/labral tear and paralabral cyst
2. Shoulder impingement/ rotator cuff tendinopathy
3. Brachial plexopathy
4. Cervical radiculopathy
5. AC joint sprain

Test Results: Initial plain films showed normal radiographic examination of the humerus. MRI: (1) Acute nondisplaced fracture of the base of the coracoid process. (2) Partial thickness tearing of the supraspinatus tendon. (3) Small glenohumeral joint effusion. (4) Small amount of fluid in the subacromial/subdeltoid bursa. (5) No evidence of labral tear or paralabral cyst. EMG: Left long thoracic nerve neurapraxia. No evidence of injury to the suprascapular nerve.

Final Diagnosis: Closed nondisplaced fracture of the coracoid process with associated rotator cuff atrophy and weakness.

Discussion: Coracoid process fractures are an uncommon type of scapula fracture. They do not often occur in isolation, which makes identification of such fractures difficult, given that it can be masked by concomitant injuries. In this case, there was a long thoracic nerve neuropraxia, which would explain the scapula winging on exam. Although highly suspicious of a suprascapular nerve injury, the timing of the EMG likely affected its sensitivity. Management is largely guided by fracture location and degree of displacement. Conservative treatment is usually preferred for coracoid fractures that are minimally displaced and even in displaced fractures closer to the tip of the coracoid.

Outcome: At 5–6 weeks post injury, he was pain-free, but rotator cuff weakness was unchanged. He was seen 3 weeks after starting PT with improvement overall, but still deemed unable to return to contact sports (light aerobic activity was permitted). After another month, there was minimal rotator cuff weakness and scapular winging, thus he was cleared to start RTP protocol.

Follow-Up: The patient had progressed to non-contact sport-specific activity without recurrence of symptoms, and ultimately released to AT-C guidance for continued progression through return protocol. His goal is to return to lacrosse season in spring 2025. No further appointments scheduled, may follow up on an as needed basis.

Chronic Right-Sided Hearing Loss and Vertigo in a Young Diver

Alexander Saikaly, MD

All Other Authors: Abdullah Saidy, MD

Affiliation: Kaiser Permanente, Fontana Fontana, CA.

History: This case involves an 18-year-old diver seeking further evaluation for right-sided hearing loss associated with episodic vertigo, tinnitus, and occasional disequilibrium. She has been experiencing these symptoms since late 2023 with no previous diagnosis. While she has been able to continue competing, her vertigo has increased in frequency and is now interfering with her daily life. The worsening vertigo has emerged as the primary concern to go along with the hearing loss. Previous treatment has included prescription medications, various forms of physical therapy, therapy for BPPV, as well as evaluation by a neurologist; yet no specific diagnosis has been identified.

Physical Exam: Notable for hearing loss in the right ear with simple testing. Audiometry results with patient confirm decreased sensitivity to high frequency sounds. Neurologic testing otherwise unremarkable. No weakness, no sensory deficits No visual field deficits No nystagmus present No reproducible vertigo.

Differential Diagnosis:

1. Internal Auditory Canal Vascular Loop
2. Meniere’s Disease,
3. Acoustic Neuroma
4. Labyrinthitis
5. Benign Paroxysmal Positional Vertigo

Test Results: Audiometry significant for right sided hearing loss Brain MRI—Vascular looping in the right internal auditory canal. The right PICA loops into the right internal auditory canal and there is looping of vessels in the right cerebellopontine angle which is more prominent on the right than on the left.

Final Diagnosis: Internal auditory canal vascular loops.

Discussion: Vascular compression of cranial nerves has been shown to lead to neuronal dysfunction and has been demonstrated in the vestibulocochlear nerve complex. Vascular loops are suspected of causing hearing loss, tinnitus, and vertigo. Surgical evaluation has been considered to try and separate the vascular loop from the eighth cranial nerve, which is believed to be responsible for the previously described symptoms. During the evaluation of our athlete, we made the necessary referrals so that she may undergo comprehensive evaluation and workup to best manage her condition. She is in discussions with her family and healthcare team for her ongoing care.

Outcome: Athlete continues to be under the care of ENT and is undergoing further testing as advised by the consulting specialties. She has voluntarily withdrawn from participation at this time as her persistent vertigo has caused significant distress in her daily life raising concerns about her safety. Final evaluation and management are still underway but will be completed in the coming weeks.

Follow-Up: The athlete continued competing before and during her initial evaluation, but was unsure about her ability to safely and effectively compete at a collegiate level. Ultimately, due to persistent symptoms, lack of improvement, and continuing workup, she decided to withdraw herself from competition while evaluation is underway.

The Kneediest Puzzle: Chronic Joint Pain With a Surprising Angle in a Young Girl

Maria Bianchi, MD

All Other Authors: Andrew Peterson, MD, MSPH

Affiliation: University of Iowa Health Care Family and Community Medicine Residency Program, Iowa City, IA.

History: 11 y.o. F with B/L knee pain that began a few years ago and has gradually worsened. Parents say patient has always had problems with her knees, and they’ve always knocked together. Pain is achy and located to B/L anterior knees with associated pain in her proximal lower legs and distal thighs. She previously played basketball and soccer but stopped due to pain with running. Endorses pain in the AM that lasts 30–60 minutes before self-resolving. No pain at night that wakes her from sleep nor at rest. Has tried OTC pain medications w/o relief. Compression sleeve didn’t help. Has done PT for 2 months w/o improvement. No swelling, bruising, warmth, redness, nor pain elsewhere. Per parents, autoimmune joint pain workup with PCP was negative with normal inflammatory markers. Parents report that she has had L knee MRI and B/L knee XR done. She takes a multivitamin daily and is still premenarchal.

Physical Exam: BP 128/80 HR 57 BMI 25.70 kg/m² B/L Knees: Inspection: Prominent B/L genu valgum. No erythema, ecchymosis, swelling, and/or atrophy. Palpation: B/L medial joint line tenderness. Lateral joint line tenderness on R. IT band tenderness B/L. No tenderness along the patellar nor quadriceps tendon, no medial/ lateral patella tenderness. No posterior hamstring insertional tenderness. No popliteal fossa fullness. ROM: Normal. Strength: Normal. Neuro: Normal. Gait: No difficulty with walking. B/L Femoral anteversion. Medial sides of knees rub against each other with walking and running. Has difficulty and pain with running, swings arms wide laterally to assist with balance. Special testing: negative.

Differential Diagnosis:

1. Prominent Genu Valgum, normal variant
2. Osteochondritis Dissecans
3. Blount’s Disease
4. Rickets
5. Patellofemoral Pain Syndrome

Test Results: B/L Knee XR: Prominent genu valgum with areas of lucency on the lateral aspect of the MFC of the R knee, in addition to on the lateral aspect of the MFC and on the medial aspect of the LFC of the L knee. Long Leg B/L XR: 8° of valgus on R axis and 10° of valgus on the L axis. L Knee MRI: Small joint effusion. Labs: BMP nl, Ca2+ nl, Mag nl, Phos 2.7 (L), Vit D nl, PTH 74 (H), ALP 556 (H). Urine: Ca2+ 2.5, Phos 63.8, Mag 5.0, Cr 46.9, Na+ 262. Genetic: Heterozygous mutation in PHEX.

Final Diagnosis: X-Linked Hypophosphatemic Rickets (XLH).

Discussion: The patient’s bilateral knee pain, genu valgum, and low phosphorus with elevated fractional excretion of phosphorus in the urine (20.19%) were consistent with X-linked Hypophosphatemic Rickets (XLH), confirmed by genetic testing revealing a PHEX mutation. XLH is characterized by lifelong hypophosphatemia and osteomalacia, which lead to skeletal deformities. Multidisciplinary management is essential, involving Pediatric Endocrinology for medication management, and Orthopedic Care for potential skeletal deformities. Early intervention and regular monitoring are crucial to optimize bone health, growth, and quality of life, helping to minimize the long-term impact of the disease.

Outcome: Per the family’s preference, the patient has been receiving oral phosphate supplementation and calcitriol, managed by Pediatric Endocrinology with periodic adjustments based on lab results. The family was educated on medication adherence for optimal management. The patient also underwent bilateral epiphysiodesis of the distal femur and proximal tibia, managed by Orthopedic Surgery.

Follow-Up: Over the past year, the patient has remained healthy, with no major concerns except for a dental issue. She has resumed sports participation, including basketball, archery, and soccer, and is active with biking, swimming, and playing with friends. She continues to be managed by Pediatric Endocrinology and Orthopedics, with regular follow-up for bone health, growth, and medication adjustments.

Feeling Weak in the Knee: Lateral Knee Pain in an Adolescent Soccer Player

Efreim Joseph Morales, MD, MS

All Other Authors: Anthony Luke, MD, MPH and Faustine Ramirez, MD

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

History: A 16-year-old female club soccer player presents to clinic with acute right lateral knee pain after being slide-tackled in a soccer game 5 days prior to presentation. She describes the injury mechanism as a varus stress to the knee. She reports a sensation of “popping out” at the lateral aspect of her knee at the time of injury. She states she had a visible deformity, which self-resolved by the time she presented to a local ED for evaluation. She was unable to bear weight after the injury. She was initially evaluated at a local ED and was recommended ACE wrap, crutches, and analgesics. Since the injury, she reports lateral knee pain with weight-bearing, knee instability, and anterolateral ankle pain. She reports minimal knee or ankle swelling. She denies mechanical symptoms in the knee or lower extremity paresthesias. She has no prior history of right knee injuries.

Physical Exam: Right Knee: no deformity; mild soft tissue swelling around fibular head; TTP at fibular head, proximal tibiofibular joint and lateral joint line; ROM 0°–135° with pain in full extension; 5/5 strength resisted knee extension; 4/5 strength resisted knee flexion limited by pain; lateral knee pain with modified Apley and McMurray’s tests; pain with varus stress testing without instability; sensation to light touch and motor function intact in right lower extremity; warm well-perfused with intact pedal pulses; Right Ankle: TTP along fibular shaft, lateral malleolus, AITFL; full passive ROM with discomfort; pain with forced dorsiflexion/external rotation stress and syndesmosis squeeze tests.

Differential Diagnosis:

1. Proximal tibiofibular joint instability
2. Distal biceps femoris tendon tear
3. Proximal fibula fracture
4. Lateral meniscus injury
5. Lateral collateral ligament injury

Test Results: (1) XR Right Knee and Tibia/Fibula: no acute fracture, possible subluxation of fibular head (2) XR Right Ankle with stress views: no acute fracture, congruent ankle mortise (3) MRI Right Knee without contrast: full thickness tearing of posterior tibiofibular ligament from fibular attachment, partial tearing of anterior tibiofibular ligament, small effusion of tibiofibular joint and slight subluxation of fibular head consistent with tibiofibular joint instability; no fracture or chondral injury.

Final Diagnosis: Acute traumatic proximal tibiofibular joint instability with low-grade high ankle sprain.

Discussion: Isolated proximal tibiofibular joint (PTFJ) instability accounts for less than 1% of all knee injuries and is often a missed diagnosis in lateral knee injuries. Common mechanisms include falls on a flexed knee with a plantarflexed and inverted foot, a twisting injury, or a direct blow. Evaluation for concurrent ankle and peroneal nerve injuries is essential. Non-operative treatment, including closed reduction, immobilization and/or physical therapy, is often recommended as first-line but has been associated with chronic pain and instability, in up to 25% of patients. To our knowledge, no cases of PTFJ instability treated with platelet-rich plasma (PRP) have been reported in young athletes.

Outcome: She was immobilized in a hinged knee brace partial weight-bearing for 4 weeks, followed by physical therapy for 8 weeks. At 12 weeks, she continued to report pain, instability and inability to return to sports, so she was referred for surgical consultation. PRP was recommended due to persistent pain and instability. She underwent ultrasound-guided PRP injection into the PTFJ 5 months after injury.

Follow-Up: She resumed physical therapy 2 weeks after PRP injection. By 4 weeks after PRP injection, she reported her pain and instability had resolved, and she had participated in a soccer practice without any symptoms. She was cleared to return to soccer without restrictions and has not had any recurrence of symptoms.

A Pedaler’s Puzzle—A Case of Recurrent Knee Pain in a Cyclist

Kelly Thao, MD

All Other Authors: Rahul Kapur, MD

Affiliation: University of Minnesota – St. John’s Family Medicine, St. Paul, MN.

History: A 58-year-old man with a past medical history of arthroscopic left knee surgery presents with one month of left-sided knee pain. The man is an avid cyclist, and is very active at baseline. Over the last month, he has been unable to kneel onto his L knee and has had trouble flexing beyond 90 degrees. At 90°, he feels significant discomfort, though he is able to push through the motion during activity. He has noticed his pain has worsened over a 2-week biking trip in Europe a month ago. He does not note any acute injuries over this time period. He denies locking, catching, or instability of the knee, and feels that his gait and strength are at his baseline. He denies any history of fever, chills, or warmth to the area. His past medical is significant for previous synovitis of the same knee over 20 years ago that required an arthroscopic cleanout for a “very rare condition.”

Physical Exam: General: Well appearing, no apparent distress Neuro: Antalgic gait. Reflexes 2+ in lower extremities Left knee: On visual inspection, there is a mild to moderate effusion of the knee. Crepitus is present with passive motion. He has full extension of his knee, but his flexion is limited to only 90 degrees of passive and active motion, with significant pain and locking beyond 90 degrees. He is tender over the lateral joint line only when his knee is flexed to 90°. He is otherwise nontender to palpation. His anterior and posterior drawer, Lachman, varus, and valgus tests are all negative. A McMurray’s test was attempted, but ultimately had to be deferred due knee locking and discomfort.

Differential Diagnosis:

1. Osteoarthritis
2. Degenerative meniscus tear
3. Rheumatoid arthritis
4. Pigmented villonodular synovitis
5. Synovial chondromatosis

Test Results: X-ray of the left knee showed only mild medial and lateral compartment joint space loss along with mild patellofemoral spurring. MRI of the left knee showed a small to moderate knee joint effusion with extensive synovitis and questionable areas of small hypointense bodies on T1 and T2.

Final Diagnosis: Recurrent pigmented villonodular synovitis (PVNS), also known as a tenosynovial giant cell tumor (TGCT).

Discussion: Pigmented villonodular synovitis is a rare neoplastic synovial overgrowth of the joints and tendons. Occurring in 1/1,800,000 cases, its growth is usually indolent and can take several years to present, making it a challenging diagnosis. This patient’s initial presentation of locking, limited motion, and pain were consistent with meniscal pathology. However, with a history of previous synovitis, this raised the possibility of recurrent disease. MRI results did show signs of PVNS, but did not show definitive tumor burden. A biopsy is needed for full diagnosis. Similar presentation in other joints may also indicate diffuse disease, which is a vital differential and affects treatment choice.

Outcome: The patient was referred to orthopedic surgery for possible synovectomy and biopsy for definitive diagnosis. Given inconclusive evidence on MRI, a biopsy is needed to confirm the diagnosis. Definitive treatment would be a full synovectomy and likely total knee arthroplasty. The patient opted for a conservative betamethasone injection for pain relief with the option for future surgery.

Follow-Up: The patient returned to cycling as tolerated. It is anticipated that if his pain worsens and is confirmed by biopsy, he will require a complete synovectomy and likely total knee arthroplasty in the future.

A Scap-tacular Surprise

Ryan Wendt, MD

All Other Authors: Nahum Beard, MD

Affiliation: UTHSC/Campbell Clinic, Memphis, Tennessee.

History: Fifteen-year-old female presents for evaluation of bilateral shoulder pain. Her pain has been ongoing for years. The pain occurs with motion of the shoulders, particularly during archery. She also notes swelling over her upper trapezius muscles. She denies any weakness, sensation changes, night pains, fever, or chills. In addition to competitive archery, she exercises in the gym frequently but has since been unable to due to pain. She first managed this pain with heat therapy and massage without improvement. Her pediatrician recently referred her for formal physical therapy which slightly improved her pain. Her only medication is Accutane. PMH, PSH, and Social History reviewed and non-contributory.

Physical Exam: Bilateral shoulders: Inspection: Bilaterally prominent trapezius muscles with left larger than right. Palpation: Moderately tender to palpation over the upper trapezius muscles without any discrete masses. ROM: Full active and passive range of motion of the cervical spine and shoulders with mild scapular winging. Strength: 5/5 strength in shoulder shrug, adduction, abduction, flexion, extension, internal rotation and external rotation. Neurovascular: Sensation intact to light touch. Radial pulses 2+. Special Tests: Supraspinatus, infraspinatus, and subscapularis intact. Negative Neer’s, Hawkin’s, Obrien’s, dynamic shear, and scarf exams.

Differential Diagnosis:

1. Scapular Dyskinesia
2. Suprascapular Nerve Entrapment
3. Soft Tissue Tumor
4. Cervical Rib
5. Subclavius Posticus

Test Results: Plain films bilateral shoulders: Normal alignment. No AC or GH degenerative joint disease, or other bony abnormality. MRI bilateral shoulders WO contrast: Muscles and tendons demonstrate normal morphology. Normal AC and GH joints. Normal brachial plexus. Ultrasound bilateral shoulders: Bilateral accessory muscle originating off the apex of the lung fascia/1st costal cartilage and inserting lateral to the levator scapulae along the upper scapular edge consistent with subclavius posticus.

Final Diagnosis: Subclavius Posticus.

Discussion: Subclavius posticus, a rare muscular anomaly, can cause neurovascular compression leading to thoracic outlet syndrome as well as localized shoulder pain and swelling which occurs from abnormal biomechanics and inflammation. Diagnosis requires imaging, such as ultrasound or MRI, to identify the anomaly. Management includes physical therapy, anti-inflammatory medications, and rest. For refractory cases, ultrasound-guided or open surgical procedures may be necessary. This case is an example of a rare accessory muscle causing myofascial pain without nerve compression that was successfully treated with Botox injection.

Outcome: Our patient completed an additional 8 months of physical therapy without significant improvement. Given her localized pain and lack of neurologic symptoms the decision was made to undergo ultrasound guided Botox injection into the left accessory muscle followed by the right 1 month later while continuing PT. After several weeks of therapy post-injection, she had near resolution of her pain.

Follow-Up: Due to the chronic nature of our patient’s pain, she continued with physical therapy for several months after her injection working on residual cervical stiffness and shoulder stabilization. Our patient returned to competitive archery with nearly no pain with range of motion of her shoulders and has been able to exercise in the gym pain free.

Point, Set, Mass: Prepatellar Loose Bodies in a Collegiate Volleyball Player

Areeba Mubarik, MD

All Other Authors: Edward Arrington, MD and Matthew Wise, DO

Affiliation: University of Texas Southwestern Medical Center, Dallas, Texas.

History: A 19 year old collegiate volleyball player presents to Sports Medicine clinic with acute worsening of intermittent anterior right knee pain and paresthesias associated with a superficial patellar mass. Symptoms started 4 years ago while playing volleyball in high school. She has a remote history of landing on a piece of metal during a volleyball dig and is worried about a retained foreign body. .er pain is sharp and worse with heavy lifting and landing on her knees while diving for balls despite wearing knee pads. Her pain improves with rest, walking, and stretching. The patient denies mechanical symptoms and giving way of her knee. The patient has missed games due to her symptoms.

Physical Exam: Right knee Visualization: normal gait and alignment. No swelling, bruising, erythema or atrophy compared to the contralateral side. No edema. Palpation: No effusion. Firm, freely mobile, nontender bodies over the patella. Nontender to palpation of the quadriceps tendon, patellar tendon, medial joint line, and lateral joint space Range of Motion: Normal, Knee can passively flex and extend from 0° to 135° Strength: 5/5 knee flexion and extension without pain. Special Tests: Negative: anterior drawer, posterior drawer, Lachman, valgus stress test at 30°and 0°, varus stress test at 30° and 0°, and McMurray. Thessaly not tested.

Differential Diagnosis:

1. Prepatellar bursitis with retained foreign body
2. Prepatellar bursitis with fat necrosis
3. Nodular synovial hyperplasia
4. Ganglion cyst
5. Lipoma

Test Results: Limited Diagnostic Ultrasound of Anterior Right Knee: Normal fibrillar appearance of tendons. Two hyperechoic ovoid lesions superficial to patella that are mobile, non-compressible, non-tender on sonopalpation, and non-vascular. Increased anechogenicity within prepatellar bursa. Impression: prepatellar bursitis with bursal calcifications. Right knee X-ray: No ossified or calcified bodies anterior to the patella. Right knee MRI: Mild prepatellar bursitis, No extra articular loose or foreign bodies.

Final Diagnosis: Right knee prepatellar bursitis with traumatic fat necrosis.

Discussion: Although traumatic fat necrosis is a common phenomenon, there are no reported cases of TFN within the prepatellar bursa presenting as masses on exam and characterized solely on ultrasound in the setting of negative Xrays and MRI. Previous research has demonstrated that the appearance of fat necrosis on MRI is varied but rarely absent. While fat necrosis has been described in 1 case from 2014, there are no documented cases of intra-bursal fat necrosis in athletes, although joint trauma is common in this population. In both cases, the definitive treatment is excision. Our case demonstrates the highly functional utility of ultrasound which in some cases is superior to cross sectional imaging.

Outcome: The patient was referred to Orthopedic surgery. Since her symptoms continued to worsen during her volleyball off-season despite conservative therapy, the patient underwent open patellar debridement. Two firm, fatty, loose bodies measuring 0.6 cm in length were excised from the prepatellar bursa and sent to pathology which showed fat necrosis. The patient was discharged weight-bearing-as-tolerated.

Follow-Up: The patient participated in her next fall season of volleyball without issue. She occasionally gets pain from diving but it does not impair her ability to play or recover as before.

I Can’t Remember: A Cheerleader With Acute Memory Loss

Aliza Williams, DO

All Other Authors: Megan Hanna, MD and Elizabeth Harpster, MD

Affiliation: Prisma Health/USC School of Medicine Greenville (Seneca) Family Medicine Residency, Seneca, SC.

History: A 20-year-old female college cheerleader with history of recurrent concussions presented to student health reporting short-term memory loss for 1–2 weeks following spring break. She endorsed increased stressors at school and more frequent cheer practices with reported trauma. She noted her symptoms were worse following physical activity and included disorientation, disassociation, and weakness resulting in missed classes. She was discharged from student health for suspected viral illness vs anxiety with recommended close follow-up. Her sister, a type 1 diabetic, brought the patient to the ED that night due to worsening short term memory recall, new intermittent paresthesia of her extremities, and difficulty initiating speech. She denied new sexual partners or medications and endorsed minimal caffeine and alcohol intake. Patient was admitted for further workup.

Physical Exam: Vitals: afebrile and normotensive during hospitalization. Physical exam: Well-appearing. Normocephalic, atraumatic head. EOMI, pupils equal and reactive bilaterally. Cardiac exam normal. Lungs clear to auscultation. Upper and lower extremities with full range of motion. Neurologic: Alert, disoriented. CN II through XII intact. Patient states incorrect year, unable to state the month. No evidence of clonus. Intact strength bilaterally. Able to ambulate. Intact finger-to-nose testing. Equal sensation bilaterally to light touch. Decreased concentration with limited attention less than 60 seconds. Able to repeat phrases without any aphasia or dysarthria.

Differential Diagnosis:

1. Post-traumatic amnesia
2. Panic disorder
3. Substance or medication-induced amnesia
4. Epilepsy
5. Encephalitis

Test Results: CMP, pregnancy test, HIV, syphilis, CK, LDH, B1, B12, folate, TSH, urinalysis, A1c: unremarkable. Toxicology: negative. Hgb 9.5 with low iron. CT head/CTA Head and Neck/Brain MRI/CT Chest/Ab/pelvis: unremarkable. Long-term EEG: 60+ subclinical focal seizures emanating from the left >> right temporal regions in less than 24 hours. Titrated up to 3 anti-epileptic medications at high dose but continued to have 40 subclinical focal seizures from left temporal region.

Final Diagnosis: Autoimmune encephalitis with anti-GAD 65 antibody without titer.

Discussion: Autoimmune encephalitis (AIE) is an immune-mediated inflammatory condition of the brain with many etiologies primarily affecting more women than men in their teens to 50s. AIE presents with a variety of symptoms that evolve over weeks to months including refractory seizures, neuropsychiatric disorders, and cognitive dysfunction. When one suspects AIE, early treatment with IV steroids/IVIG/plasmapheresis improves outcomes. In an athlete with recurrent concussions, post-traumatic amnesia is a common finding. However, in the setting of acute and worsening memory changes, one must expand their differential to include more rare causes like AIE.

Outcome: Patient was treated with 4 anti-epileptic medications, regular plasmapheresis infusions, and IV steroids with transition to oral prednisone at discharge. She was discharged with cessation of focal status epilepticus and given close neurology follow up for repeat MRI and antibody titers in 3 weeks. Her type 1 diabetic sister was later identified as an anti-GAD 65 Ab carrier.

Follow-Up: Patient returned to college where she passed her final exams with honors and resumed regular physical activity. Neurology weaned her down to 2 antiepileptics and continued oral prednisone with monthly plasmapheresis infusions. Repeat MRI was stable without signs of pathologic signaling or volume loss of the temporal region. Antibody titers remained positive for anti-GAD 65 Ab.

Odynophagia and Dyspnea in a College Basketball Player

Dominic Haragos, MD

All Other Authors: Samuel Saunders, DO and Philip Van de Griend, MD

Affiliation: ISU Family Medicine Residency, Pocatello, Idaho.

History: A 23 year old male presented with 2 days of odynophagia, dyspnea and sore throat. He initially noted the pain following being struck in the throat during basketball practice. The pain was localized to the anterior neck and worsened with swallowing, pressing on the anterior neck and with rapid breathing during exercise. The symptoms were reproduced the next day at practice. He denied any history of allergies, smoking or vape use. The patient had no history of thyroid disease.

Physical Exam: Mouth: no abnormality of the visible tissues of the mouth or oropharynx Cervical neck: slight right-sided deviation of the laryngeal prominence, more notable during swallowing. Tender to palpation of the anterior neck at the level of C5-C6. Full ROM. No lymphadenopathy.

Differential Diagnosis:

1. Laryngitis
2. Laryngeal edema secondary to trauma
3. Thyroid Cartilage Lamina Fracture
4. Tracheal diverticula
5. Paratracheal Hematoma

Test Results: X-ray Neck, Soft Tissues; AP, Lateral: Patent airway. Normal adenoids. No epiglottis or paravertebral soft tissue thickening. Left curvature of cervical spine. CT Neck Soft Tissues: Traumatic injury to the thyroid cartilage with a mildly displaced fracture of the right thyroid cartilage lamina. No other soft tissue injury noted Nasolaryngoscopy: Patent airway with symmetric pharyngeal walls and clear tongue base/vallecula. Mild edema of the right TVF with some faint blood staining.

Final Diagnosis: The patient was diagnosed with right paramedian vertical thyroid fracture with anterior-posterior subluxation.

Discussion: Laryngeal fractures are uncommon injuries of the anterior neck that predominantly occur in settings of trauma. These are potentially life threatening given airway involvement but go undiagnosed up to 40% of the time. Odynophagia and dyspnea are common symptoms of mild to moderate injury. CT of the neck is the preferred imaging modality for laryngeal injuries. Management should focus on identifying severity of injury and airway patency. Endotracheal intubation and tracheostomy are preferred methods for airway management. Surgical fixation is the definitive treatment though not always required for more mild injury. Early intervention can prevent development of long-term complications.

Outcome: He was non-emergently transferred to a larger academic facility for open reduction and internal fixation of the right thyroid cartilage. Following fixation, he was observed with penrose drain in place for 24 hours, then discharged home.

Follow-Up: He returned to activity and lifting at 2 weeks status post open reduction and internal fixation, then full contact play without restrictions at 6 weeks.

Just Another Case of Lateral Elbow Pain…

Olutimilehin Oyeniran, MD, MS

All Other Authors: Zachary Maass, MD

Affiliation: University of Connecticut Primary Care Sports Medicine Fellowship.

History: In May 2024, a 28-year-old female graduate student presented with chronic left lateral elbow pain and stiffness. The patient attributed both her pain and 15° extension block to a prior fall onto a flexed elbow while wrestling years prior. Workup at the time of original injury was described to be minimal with no advanced imaging. Her evaluation in May 2024 noted reports of pain on and around the lateral epicondyle worsened with palpation as well as gripping and twisting with the left hand. No medial elbow pain. She reports to being right-hand dominant. No associated skin changes. No appreciable bruising or soft tissue swelling. No recent new trauma. The patient was sent to physical therapy for 6 weeks with subsequent follow-up noting persistent left lateral elbow symptoms with new but vague radial distribution numbness and subjective forearm weakness.

Physical Exam: Vital signs: Normal Elbow exam: 2+ tenderness over the lateral epicondyle. 4+/5 strength with resisted wrist extension with pain localized over the lateral epicondyle region. No medial epicondyle tenderness. Cubital tunnel and ulnar nerve evaluation were normal, with no nerve instability, negative ulnar tinel’s. Flexion and extension strength across the elbow were 5/5 and non-painful. Passive range of motion showed a painless arc from 15–130 degrees. Supination and pronation were painless and symmetrical to the contralateral side. Radial tunnel palpation was minimally tender. No varus or valgus instability was noted on collateral ligament testing.

Differential Diagnosis:

1. Lateral epicondylosis
2. Radial tunnel syndrome
3. Radiocapitellar OCD/loose body
4. Cervical radiculopathy
5. Chronic LCL injury with rotary instability

Test Results: 7/2024: MRI L elbow w/o contrast: Probable peripheral nerve sheath tumor of the radial nerve juxtaposed between the brachioradialis, supinator muscle and biceps tendon measuring 3.2 × 2.8 × 4.8 cm. Joint space well-preserved. No evidence of tendinous or ligamentous injury. 09/2024: US guided core needle biopsy: Synovial Sarcoma 10/2024: MRI L elbow ww/o contrast: Interval increase in size of the soft tissue mass 2.9 × 6 × 5.3 cm.

Final Diagnosis: Synovial Sarcoma of the Left Forearm.

Discussion: While initially thought to be a relatively benign case of chronic lateral elbow pain, this case underscores the importance of broad differentials for chronic musculoskeletal pain. Synovial sarcoma typically presents insidiously in young adults, usually around large joints in the extremities. Its name is derived from the fact that its cells resemble that of normal synovial cells in appearance. Synovial sarcoma is relatively slow growing but can metastasize, usually to the lungs. Synovial sarcoma has an age-adjusted incidence of 0.15 per 100,000. Repeat exams noted that the mass was palpable, just proximal and medial to the radial tunnel.

Outcome: Six months of chemo initiated 10/2024. Surgical excision likely 01/2025 followed by radiation. Excision of the involved portion of the radial nerve likely with subsequent allograft. Pain reportedly improved with chemo, however s/e of nausea, altered taste, and increased smell sensitivity are noted. Recent inpatient admission 10/2024 for fever and neutropenia with successful discharge.

Follow-Up: PET CT noted 2 pulmonary nodules in need of monitoring, currently thought to not be metastases. Concerns remain regarding the viability of the nerve allograft s/p excision given the need for radiation. Should the graft fail, tendon transfers would be needed, though post-radiation scarring will likely complicate matters. Close follow up enacted with Heme/Onc given recent hospital admission.

Chest Pain in a 22 Year Old Male Collegiate Lacrosse Player

Lauren Hibshman, DO

All Other Authors: Kristopher Fayock, MD

Affiliation: Hospital of University of Pennsylvania, Philadelphia, PA.

History: Twenty-two-year-old male collegiate lacrosse player presented to clinic for 1 month of chest pain that developed during summer training. He reports that he had increased his weightlifting sessions, specifically chest and upper extremity. Patient reports anterior chest pain that is worse with weightlifting and associated with morning stiffness. He gets some relief with a popping sensation when he sneezes. Pain rates 2 out of 10 in intensity. Patient denies injury or trauma. No significant past medical or surgical history. Allergies to erythromycin. Not currently taking any medications. Social history: senior undergraduate student-athlete. Denies family history of inflammatory or rheumatologic conditions. Denies any swelling, polyarthralgia, or skin changes.

Physical Exam: Vitals: afebrile, hemodynamically stable. BMI 27. Musculoskeletal: Tenderness to palpation at manubriosternal joint without erythema, edema, or calor. No tenderness to palpation of clavicle, sternoclavicular joint, pectoralis or intercostal musculature, costochondral joints, or ribs. Pain cannot be reproduced with active shoulder adduction, flexion, or internal rotation.

Differential Diagnosis:

1. Stress reaction or fracture of sternum
2. Manubriosternal joint inflammatory arthropathy
3. Bone contusion of the sternum
4. Pectoralis or intercostal muscle strain
5. Costochondritis

Test Results: Chest XR unremarkable for acute osseous changes. MRI sternum revealed osseous stress response or early arthropathy (possibly inflammatory) at the manubrial aspect of the manubriosternal joint. Given persistent pain at follow up, repeat MRI Chest Wall revealed persistent marrow edema at the manubriosternal joint with minimal cystic changes greatest at sternal end concerning for osseous stress response with possible underlying arthropathy and an incidental finding of acute multifocal pneumonia.

Final Diagnosis: Manubriosternal joint inflammatory arthropathy.

Discussion: Sternum stress reactions are quite rare, accounting for only 0.5% of all sternal fractures. The limited case reports published on this topic have discussed stress reactions within the manubrium or sternum, but none of these cases reported inflammatory changes extending into the manubriosternal joint as seen in this case. Nearly all previous cases reported complete resolution of symptoms with rest and conservative measures, therefore the persistent pain despite adequate rest is suggestive of an underlying inflammatory arthropathy in this case. More research is needed to understand risk factors that may predispose some athletes to develop stress reactions within the manubriosternal complex.

Outcome: Patient was initially treated with activity modification, avoiding upper extremity exercises, Vitamin D supplementation, and a bone stimulator. Due to persistent pain despite conservative measures, repeat was MRI obtained at follow up revealed persistent osseous stress reaction associated with underly joint arthropathy and acute pneumonia. Patient treated with oral diclofenac and antibiotics.

Follow-Up: Patient tolerated gradual return-to-play progression with athletic trainer and has been completely integrated back into lacrosse activities, but continues to avoid upper extremity lifting exercises due to mild persistent anterior chest wall pain.

The Eyes Do Not Lie or Do They

Jessica Tomazic, MD

Affiliation: Cleveland Clinic Foundation, Cleveland, OH.

History: 17 yo M HS football player without significant PMHx presented in outpatient sports medicine for evaluation 3 days after sustaining his first concussion, which he was noted to have a brief LOC (less than 1 minute). He had sustained a hard tackle and was found unresponsive on the field but was roused within seconds of the AT arriving at his side. The pt was dazed but cleared and able to walk to the sideline, where he had an otherwise normal sideline exam and was withheld from play for the remainder of the game. Brief exam after the game revealed no acute abnormalities. At morning training room 2 days later, the pt was again examined by the AT when a lateral gaze defect of the left eye was noted on near-point convergence. Parents reported that this had never been noticed before. The pt reported neck pain as a one but was otherwise asymptomatic.

Physical Exam: BP (supine) 108/50. Pulse 54. WNWD, NAD. PERRLA. Normal cervical spine exam. Normal palatal elevation. No pronator drift. 5/5 strength in all extremities. 2+ and symmetric triceps, biceps, brachioradialis, patellar, and Achilles reflexes. Normal finger-to-nose and heel-to-shin testing. Romberg normal. Usual gait, heel, toe, and tandem walk normal. Normal smooth pursuits, horizontal and vertical saccades, horizontal and vertical vestibulo-ocular and visual motion sensitivity. Average near point of convergence 1 cm from the tip of the nose, with left eye deviation away from the midline that began about 3 cm from the nose.

Differential Diagnosis:

1. Internuclear ophthalmoplegia
2. Convergence paralysis
3. Convergence insufficiency w intermittent exophoria
4. Accommodative insufficiency
5. Duane’s retraction syndrome

Test Results: PHQ-9: 0 GAD-7: 0 C3 Total Symptoms: 1/27 C3 Symptom severity score: 3/162 BESS: 7 errors Processing speed: 60 correct Simple reaction time: 310 m—seconds Choice reaction time: 390 m—seconds Trails Test A: 29.5-seconds Trails Test B: 67.6-seconds Trails Test B-A: 38.1-seconds IMPACT test: all scores at or above baseline MRI brain w/o IV contrast obtained 3 days after outpatient exam: normal study.

Final Diagnosis: Convergence insufficiency w/ intermittent exophoria, usually diagnosed in childhood, is a temporary malalignment of one eye as it drifts away from the midline when focusing on nearby objects.

Discussion: American high school football players have a higher rate of sports-related concussions than collegiate and professional football combined. Most of the brain’s neural pathways control eye movement and vision, so it’s no surprise that SRC can lead to ocular dysfunction. A 2016 study by Master et al. suggests a high prevalence of ocular pathologies after even mild traumatic brain injuries. Vestibular Ocular Motor Screening is a highly accurate and reliable concussion screening tool although can have a false-positive rate of approx. 10%–29%. Intermittent exophoria affects about 1 percent of the general population. Any baseline change in vision or ocular exam warrants additional workup.

Outcome: The pt was referred a hospital-based optometrist who specializes in ocular dysfunction after concussions. Visual acuity, tonometry, refraction, accommodation, external exam, slit lamp and fundus exam were normal. Near point of convergence was 7 cm from the nasal bridge. Since the patient had no vision changes and was otherwise asymptomatic, that the exophoria noted was most likely congenital.

Follow-Up: The pt was returned to full, contact activity and finished the season with no additional issues. The pt plans to pursue competitive collegiate athletics. Moving forward, it was recommended that these findings be noted as his baseline and listed appropriately on future PPEs to prevent unnecessary workup should he sustain further injury.

Pop-in My Collar: A Unique Case of Shoulder Pain

Zachary Sitton, MD

All Other Authors: Luting Eckensweiler, DO

Affiliation: Duke University Primary Care Sports Medicine, Durham, North Carolina.

History: A 17-year-old male high school football player with no significant PMH presented to our clinic with right medial clavicle pain. Three weeks prior to presentation, he was tackled and driven into the turf directly onto his right shoulder and felt immediate pain over his medial clavicle. He was seen in Urgent Care within 24 hours and had normal x-rays but was placed in a sling due to significant pain. Upon re-evaluation in our clinic 3 weeks post-injury, he reported that 2 weeks after the injury he was abruptly woken up from his sleep due to severe worsening of pain and felt like his right clavicle had shifted. This severe pain subsided quickly; however, he was still having persistent medial clavicle pain that radiated up to his trapezius and neck. He denied any numbness, tingling, swelling, shortness of breath, cough, chest pain, fever, chills, trauma, prior injury or surgery.

Physical Exam: Vitals: T 98.4°|BP 112/68|Pulse 80|Ht 5’8|Wt 168 lb|SpO2 98% Right Shoulder-Inspection: No localized swelling or deformity of the clavicle or sternoclavicular joint. No erythema or ecchymosis. Palpation: Tender to palpation over the medial clavicle and sternoclavicular joint. ROM: forward flexion limited to 135 degrees, abduction limited to 120 degrees, internal rotation limited to the sacrum, external rotation at 90 degrees abduction limited to 70 degrees. No difference between active and passive range of motion. Strength: 5/5 strength (with pain) with Jobe test, Belly Press, and resisted external rotation. Neurovascular: reflex intact, 2+ radial pulses, no deficits in sensation.

Differential Diagnosis:

1. SC Joint Dislocation
2. Clavicular/Physeal Fracture
3. Rib Fracture
4. SC Joint Arthropathy
5. Pectoralis Major Injury

Test Results: XR Right Clavicle (day after injury): Normal. XR Right Clavicle (3 weeks post-injury): periosteal new bone formation about the medial clavicle, which could represent a healing occult fracture. MRI Chest and CT Right Shoulder: Posterior SC joint pseudodislocation characterized by a displaced medial clavicle physeal fracture (Salter-Harris I) and posterior displacement of the medial clavicle metaphysis with resultant impression on the anterior aspect of the right brachiocephalic vein.

Final Diagnosis: Posterior SC joint pseudodislocation secondary to displaced medial clavicle physeal fracture (Salter-Harris I).

Discussion: Medial clavicle physeal fractures, aka pseudodislocations of the SC joint, are rare injuries to the medial clavicle physis in children and most often present with medial clavicle pain after trauma. These injuries are considered a childhood equivalent to SC dislocations in adults, and similarly can displace anteriorly, resulting in a palpable bump, or posteriorly, with compression of mediastinal and/or neurovascular structures. X-rays are recommended initially with serendipity views, followed by CT scan or MRI to visualize underlying structures for injury. Treatment is typically non-operative for anterior displacement and closed reduction vs. ORIF for posterior displacement.

Outcome: Following diagnosis with MRI and CT scan, patient opted for ORIF of posterior SC joint pseudodislocation given his desire to return to playing football.

Follow-Up: Following surgery, he did well and was cleared to begin rehab with passive range of motion for 6 weeks. At his 6-week follow up he demonstrated adequate healing and was cleared to progress to active, assisted range of motion. At 16 weeks he was allowed to progress to full active range of motion with strengthening exercises. He was cleared to begin sport-specific exercises at 20 weeks post-op.

An Unexpected Radiographic Finding in an Adolescent Boxing Athlete With Shoulder Pain

John DeWaard, DO

All Other Authors: Andrew Cunningham, MD

Affiliation: Henry Ford Health Sports Medicine-Detroit, MI.

History: Patient is a 15 year old male boxing athlete who presented with complaint of right shoulder pain that had been ongoing for the past year, but had acutely worsened. His pain initially started after throwing a jab in a match one year prior and acutely worsened to the point where it was difficult for him to complete his training sessions. Pain was located to the posterior and lateral shoulder. Rated as a 6/10. Pain worse with reaching back behind his body and across his body. Pain improved with rest. Symptoms also associated with intermitted tingling over the lateral deltoid that occasionally traveled down to his right thumb lasting a few seconds. No prior shoulder surgeries, instability events, or other injuries.

Physical Exam: Inspection: No appreciable asymmetry or atrophy Palpation: AC joint tenderness: negative, biceps tenderness: negative. Range of Motion: Flexion 170°, Abduction 160°, External Rotation at Side 50°, Posterior Internal Rotation T8, External Rotation at 90° of abduction 100°, Internal Rotation at 90° of abduction 45°. Muscle Strength: Internal Rotation 5/5, External Rotation 5/5, Forward Elevation 5/5. Special Tests: Speeds negative, Cross body negative, Hawkins and Neer negative, Bear hug negative, lift off negative, Obrien negative, Anterior load/shift negative, Apprehension/relocation produced posterior pain with end range external rotation, but no apprehension.

Differential Diagnosis:

1. Internal impingement of the shoulder
2. Labral tear
3. Little league shoulder
4. Suprascapular nerve entrapment syndrome
5. Loose body

Test Results: 4-View Bilateral Shoulder X-ray: No growth plate widening when compared to the left. Small rounded ossific body projecting over the inferior/medial aspect of the humeral head on the right, may be a joint body of unknown donor site. MRI: Chronic avulsion of the lesser tuberosity at the attachment of the subscapularis tendon. No rotator cuff tear. Blunting of the posterior labrum and cystic changes within the posterior humeral head suggestive of internal impingement.

Final Diagnosis: Internal impingement of the shoulder with chronic avulsion of the lesser tuberosity.

Discussion: Internal impingement of the shoulder is a relatively common diagnosis in overhead/throwing athletes that is often associated with a glenohumeral internal rotation deficit. Lesser tuberosity avulsion fractures, on the other hand, are of rare occurrence with an estimated incidence of 0.46 in 100,000 people. There have not been any documented cases of lesser tuberosity avulsion fractures jointly associated with internal impingement of the shoulder. It is unclear whether these 2 findings are related, however it is well documented in case reports that lesser tuberosity avulsion fractures often result in a decrease in internal rotation. Thus, it is possible this was a contributing factor.

Outcome: The patient completed 6 weeks of physical therapy with complete resolution of his shoulder pain and glenohumeral internal rotation deficit. Due to his symptom resolution and lack of a functional deficit, surgical intervention was avoided.

Follow-Up: After the completion of physical therapy, the patient was cleared to return to boxing without complication.

The Curious Case of the Stinger That Did Linger

Cord Sheehy, MD

All Other Authors: Joseph Powers, MD, Clay Guynn, DO, Harrison Goodno, MD, Torrance Laury, MD, and Todd Bonvallet, MD

Affiliation: Northside Hospital Orthopedic Institute. Lawrenceville, Georgia.

History: Fifteen-year-old male presented to outpatient sports medicine clinic for evaluation of neck and bilateral anterior shoulder pain. Reports associated numbness and tingling into the palm of his hands. Five days prior, he was playing in a football game when he experienced a head-to-head collision. He was spine-boarded by on-site ATC and taken via EMS to an outside hospital where cervical, thoracic, and bilateral shoulder radiographs were obtained and reportedly negative. He was discharged home from ED the same evening with provisional diagnosis of stinger. He was recommended for outpatient follow-up. Patient noted progressive difficulty with handwriting over the next 2 days prior to evaluation in clinic. He had been using acetaminophen and ibuprofen for pain which he rated a 4/10.

Physical Exam: General: NAD, well appearing. AAO ×3. Cervical: TTP Midline at C7. No step off. Normal ext, flex, lateral bend, rotation. Spurling and Hoffman’s negative. 3/5 strength bilateral deltoids, biceps, triceps. Neuro: PERRLA, EOMI, CNII-XII intact. DTR absent in biceps. 2 and symmetric in brachioradialis and triceps. DTR 3+ in patella and achilles. Light touch hyperesthesias C5/C6, otherwise sensation intact. Shoulder: Full active ROM with forward flex, ext, abd, IR/ER. No TTP throughout shoulders, negative provocative testing. Skin: No erythema or ecchymosis. Pulses intact, digits well perfused.

Differential Diagnosis:

1. Brown-Sequard syndrome
2. Brachial neurapraxia/stinger
3. Central cord syndrome
4. Cervical stenosis/radiculopathy
5. Cervical spinal fracture

Test Results: Cervical and thoracic radiographs: Cervical straightening. Normal kyphosis. Disc heights, vertebral heights well maintained. No fractures appreciated. Cervical MRI: Loss of cervical lordosis. Anterior superior endplate edema at T3-T4 vertebrae without evidence of collapse. Underlying congenital stenosis at C3-C4 and C4-C5. There is some edema within the cord at C3-C4 with questionable slight cord expansion.

Final Diagnosis: Central cord syndrome C3-C4 with associated cord edema. Congenital stenosis C3-C4, C4-C5. Superior endplate fracture at T3, T4.

Discussion: Ten thousand C-spine injuries occur per year, 10% from athletic injuries. Central cord syndrome is the most common partial cord syndrome, presenting with upper extremity paresthesias, numbness or weakness with variable bladder and sensory impairment. It often results from neck hyperextension and buckling of the ligamentum flavum, leading to increased pressure on the central cord. Motor and sensory fibers of the upper extremities have a central location, providing anatomic explanation for upper extremity predominance. If sx are missed and an athlete is allowed to continue play, there is a risk of paralysis and death highlighting the importance of C-spine and neurologic symptom assessment.

Outcome: After the MRI revealed cord edema, he was evaluated by neurosurgery, placed in an Aspen collar and prescribed a 12 day prednisone taper. One month post injury he showed partial improvement in strength and sensation, collar continued. Two months post injury, strength and sensation continues to improve but has not returned to baseline.

Follow-Up: Patient is continuing his recovery with serial medical follow ups and intensive physical therapy. Due to severity of injury with underlying congenital stenosis, he has been restricted from football participation moving forward.

The Finish(ed) Line: Altered Mental Status in a Post-Race Endurance Athlete

Ari Epstein, DO

All Other Authors: Rondy Lazaro, MD and Daniel Curtin, MD

Affiliation: University of Rochester School of Medicine and Dentistry.

History: A 29-year-old female presented in a wheelchair via EMS personnel to the medical tent after collapsing across the finish line of an Ironman 70.3 triathlon. At this time of day (approximately 13:20), the Wet-Bulb Globe Temperature (WBGT) was approximately 82°F with variable winds (0–4.7 mph), variable humidity (0–47%), and no cloud cover. According to transport personnel and the patient’s family members who concurrently arrived at the tent, there were no previous signs of illness or distress during the event, including after the swim portion of the race, or reports of the athlete crashing during the bike portion. The patient completed the race over approximately 6 hours. The patient’s past medical and prescription medication history was not available for chart review.

Physical Exam: Constitutional: Toxic-appearing, acutely distressed, non-diaphoretic, and pale-appearing Eyes: PERRLA bilaterally Mouth: Dried mucous membranes, negative loss of palatal arch or posterior oropharyngeal edema Pulm: Clear to auscultation bilaterally; negative wheezes, rales, or ronchi Cardio: Tachycardic with regular rhythm; negative murmurs, rubs, or gallops; +2 distal radial pulses bilaterally Neuro: Glasgow Coma Scale 10 (E 2, V 3, M 5) Skin: Cool and dry; negative ecchymoses, avulsions, abrasions, or ulcerations along proximal or distal extremities bilaterally.

Differential Diagnosis:

1. Vasovagal Syncope
2. Heat Exhaustion
3. Hypoglycemia
4. Exertional Heat Stroke
5. Hypertonic Hypovolemic Hyponatremia

Test Results: While the patient had been immersed in an 80-gallon tub of ice water for approximately 5 minutes, a rectal probe (Bel-Art H-B Durac Calibrated Thermometer) was obtained and recorded a core temperature of 108°F (42.2°C). No portable blood analysis systems were available in the field, though a blood glucose sample was euglycemic. Lastly, a 12-lead EKG demonstrated sinus tachycardia with negative ST elevations/depressions, wave deformities, QT prolongation/shortening, or QRS widening.

Final Diagnosis: Exertional Heat Stroke (EHS). The patient’s persistently-elevated core temperature with altered mentation required rapid management via Cold Water Immersion (CWI) before assessing comorbid conditions.

Discussion: EHS is a medical emergency in which core body temperature exceeds 104°F (40°C), inducing CNS dysfunction, organ failure, and death. When staff identify EHS and rapidly implement its treatment via CWI from the neck down within 30 minutes, they minimize morbidity and mortality by reducing core temperature by at least 0.15°C/min. To prevent rebound hypothermia, CWI terminates at 101.5°F (38.6°C). Athletes competing in conditions (i.e., humid, sunny, low winds) that limit heat of vaporization (i.e., sweating) are at risk for EHS. WBGT is a validated metric that holistically assesses EHS risk, and guidelines apply it to recommended adaptations that limit exertion time and maximize breaks.

Outcome: After 2 rounds of CWI, the rectal probe shorted after submersion, so a sublingual probe was used. The patient then seized and was given IV Versed with minimal response. She then lost her airway, requiring field intubation. En route to ED, she received analgosedative and paralytic medications, and she was hypothermic on arrival (84.2°F). ED labs demonstrated EHS sequelae, like rhabdomyolysis.

Follow-Up: The patient ultimately extubated without neurologic sequela, and she later discharged from inpatient stay with no persistent metabolic derangements. For future long-course triathlons, WBGT monitoring is key for variable conditions that increase her EHS risk. Separately, event med staff agreed to redundancy in core temp gauges, and EMS is improving transfer protocols to avoid rebound hypothermia.

Unusual Foot Pain in a Healthy Athlete

Landon Stevenson, DO

Affiliation: Montana Family Medicine Residency Program. Billings, Montana.

History: A 30-year-old male athlete presents with a 1-month history of progressively worsening pain and paresthesia in his right foot and ankle. The symptoms are primarily localized to the antero-medial aspect of the ankle and radiating to the plantar surface. He describes the pain as a burning sensation with ankle swelling, exacerbated by over 4 miles or prolonged standing. He also reports intermittent numbness and tingling in the toes, particularly at night. He does not recall associated trauma but notes that a few weeks before symptoms onset during an off-road motorcycle race while wearing boots his right foot was extended with his foot becoming trapped between a rock and his footpeg causing mild temporary discomfort. The patient has no significant medical history and is otherwise healthy. His training includes long-distance running, weightlifting, and interval training.

Physical Exam: Inspection: Mild swelling noted anterior to the medial malleolus on the right foot. Palpation: A firm, slightly tender, and mobile mass (∼1.5 cm in diameter) is palpated anterior to the medial malleolus. Tinel’s sign is positive over the mass, with tingling radiating to the plantar foot. Range of Motion: Full range of motion at the ankle and subtalar joints without pain. Neurological Exam: Decreased sensation to light touch over the plantar surface of the foot. Motor strength is intact. Gait Analysis: Slight antalgic gait noted.

Differential Diagnosis:

1. Stress Fracture of the Medial Malleolus
2. Tarsal Tunnel Syndrome from a Ganglion Cyst
3. Morton’s Neuroma
4. Posterior Tibial Tendon Dysfunction (PTTD)
5. Plantar Fasciitis

Test Results: Ultrasound: Reveals a 1.5 cm round, well-circumscribed, hypo-echoic fluid filled structure anterior to the medial malleolus. MRI: Confirms the presence of a ganglion cyst compressing the tibial nerve as it enters the tarsal tunnel. No evidence of other structural abnormalities.

Final Diagnosis: Tarsal Tunnel Syndrome from a Ganglion Cyst.

Discussion: Ganglion cysts near the tarsal tunnel can compress the tibial nerve, leading to tarsal tunnel syndrome characterized by pain, paresthesia, and even motor dysfunction. This cyst developed from the motorcycle peg blow to back of the ankle. The timeline is fitting as symptoms developed over weeks as the cyst developed. Initial management can include rest, physical therapy, ice and aspiration. Aspiration can provide relief by decompressing the nerve and reducing inflammation however cysts can reoccur if not surgically excised. Use of a corticosteroid injection may reduce inflammation and inhibit cyst regrowth, potentially leading to longer-lasting symptom relief, as observed in this case.

Outcome: After the second aspiration, which included a corticosteroid injection, the patient experienced significant improvement, with complete resolution of symptoms and no recurrence of the cyst over an 8-month follow-up period. The injection likely addressed both the mechanical compression and the inflammatory response contributing to his symptoms.

Follow-Up: Following resolution of symptoms, the patient gradually returned to his training regimen. Low-impact activities were introduced first, followed by a phased reintroduction of long-distance running and other high-impact exercises. Physical therapy improved ankle strength, stability, and nerve mobility. Follow-ups at 2 weeks, 3 and 6 months to monitor for recurrence of the cyst or new symptoms.

Not All Cheerleaders Read the Textbook: An Uncommon Injury With a Common Presentation

Caroline Fryar, MD

All Other Authors: Michael Stewart II, MD and Michele Kirk, MD

Affiliation: JPS Health Network.

History: A 16-year-old female varsity cheerleader without significant PMH developed acute worsening of low back pain after underrotating a full twist during a Friday night football game. On the sideline, she reported cheering for 2 additional competitive teams, and that pain had been present for 4 weeks, starting after a game that required her to hold the megaphone above her head during multiple kickoffs. Pain had been gradually increasing, especially with tumbling and stunting, with a sudden increase after landing with a hyperflexed posture that night. She was unable to continue cheering during the game due to pain and muscle spasm. Denied numbness, weakness, or saddle anesthesia. She presented to injury clinic Saturday morning for imaging and reported some improvement in pain overnight with OTC NSAIDs and Tylenol.

Physical Exam: Sideline exam Friday night revealed paraspinal muscle spasm, with no neurologic defects. Repeat exam Saturday morning as follows: No bruising or swelling, significant tenderness to palpation over upper lumbar spinous processes above the level of the iliac crest. Sensation intact to light touch and full 5/5 strength in bilateral lower extremity distributions. 2+ lower extremity reflexes with downgoing Babinski. Normal range of motion with lateral bending and rotation, increased pain with forward flexion and extension. No pain with facet loading. Positive stork test bilaterally.

Differential Diagnosis:

1. Lumbar spondylolysis
2. Lumbar spondylolisthesis
3. Myofascial low back pain
4. Spinous process avulsion fracture
5. Baastrup’s disease

Test Results: AP and lateral XR showed no acute fracture or listhesis. Lateral view concerning for bilateral pars defect at L4 and L5 MRI showed robust edema between the spinous processes at L2-L3 with partial interruption of the supraspinous ligament, cortical interruption to the inferior margin of the L2 spinous process and increased signal between L1–2, L3–4 and L4–5 spinous processes. No abnormal signal in the pedicles suggesting an underlying stress reaction/fracture. No disc desiccation or herniation.

Final Diagnosis: Impaction fracture of the inferior margin of L2 spinous process with posterior supraspinous ligament tear.

Discussion: Despite having many of the risk factors for spondylolysis, including high training volume in an extension-based sport, our patient ultimately did not have a pars injury. The supraspinous ligament limits lumbar flexion and is one of the first structures to fail during hyperflexion, likely causing her acute pain increase. While irritation of the spinous processes and interspinal ligaments are seen during extension in Baastrup’s disease, there are very few reports of impaction fractures of the lumbar spinous processes, even in osteoporotic patients. While common injuries are common, it is important to consider both the mechanism of injury and other structures that may be loaded causing injury.

Outcome: X-rays with flexion/extension views were repeated at 2 weeks and physical therapy started once stability was confirmed. Lumbar bracing was used as a proprioceptive reminder during the early stages of rehabilitation and return to practice. Injection to the supraspinous ligaments was considered, but given age and clinical limitations, it was ultimately deferred during the acute phase of the injury.

Follow-Up: Two weeks post-injury, she was cleared for cheers and chants only with strict relative pain guidelines. Initial physical therapy focused on shoulder and hip range of motion to promote extension throughout the kinetic chain and not just the lumbar spine. She will return to stunts as a base after 6–8 weeks of PT, and low impact tumbling with focus on power generation to prevent under-rotation.

Be-Sleeve It or Not

Jeffrey Balkenbush, MD

All Other Authors: James Barrett, MD and Taryn Kedzior, BS

Affiliation: University of Oklahoma Health Science Center.

History: Patient is a 10-year-old male with no known medical history, who presented for left knee pain. He was playing baseball when he slid into 3rd base with his left leg straight and felt a pop in the anterior aspect of his knee. He had 7/10 pain immediately after the injury with a limited and painful gait. He initially used ibuprofen and ice, with significant relief, and was able to ambulate without pain one week later. He returned to baseball practice after one week but noted pain was reproduced with running over his anterior knee. He was instructed to rest for the next 4–6 weeks then return. On follow-up, the pain resolved, and he was cleared to return to sports as tolerated. Initially, he tolerated his return to athletics, but then had an episode of a pop with repeat anterior knee pain and swelling after jumping off his left leg during basketball practice.

Physical Exam: General: NAD, well-developed Musculoskeletal: Left Knee: Normal appearance, small effusion. Tenderness to palpation overlying patellar tendon and patella with some crepitus with passive range of motion. ROM: Flexion 140 deg, Extension 0 deg. Positive patellar apprehension. Negative valgus and varus stress testing. Negative Lachman and Posterior Drawer. Negative McMurray.

Differential Diagnosis:

1. Patellar sleeve avulsion fracture
2. Patellar Tendon Tear
3. Patellar Tendonitis
4. Quadriceps Tendon Tear
5. Patellar Subluxation

Test Results: Initial X-ray: Left Knee AP, Lateral, Sunrise: Normal growth plates open. No obvious deformities, fractures, avulsions, dislocations, or other bony abnormalities. MRI Left Knee w/o contrast: Acute on chronic patella inferior pole periosteal sleeve avulsion injury.

Final Diagnosis: Patella inferior pole periosteal sleeve avulsion.

Discussion: Patellar sleeve fractures are rare injuries in children that normally occur between the ages of 8 and 12 when patellar ossification is nearly complete. The mechanism is usually an indirect injury from a powerful contraction of the quadriceps muscle applied on a flexed knee, most commonly during jumping, which is what occurred in this patient. MRI is indicated for when diagnosis is not clear from clinical or radiographic findings, which is what eventually led to diagnosis and proper management. This is an interesting example of a patellar sleeve avulsion not seen on basic imaging, requiring MRI for diagnosis after reinjury when returning to sport.

Outcome: Patient was immobilized for 4 weeks in full extension, then completed 4 weeks of formal physical therapy which he tolerated well without pain or re-injury.

Follow-Up: Patient returned to sport after completing physical therapy and slowly increasing activity as tolerated.

No Pain, No Gain: Clavicular Injury in Pediatric Hockey Athlete

Connor Fultz, MD

All Other Authors: Hamza Raja, MD and Jeffrey Fleming, DO

Affiliation: University of Pittsburgh Medical Center.

History: Patient is a 12-year-old male hockey player who presented with his mother to outpatient Sports Medicine clinic with left-sided clavicle injury 1 week prior to presentation. Patient reports he was attempting a shot when he was struck by an outstretched elbow of an opponent directly onto the left clavicle. He immediately fell with brief episode of loss of consciousness, followed by pain and focal swelling in his clavicular region. He later had 2 subsequent syncopal episodes that day. Since injury, he has been immobilizing his left arm with a sling. He noted improved range of motion (ROM) and pain as well as a reduction in swelling. He denies any chest pain, dysphagia, shortness of breath, numbness/tingling, swelling or vascular changes of extremities, headache, dizziness, or subsequent syncopal episodes. His current symptoms consisted only of focal pain in the medial clavicle region.

Physical Exam: General: No acute distress; Resting comfortably. Psych: Pleasant and cooperative. Cardiac: Normal peripheral perfusion. No cyanosis. No vascular distension. Lungs: Non-labored respirations. Neuro: Sensation intact to light touch. Manual muscle testing with 5/5 strength throughout bilateral upper extremities. MSK: Inspection notable for mild swelling and ecchymosis to medial clavicle overlying sternoclavicular joint. There is focal tenderness to palpation in this region, but non-tender across mid and distal clavicle. No palpable step-off. Full passive ROM of left shoulder without elicitation of pain.

Differential Diagnosis:

1. Medial Clavicle Physeal Fracture
2. Anterior Sternoclavicular Joint Dislocation
3. Posterior Sternoclavicular Joint Dislocation
4. Bony Contusion
5. Sternal Fracture

Test Results: X-ray of left shoulder, clavicle, and chest negative for acute fracture. MRI of left shoulder demonstrated left posterior sternoclavicular (SC) joint dislocation, medial clavicle avulsion fracture, and compression of left brachiocephalic vein. CT chest re-demonstrated posterior SC joint dislocation, but non-diagnostic evaluation of venous structures. Repeated imaging with arms repositioned above head showed severe narrowing of left brachiocephalic vein due to posteriorly displaced clavicle.

Final Diagnosis: Traumatic left, posterior sternoclavicular joint dislocation due to displaced medial clavicle avulsion fracture with resultant severe brachiocephalic vein compression and narrowing.

Discussion: Posterior sternoclavicular (SC) dislocations are rare but dangerous traumatic injuries due to adjacent mediastinal structures. Hemodynamic compromise prompts emergent reduction; however, patients can appear stable with minor symptoms despite significant injury. In this case, initial CT imaging was non-diagnostic for vascular compression, but repositioning with arms overhead demonstrated severe vascular narrowing via posterior clavicular displacement. This case highlights the importance of a thorough clinical assessment and a high index of suspicion for SC dislocations with traumatic clavicular injuries, as well as the utility of patient arm repositioning for optimization of CT imaging.

Outcome: Following MRI, patient was referred to Pediatric Orthopedic Surgery for surgical evaluation. Given the dangerous location of posteriorly dislocated clavicle adjacent to mediastinal structures with compression of brachiocephalic vein, surgical intervention was recommended. Patient then successfully underwent open reduction of left sternoclavicular joint with reconstruction using allograft tendon.

Follow-Up: Patient was discharged home 1-day following operation, and placed in a shoulder abduction brace at all times with non-weight-bearing restrictions of the left upper extremity. There were no complications noted at 2-weeks post-operative follow-up. Anticipated plan for discontinuation of bracing and initiation of physical therapy at 4-weeks post-operatively.

Poppin Off: An Uncommon Case of Knee Pain

Cati Kral, DO

All Other Authors: Brian Harvey, DO

Affiliation: Children’s Mercy Hospital, Kansas City, MO.

History: Seventeen-year-old male was evaluated in clinic for left lateral knee pain. He initially hurt his knee 3 days prior during a football game when he planted his left leg to cut and change direction. He was not able to continue playing. He developed mild swelling to his knee that night that had started to resolve by the time he showed up in clinic. He did not endorse any popping, clicking, catching, locking, or numbness or tingling. He reported the most pain associated with flexion and extension of his knee.

Physical Exam: He had minimal effusion and swelling over the lateral knee down into the proximal fibular head. Tenderness to palpation of the biceps femoris insertion on the fibular head posteriorly and at the lateral joint line. He had full active and passive range of motion testing of his knee, but pain was elicited at the end of full range flexion. He had normal strength with flexion and extension testing of the left knee and dorsiflexion of his ankle. The rest of the examination found negative McMurray, negative valgus/varus testing, and Lachman with a good endpoint. He had a normal walking pattern without antalgic gait. Hopping/jumping did induce subtle pain to the lateral aspect of his knee.

Differential Diagnosis:

1. Biceps femoris strain
2. Occult fracture of proximal fibular head
3. Posterior lateral corner injury
4. Lateral meniscal injury
5. LCL Injury

Test Results: MRI was obtained which demonstrated avulsion of the biceps femoris with clear tearing of the posterior lateral corner, including the popliteal fibular ligament from the fibular side. Given that both the lateral hamstring and the PLC were involved, surgical intervention was recommended by Ortho. Intra-operatively, it was noted that the biceps tendon was completely avulsed. Operative management included left distal bicep tendon repair as well as the avulsed posterior lateral corner structures.

Final Diagnosis: Bicep femoris avulsion from fibular head with subsequent posterior lateral corner instability.

Discussion: The posterior lateral corner (PLC) is a highly complex blend of soft tissue structures to the lateral aspect of the knee. Clinically, posterior lateral corner injuries are caused by a wide variety of scenarios involving hyperextension, varus force, or hyperextension and external rotation combination. Patients typically describe instability or giving way which can be exacerbated with weightbearing and extension. PLC injuries cause increased external rotation laxity of the knee. Distal avulsion insertional injuries are quite rare and account for about 2% of all hamstring injuries. Avulsion injuries of the biceps femoris have been reported to involve the PLC in the limited existing studies.

Outcome: Following surgery, he was placed in a knee Ranger and locked at 30 degrees. At his 2-week follow-up appointment he had improvement in his range of motion and was able to activate his biceps femoris. By 6-weeks he progressed to full weight bearing in his knee Ranger and significantly improved ROM. By 18 weeks he was back to playing basketball without any pain, instability, or swelling.

Follow-Up: He started physical therapy one week after surgery. At that time, he was partial weight bearing in a long-leg hinged knee brace locked at 30° flexion. He completed 12 weeks of formal physical therapy; at which time he had met all goals and had demonstrated return to prior level of function. By the 18-weeks post-op visit, he was able to return to his prior level of competition and play.

Unusual Complication of Elbow Dislocation in Collegiate Football Player

Marissa Meyer, DO

All Other Authors: Sean Thuesen, DO, Christopher John, MD, and Briana Beach, DO

Affiliation: Carilion Family Medicine, Roanoke, Virginia.

History: Eighteen-year-old male collegiate football player with no significant past medical history presenting to injury clinic 5 days after injury of his right elbow. He reports going for a pass during practice when he fell on his outstretched hand causing hyperextension and hearing a pop. Collateral information from his athletic trainer confirms dislocation of the elbow with need for mechanical reduction. Since the injury, he had been wearing a splint with a sling and experiencing a moderate level of pain worsened by movement.

Physical Exam: At time of initial evaluation, moderate posterior and medial swelling was noted with intact overlying skin. ROM: 20°–100° flexion/extension, 30° supination, 45° pronation. Pain with valgus stress. Neurovascularly intact.

Differential Diagnosis:

1. Olecranon bursitis
2. Olecranon stress fracture
3. Elbow plica
4. Posterolateral rotatory instability
5. Terrible triad of elbow

Test Results: Right Elbow XR Impression: (1) Avulsion fracture fragments posterior to humerus on lateral view MRI Impression: (1) Bony avulsion of the triceps accounting for the fracture fragments seen on preceding radiographs. (2) Moderate to high-grade ulnar collateral ligament tear involving the distal attachments to the sublime tubercle of the ulna.

Final Diagnosis: Transient elbow dislocation with complete triceps tendon tear and associated bony avulsion and partial tear of ulnar collateral ligament.

Discussion: Triceps tendon rupture remains a rare injury but what makes this specific case so unique is the unusual nature of elbow dislocation and triceps tendon rupture together. It could be conceived that the athlete had a FOOSH event causing forceful eccentric contraction of the triceps with subsequent instability and dislocation. To note, the Terrible Triad is a well-documented phenomenon of elbow dislocation with radial head/neck fracture and coronoid fracture. However, there have only been a handful of documented cases that report triceps tendon rupture as a complication of elbow dislocation.

Outcome: Due to the complete rupture of the triceps tendon, it was recommended that the patient undergo immediate primary repair. Intra-operative findings included retracted triceps tear with 1 × 1 cm bony fragment. Overall, he tolerated the procedure well.

Follow-Up: At subsequent post-operative follow-up visits, the patient reported minimal pain with well healing surgical incision and incremental improvement in range of motion. He will continue physician-directed rehab progression with his athletic trainers with anticipation of a full recovery approximately 6 months post-op.

A Fellow’s Role in Multiteam Coordination for Severe Brain Injury Management in Football

Chris Grijalba, DO

All Other Authors: Mark Carrasco, MD, Steven Brown, MD, Ian McKeag, MD, and Irfan Asif, MD

Affiliation: University of Alabama at Birmingham.

History: A 19-year-old male collegiate football player with no significant PMH sustained a head-to-head collision during an onside kick and was evaluated on the field by medical staff for a potential concussion. Initially, he was alert, responsive, and able to walk to the sidelines unassisted. Shortly after, he became altered, unresponsive, and began seizing. He was assisted to the ground, and his uniform, pads, and helmet were removed. On a subsequent play, a second injury occurred on the field, prompting the medical team to assist with a suspected cervical spine injury with bilateral upper extremity paresthesia. EMS promptly transported the patient to the ED in less than 10 minutes. En route, the patient was administered intramuscular benzodiazepines which did not improve his condition. On arrival, he was intubated for airway protection, and neurosurgery was consulted for further evaluation.

Physical Exam: Physical Exam on the Sidelines: General: Unresponsive Eye: Bilateral pupils blown/dilated, unreactive. Mouth: Mucous secretions noted. Respiratory: Labored breathing. Back: No step-off palpated. Musculoskeletal: No visible deformities noted. Neurologic: Extensor posturing. Glasgow coma scale: Total Score: 3/15. Eyes Open: 1/4: No Response. Verbal: 1/5: None Motor: 1/6: No Response.

Differential Diagnosis:

1. Seizure 2/2 traumatic brain injury
2. Seizure 2/2 intracranial hemorrhage
3. Seizure 2/2 possible epilepsy history
4. Seizure 2/2 concussion
5. Seizure 2/2 electrolyte imbalances

Test Results: CT Head WO: Acute b/l cerebral convexity subdural hematomas, 5.5 mm on the L and 3.7 mm on the R extending along the falx and b/l tentorium. Scattered subarachnoid hemorrhage, mostly along the prepontine and anterior perimedullary cisterns, frontotemporal sulci and sylvian fissures. Superimposed acute retroclival hematoma, measuring 5.4 mm. Diffuse loss of the white-gray matter differentiation with bihemispheric white matter hypoattenuation.

Final Diagnosis: Sports-related structural brain injury 2/2 multicompartment intracranial hemorrhages, cerebral edema, and acute hypoxic ischemic injury.

Discussion: Despite advances in football equipment, intracranial hemorrhages remain a serious concern. Acute SDH were linked to 429 of 497 football-related brain injury fatalities from 1945–1990. Subarachnoid hemorrhage carries a 43% mortality rate and often leads to disability. Recognizing decorticate posturing is critical, as rapid decompression can preserve brain tissue. Concurrent on-field injuries underscore the importance of cohesive triaging, communication, and proactive protocols. Coordinating across 3 medical teams, with the inclusion of sports medicine fellows, enhances preparedness, ensures seamless recognition, and supports timely management during complex, high-stakes events.

Outcome: The athlete was admitted to the ICU, where he remains on ventilatory support and monitored with continuous EEG. Neurosurgery initially placed an external ventricular drain but later performed a right decompressive hemicraniectomy due to difficulty in controlling intracranial pressures. He continues to be medically paralyzed and sedated.

Follow-Up: Forty-nine percent of athletes with catastrophic brain injuries have lasting deficits and do not return to football. RTP following burr holes is typically at 6 months, while post-craniotomy guidelines are more conservative, with 40% advising low-contact sports. RTP decisions require a cautious, multidisciplinary approach involving neurologists, sports medicine, and rehabilitation specialists.

Tackling Trauma: Recurrent Shoulder Injuries in a Football Athlete

Kieran Richards, BS

All Other Authors: Justin Chu, MD and Neel Patel, BS

Affiliation: University of Louisville, Louisville, KY.

History: A 17-year-old male football player presents to the Sports Medicine Urgent Care Clinic with chronic left shoulder pain. The athlete says he first injured the shoulder 6 months prior while blocking a player; he felt a popping sensation. He shook his arm out and felt better, so he continued playing the rest of the game. About 5 months later, he felt another painful sensation while reaching out with his shoulder to get a ball during gym class. Most recently, he reinjured himself playing catch and fell on his shoulder, now experiencing global shoulder pain as well as pain deep within his shoulder. He feels as if his shoulder is unstable and going to pop out. Denies any numbness or tingling in his arms or hands. He has applied diclofenac, which helps relieve the pain. The patient is anxious to return to sport to gain the favor of college recruits for athletic offers.

Physical Exam: Ht 5 ft 9.5 in (1.765 m); Wt 182 lb (82.6 kg); BMI 26.49; BSA 2.01 Normal head, eye, neurologic, peripheral pulse, and skin findings. Musculoskeletal exam findings reveal left shoulder grade 2 laxity with posterior load on posterior shoulder Lachman, but without pain. This is equal to the right shoulder posterior grade 2 laxity without pain. The left shoulder is also negative for anterior/inferior instability and apprehension/relocation. No winging or scapular dyskinesis. Full range of motion. Positive Hawkins, Impingement, Bear Hug, O’Brien’s, Apprehension tests. Crank test notable for instability, but no catching.

Differential Diagnosis:

1. Injury of glenoid labrum of shoulder
2. Shoulder Pain
3. Rotator Cuff Tear
4. Biceps Tendonitis
5. Shoulder Subluxation

Test Results: XR shoulder 2+ views left Narrative: Normal alignment. No obvious fracture, dislocation, or acute bony injury. MR shoulder arthrogram left Narrative: Findings most consistent with anterior labral ligamentous periosteal sleeve avulsion (ALPSA) involving the anterior inferior labrum with extension onto the anterior labrum with the overall labral tear extending from the 12:00 to 6:00 positions. No osseous Bankart or Hill-Sachs deformity was identified. The rotator cuff is intact.

Final Diagnosis: Anterior Labral Ligamentous Periosteal Sleeve Avulsion (ALPSA).

Discussion: The primary objective of this case is to outline the appropriate diagnostic workup and management for athletes who present with ALPSA-like symptoms. In this situation, the patient experienced repeated trauma to the left shoulder and displayed recurrent anterior shoulder instability. The secondary objective is to use a multi-disciplinary team approach to discuss the return to sport process for athletes following ALPSA (Anterior Labroligamentous Periosteal Sleeve Avulsion). Even though this is not a common diagnosis amongst athletes, it is important to understand the possible symptoms of presentation and the early rehabilitation process.

Outcome: After discussing his diagnosis with the patient and his mother, he plans to participate in the fall football season rather than rest and seek treatment.

Follow-Up: Although athlete faces difficult decision of continuing play rather than rest, he is agreeable to participate in football with a Sully brace to minimize worsening his labral tear. The current plan has been relayed to his athletic trainer, and has been referred to physical therapy. He plans to follow up if he decides to proceed with surgery or experiences another shoulder instability event.