Disclosure Medical Problems in the I have no financial disclosures - PowerPoint PPT Presentation

Disclosure Medical Problems in the I have no financial disclosures or conflicts of interest in relation Young Athlete to this presentation Cases from My Clinic Ossur Americas: I presented an independent lecture on knee osteoarthritis Cindy J. Chang, M.D. UCSF Clinical Professor Primary Care Sports Medicine Depts. of Orthopaedics and Family & Community Medicine Cindy J. Chang, M.D. 2 Case #1: P QRS T : P rovocation and T iming  17 yo female w/ intermittent R shoulder pain since 2016. She  As an athlete: was in cheer in high school but denies any injury from this. She denies any known injury. Works as server at restaurant. Her When did injury occur? - pain is posterior in upper shoulder and when she has pain she What activities cause/increase the symptoms? - will also have numbness radiating down her right medial arm. Denies weakness.  As a student/worker:  5/10 Pain Scale When did symptoms start? -  Aching and sharp, and constant What maneuvers/positions cause/increase the symptoms? -  Night pain that wakes patient up: yes  Previous treatments include: nothing  Has not tried anything that makes the pain better; has not noted anything that makes the pain worse 4 3 Medical Problems in the Young Athlete: Cases from My Clinic – Cindy J. Chang MD Cindy J. Chang, M.D. 1

P QR ST: Q uality and R adiation Cindy J. 5 Chang, M.D. 6 Cindy J. Chang, M.D. Case #1  C-spine FROM, no pain, neg Spurlings  No erythema, ecchymoses or deformity noted of shoulder Areas of girdle Compression:  No mm atrophy - Costoclavicular  R shoulder FROM w/o pain. Motor 5/5 w/o pain. Sensory intact. triangle  No pain to palpation along the clavicle, scapula - Interscalene triangle  Tenderness to palpation over supraclavicular space/first rib, just lateral to R side of C7, coracoid-clavicular interval - Subcoracoid space  Positive Adson's test bilaterally  Positive Roos test duplicating ulnar nerve pain 7 8 Cindy J. Chang, M.D. Cindy J. Chang, M.D. 2

Classification of Thoracic Outlet Syndrome Vascular TOS 1. By Affected structure :  Rare; involves subclavian artery and/or vein a. Neurogenic or vascular (arterial or venous) or a combination More likely to occur in younger patients; vigorous overhead arm activity - 2. By Cause of compression: Venous obstruction - a. Scalene  Can be secondary to thrombosis, Paget-von Schrötter syndrome b. Cervical rib  Diffuse arm, forearm, or hand pain (“tourniquet”); UE swelling; venous distention 3. By Event: Arterial obstruction - a. Trauma  color changes; claudication; diffuse arm, forearm, or hand pain  Due to arterial collateral blood flow, initial symptoms may be mild (arm ache and b. Repetitive stress fatigue, esp. after overhead activity) c. Posture Twaij H et al. BJSM 2013 9 10 Cindy J. Chang, M.D. Cindy J. Chang, M.D. Nonspecific-type or Functional/Dynamic TOS Neurogenic TOS  Pain in the arm or both arms, scapular region, and cervical region  Compression of brachial plexus; pure neurogenic presentation also rare  Dynamic transient mechanical restriction Also tends to affect those who perform overhead and repetitive -  What event caused/causes/worsens the activities symptoms? Traumatic event (eg, MVA, fall) - Can present with - Computer work -  painless atrophy of intrinsic muscles of hand Mobile device -  difficulty grasping a racket or ball due to weakness  report of sensory loss or paresthesias Pain usually mild - 11 12 Cindy J. Chang, M.D. Cindy J. Chang, M.D. 3

Special TOS Tests Nonspecific TOS Signs and Tests  Adson’s maneuver - Neck extended and rotated to Affected  Weakness and decreased sensation, tingling, heaviness, fatigue, side w/ Arm at side while deeply inspiring and holding the achiness, coolness breath, pulse checked  Non-focal and non-radicular findings  Wright’s test – ( airplane ) Affected arm slowly abducted and externally rotated, pulse checked, while taking a deep breath  Diffuse UE pain w/ or w/o guarding  Roos stress test – ( Raise the Roof ) Shoulder abducted  Poor posture above the head, externally rotated and repetitive opening and closing both hands into fists for at least 1 minute  Tenderness over coracoid, pectoralis mm, scalenes; tightness of mm Tests considered + if reproduce symptoms and/or a decrease in pulse detected, or paresthesias, or can’t complete Roos  Fullness in supraclavicular space from elevated rib Nord KM et al. Electromyog Clin Neurophys 2008 13 14 Cindy J. Chang, M.D. Cindy J. Chang, M.D. Special TOS Signs and Tests TOS Diagnostic Testing  Plain XR films: cervical rib, callus from a clavicle/upper rib fx, apical tumor  Venous US studies, Doppler US, angiogram, venogram, CT/CTA, NCS/EMG, NeuroMSK US  MRI/MRA: brachial plexus anatomy, subclavian vein anatomy, vascular occlusion/compression Positional scans with arm in dynamic position - to reproduce sx can improve validity of tests MRI alone: 41% sensitivity, 33% specificity -  Neg predictive value 4% Lewis M et al. J Vasc Diag 2014 Singh VK et al. J Ortho Surg 2014 15 16 Cindy J. Chang, M.D. Cindy J. Chang, M.D. 4

Case #1 Case #1  6 wk follow-up: - Pain is worse and now has coldness in the R arm down ulnar side of arm to ring and pinky fingers, still numbness. Denies swelling or blue tint in arm. - PT helping with decreased pain during walking - Also quit job to focus on school 17 18 Cindy J. Chang, M.D. Cindy J. Chang, M.D. Case #2  15 yo female, referred to see me for second opinion by peds ortho colleague  8 months prior first experienced left iliac crest pain during dance class Can’t recall injury, was just standing when first had pain -  Then during summer intensive dance class (12 hrs a week, 3-5 hr max a day, for 4 wks) much worse, and right ant superior iliac crest began hurting as well. Had to quit dance. No relief with ice, stretching, NSAIDs - 19 20 Cindy J. Chang, M.D. Cindy J. Chang, M.D. 5

Case #2 Case #2  Hx fractured foot, stress fx foot left MT, and achilles tendonitis left ankle. Also shin splints bilat with dance. Injuries since 11 - yoa  Mom says has had slow healing esp the achilles injury 21 22 Cindy J. Chang, M.D. Cindy J. Chang, M.D. Case #2 Case #2  Vit D 22.2; 2000 IU BID started  Was on crutches partial weightbearing x 3 wks, then wheelchair to totally unload x 4 wks, then back to crutches  Started using bone stimulator  I reviewed her chart 23 24 Cindy J. Chang, M.D. Cindy J. Chang, M.D. 6

Case #2 Case #2  Summary of findings:  Summary of findings (cont.):  12/15/11: had left 5th MT base fracture, treated with cast.  6/19/12-10/11/13: began to see Dr. S. No notes accessible in  2/22/12: saw Dr. P for left achilles pain that developed since Epic. cast off.  8/23/12 MRI of left foot- Stress injury and/or nondisplaced  4/4/12: f/u visit and per PT rec had been in walking boot fracture of the proximal right 2nd metatarsal bone already x 3 wk.  11/29/12 - MRI left foot for lat foot pain - Resolving edema in  5/3/12: no real improvement, so MRI ordered. the metatarsal bone of the 2nd toe.  5/18/12 MRI of left ankle- Mild swelling as well as some fluid Interval development of marrow edema in the lateral calcaneus - around a portion of the flexor hallucis longus tendon. Achilles adjacent to the calcaneal cuboid articulation. Minimal adjacent soft tendon is normal. tissue edema. May be post traumatic in etiology. Alternatively, this appearance may be on the basis of altered weight bearing  5/24/12: completely immobilized in walking cast x 4 wks. mechanics. 25 26 Cindy J. Chang, M.D. Cindy J. Chang, M.D. Case #2 Case #2  Summary of findings (cont.):  Summary of findings (cont.):  7/1/14 visit with Dr. S: has had acupuncture, and has drawn labs. "Her pain bothers her with impact from running and jumping.  5/20/14: visit with Dr. S; still in formal PT once a month, still She has had an extensive work-up that is negative for any specific unable to do gymnastics, hurts with running. Dr. D second pathology. She has also seen another orthopaedic surgeon for opinion, no good solns. MRI ordered. second opinion and no cause for her foot pain was found. MRI is  6/19/14 - MRI left foot - Minimal ankle joint effusion with negative for pathology in the area of her symptoms. I have done an minimal synovial thickening, nonspecific finding. Otherwise extensive work-up and do not have a explanation for her pain." normal MRI of the foot.  10/8/14: visit with dr. K, for follow up of left leg and foot pain. Note never able to return to gymnastics. Now left leg pain x 4 months, now in dance.  xrays neg and back in PT for this until 10/9/15.  10/9/15: first mention of iliac crest pain to PT. She was to have been discharged for her shins. 27 28 Cindy J. Chang, M.D. Cindy J. Chang, M.D. 7