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“Doc,I can’t walk now!” Rick Horak, MD Primary Care Sports Medicine Fellow ASMI SEACSM 11 Feb 2012 Initial Clinic Visit: 27 OCT 2011 • 16 yo football player who suffered a direct blow to his right thigh one week prior to presentation – Injury date: 19 OCT 2011 • Mild pain with motion and knee bending • Swelling and pain localized to mid lateral thigh • Nocturnal pain the worst and interfering with sleep • Home treatment consisted of RICE and Aleve PRN Medical History • PMHx: Negative, especially for any bleeding or clotting disorders • Medications: Periactin PRN • Allergies: None • FHx: Negative • SHx: No tobacco or ETOH Physical Exam • General: WD WN 16 yo male • MMSE: Alert and Oriented x 4 • Vitals: 6 feet, 175 pounds Musculoskeletal Exam • CV: No peripheral edema, pulses +2 • Skin: Intact with no scars, bruising or abrasions • Inspection: Normal alignment, moderate swelling lateral thigh • Palpation: – Musculature in the right lateral thigh (approx 5-8 cm above lateral joint line) tender to palpation. – Deep palpation over vastus lateralis is painful Musculoskeletal Exam Continued • Range of Motion: – Full internal/external rotation with hip at 90 degrees flexion – No flexure contracture – Normal hip flexion/extension – Decreased knee flexion: approximately 90 degress • Elicited moderate/severe pain past that point Musculoskeletal Exam Continued • Strength/Tone: – No appreciable atrophy – Hip flexion strength 4/5 – Knee flexion 4/5 – Knee Extension 4-/5 • Gait: Antalgic without assistance • Neurological: Intact to light touch throughout Questions Differential Diagnosis • Trauma Causes: – – – – Hip/femur fracture Tendinitis/ITB sydrome Trauma, hematoma Muscle Strain • Infectious Disorders: – Herpes Zoster – Hip/femur Osteomyelitis – Cellulitis • Neoplastic Disorders – Metastatic Bone Disease – Osteogenic Sarcoma Differential Diagnosis Continued • Congenital, Developmental Disorders – Hip osteochondrosis – Capital Epiphysitis • Anatomic, Structural Disorders – Lumbar Herniated Disk Syndrome – Hamstring tightness – Slipped Capital Epiphysitis – Meralgia Paresthetica IMAGING Imaging Initial Working Diagnosis • Deep right thigh bruise INITIAL TREATMENT PLAN: • Indomethacin 75mg BID • Physical Therapy – Specific orders: No heat, No Ultrasound • Continue RICE • No football or contact sports • RTP when range of motion and strength of RLE is equal to the unaffected side Second Clinic Visit: 1 NOV 2011 • Five days after initial visit • According to patient, had been making progress with PT • However, the night before patient experienced acute onset severe pain in right thigh – Had been to PT that afternoon but no new exercises – Was given iontophoresis patch which was removed by family at the onset of the pain – Family noted increased swelling in the right thigh • Went to local ER and informed nothing broken • Unable to straighten his right leg all night – Kept right leg in a flexed position • Carried into clinic and had to be helped out of car Musculoskeletal Exam • Inspection: – Marked swelling over the lateral aspect of the right thigh near the vastus lateralis • Palpation: – Very tense over the swollen area and exquisitely tender to touch – Palpation of the vastus lateralis insertion very difficult • Range of Motion: – Limited hip flexion – Knee extension/flexion Musculoskeletal Exam Continued • Strength and Tone: – No atrophy – Limited knee extension against resistance • Gait: – Limited weight bearing secondary to pain • Neurological: – Sensation intact throughout Questions Differential Diagnosis • Hematoma • Tendon Rupture • Myositis Ossificans Treatment Plan • Continue using crutches provided by the ER • Obtain MRI of the right thigh MRI: T1 Axial MRI: T1 Sagittal MRI: T2 Axial MRI: T2 Coronal MRI: T2 Sagittal MRI Report • Large Intramuscular Hematoma • Occupies predominately the vastus intermedius and to a lesser degree the vastus lateralis muscle • Hematoma measures 9.8 X 5.6 cm • Heterogenous signal consistent with acute to subacute blood product • Quadriceps tendon intact, no fracture Third Clinic Visit: 16 NOV 2011 • Stated after three days he was back to normal • Had been wrestling without release • Had been released from Physical Therapy Musculoskeletal Exam • Inspection: – Normal alignment and symmetry – No swelling • Palpation – Previous tense area resolved – Non tender throughout the lower extremity • Range of Motion – Full Internal/External rotation – Full hip flexion/extension and full knee flexion/extension • Strength/Tone – 5/5 motor strength in all muscle groups Final Plan • Release to all sports without restrictions