Unilateral Hypoglossal Nerve Injury in a Collegiate Wrestler: A Case Report

Objective:

To introduce the case of a collegiate wrestler who suffered a traumatic unilateral hypoglossal nerve injury. This case presents the opportunity to discuss the diagnosis and treatment of a 20-year-old man with an injury to his right hypoglossal nerve.

Background:

Injuries to the hypoglossal nerve (cranial nerve XII) are rare. Most reported cases are the result of malignancy, with traumatic causes less common. In this case, a collegiate wrestler struck his head on the wrestling mat during practice. No loss of consciousness occurred. The wrestler initially demonstrated signs and symptoms of a mild concussion, with dizziness and a headache. These concussion symptoms cleared quickly, but the athlete complained of difficulty swallowing (dysphagia) and demonstrated slurred speech (dysarthria). Also, his tongue deviated toward the right. No other neurologic deficits were observed.

Differential Diagnosis:

Occipital-cervical junction fracture, syringomyelia, malignancy, iatrogenic causes, cranial nerve injury.

Treatment:

After initial injury recognition, the athletic trainer placed the patient in a cervical collar and transported him to the emergency department. The patient received prednisone, and the emergency medicine physician ordered cervical spine plain radiographs, brain computed tomography, and brain and internal auditory canal magnetic resonance imaging. The physician consulted a neurologist, who managed the patient conservatively, with rest and no contact activity. The neurologist allowed the patient to participate in wrestling 7 months after injury.

Uniqueness:

To our knowledge, no other reports of unilateral hypoglossal nerve injury from relatively low-energy trauma (including athletics) exist.

Conclusions:

Hypoglossal nerve injury should be considered in individuals with head injury who experience dysphagia and dysarthria. Athletes with head injuries require cranial nerve assessments.     

Recalcitrant Infrapatellar Tendinitis and Surgical Outcome in a Collegiate Basketball Player: A Case Report

OBJECTIVE: To present the history, surgery, rehabilitation management, and eventual functional and surgical outcomes of a collegiate basketball player with recalcitrant jumper's knee. BACKGROUND: A 21-year-old, male collegiate basketball player had a 2-year history of anterior knee pain. DIFFERENTIAL DIAGNOSIS: Injuries that often mimic symptoms of infrapatellar tendinitis include infrapatellar fat pad irritation, Hoffa fat pad disease, patellofemoral joint dysfunction, mucoid degeneration of the infrapatellar tendon, and, in preadolescents and adolescents, Sinding-Larsen-Johannsson disease. TREATMENT: After conservative treatment failed to improve his symptoms, the athlete underwent surgical excision of infrapatellar fibrous scar tissue and repair of the infrapatellar tendon. UNIQUENESS: This patient's case was unique in 3 distinct ways: (1) outcome surveys helped me to understand how this injury affected various aspects of this patient's life and how he viewed himself as he progressed through rehabilitation; (2) a modified functional test was used to help determine whether the athlete was ready to return to sport; and (3) the athlete progressed rapidly through rehabilitation and returned to competitive athletics in 3 months. CONCLUSIONS: This patient was able to return to sport without functional limitations. The surgical outcome was also considered excellent.     

An Abnormal Bone Lesion of the Scapula in a Collegiate Basketball Player: A Case Report

Objective:

To present the case of a bone lesion of the scapula in a collegiate basketball player.

Background:

A 19-year-old National Collegiate Athletic Association Division I male basketball player presented with pain in the posterior region of the right shoulder. During practice, he was performing a layup when his arm was forced into hyperflexion by a defender. Evaluation revealed a bone lesion involving the scapular spine and base of the acromion.

Differential Diagnosis:

Acromioclavicular joint sprain, subacromial bursitis, subscapular bursitis, humeral head contusion, acromial fracture.

Treatment:

The patient was treated for 2 months with therapeutic modalities and rehabilitation exercises. Because of persistent pain and the risk of a pathologic fracture, open surgical biopsy and bone grafting were then undertaken.

Uniqueness:

Most simple bone cysts affect the proximal humerus and femur, whereas our patient''s lesion was in the acromial complex.

Conclusions:

Athletic trainers should be alert to the unusual possibility of bone cysts, which are usually identified incidentally when radiographs are obtained for other reasons. Most simple bone cysts are asymptomatic, but a pathologic fracture can occur with trauma.Key Words: bone cysts, chondromyxoid fibromas, upper extremity, shoulderSimple bone cysts make up 3% of all bone lesions¹ and occur twice as often in males as in females.^2,3 Several simple bone cysts of the scapula have been described. However, the reported sites included the glenoid and neck, coracoid process, and body of the scapula.^4–7 We present the case of a collegiate athlete with a bone lesion of the scapular spine and acromial base.     

Traumatic Hemarthrosis of the Knee Secondary to Hemophilia A in a Collegiate Soccer Player: A Case Report

OBJECTIVE: To present the case of a collegiate soccer player who suffered from a traumatic knee hemarthrosis secondary to hemophilia A. This case presents an opportunity to discuss the participation status of athletes with hemophilia. BACKGROUND: Hemophilia is a hereditary blood disease characterized by impaired coagulability of the blood. Hemophilia A is the most common of the severe, inherited bleeding disorders. This type, also called classic hemophilia, is due to a deficiency of clotting factor VIII. The athlete with hemophilia A reported pain and loss of function of his knee during a soccer game despite the absence of injury. DIFFERENTIAL DIAGNOSIS: Anterior cruciate ligament tear, intra-articular fracture, meniscus tear, capsular tear, hemarthrosis. TREATMENT: After the injury, the athlete was admitted to the hospital, where his knee joint was aspirated and he was infused with factor VIII. Later, he participated in traditional knee rehabilitation and was returned to play at the discretion of the orthopaedist and the hematologist. UNIQUENESS: In past participation guidelines, individuals with bleeding disorders were disqualified from athletic participation; however, with advances in medical care, these individuals may be permitted to participate in accordance with the law. CONCLUSIONS: Individuals with hemophilia participate in athletics; therefore, team physicians and athletic trainers must be prepared to care for these individuals.     

Madelung Deformity in a Collegiate Gymnast: A Case Report

OBJECTIVE: To present the case of a 21-year-old female collegiate gymnast with acute left wrist pain. BACKGROUND: Madelung deformity is a developmental abnormality of the wrist. It is characterized by anatomic changes in the radius, ulna, and carpal bones, leading to palmar and ulnar wrist subluxation. It is more common in female patients and is usually present bilaterally. The deformity usually becomes evident clinically between the ages of 6 and 13 years. DIFFERENTIAL DIAGNOSIS: Traumatic distal radius physeal arrest, congenital anatomic variant. TREATMENT: The athlete was treated with symptomatic therapeutic modalities and nonsteroidal anti-inflammatory medication for pain. She was able to continue to participate successfully in competitive gymnastics, minimally restricted, with the aid of palmar wrist tape and a commercially available wrist brace to prevent end-range wrist extension. UNIQUENESS: Madelung deformity can result in wrist pain and loss of forearm rotation, leading to decreased function of the wrist and hand. This patient was able to participate successfully in elite- and college-level gymnastics with no wrist pain or injury until the age of 21 years. Furthermore, she was able to continue to participate, experiencing only periodic pain, with the aid of taping and bracing support and without the need for reconstructive surgery. CONCLUSIONS: Although rare, Madelung deformity is typically corrected surgically in athletes with chronic pain and disability. This case demonstrates an example of successful conservative management in which the athlete continued to participate in sport.     

面神经腮腺内走行变异1例报道

1 病例介绍 患者女性,28岁.右耳后肿物进行性增大10a余,以"右耳下肿物性质待查、腮腺混合瘤可能"收治入院.入院查体:右耳下触及约3.0 cm×3.5 cm大小肿物,质地硬,表面光滑,活动可,无触痛,边界清.     

Slipping Rib Syndrome in a Collegiate Swimmer: A Case Report

Objective: To present the unique case of a collegiate swimmer who experienced nearly 9 months of unresolved rib pain.Background: A 20-year-old collegiate swimmer was jumping up and down, warming up before a race, when she experienced pain in the area of her left lower rib cage. She completed the event and 2 additional events that day with moderate discomfort. The athlete was evaluated by a certified athletic trainer 3 days postinjury and followed up over the next 9 months with the team physician, a chiropractor, a nonsurgical sports medicine physician, and a thoracic surgeon.Differential Diagnosis: Intercostal strain, oblique strain, fractured rib, somatic dysfunction, hepatosplenic conditions, pleuritic chest pain, slipping rib syndrome.Treatment: The athlete underwent 4 months of conservative treatment (eg, activity modification, ice, ultrasound, hot packs, nonsteroidal anti-inflammatory drugs) after the injury, independently sought chiropractic intervention (12 treatments) 4 to 6 months postinjury, was referred to physical therapy (10 visits) by a nonsurgical sports medicine physician 6 to 8 months postinjury, and finally underwent surgical intervention 9 months after the onset of the initial symptoms.Uniqueness: Slipping rib syndrome was first described in 1919. However, many health care professionals who are involved with diagnosing and treating athletes and active individuals (eg, athletic trainers, physicians) are relatively unfamiliar with this musculoskeletal condition.Conclusions: It is important for clinicians and team physicians to familiarize themselves with and consider the diagnosis of slipping rib syndrome when assessing and managing individuals with persistent abdominal and/or thoracic pain.     

Bilateral Pulmonary Emboli in a Collegiate Gymnast: A Case Report

Objective:

To characterize the diagnosis of pulmonary embolism in collegiate student-athletes and to raise awareness among sports medicine providers of the possibility of this potentially fatal disease in the student-athlete population.

Background:

An 18-year-old, previously healthy National Collegiate Athletic Association Division I female gymnast complained of intense pain, bilaterally, deep in her chest. The athlete was referred to her team physician, who identified normal vital signs but referred her to the emergency room because of significant pain. The student-athlete was diagnosed with bilateral pulmonary emboli in the emergency room.

Differential Diagnosis:

Pneumonia, renal calculi, upper urinary tract infection, intercostal muscle strain or rib fracture, pancreatitis, gall bladder disease, gastritis, ulceration, esophagitis, infection, tumor, pulmonary embolism.

Treatment:

The student-athlete was immediately placed on anticoagulants for 6 months. During that time, she was unable to participate in gymnastics and was limited to light conditioning.

Uniqueness:

Documented cases of female student-athletes developing a pulmonary embolism are lacking in the literature. Two cases of pulmonary embolism in male high school student-athletes have been documented, in addition to many cases in elderly and sedentary populations.

Conclusions:

All health care providers, including sports medicine professionals, should be aware that this condition may be present among student-athletes. During the initial evaluation, prescreening should include questions about any previous or family history of pulmonary embolism or other blood clots. Athletes who answer positively to these questions may have a higher likelihood of pulmonary embolism and should be referred for testing.     

Pancreatic Laceration in a Female Collegiate Soccer Athlete: A Case Report

Objective:

To characterize the diagnosis of pancreatic trauma in an athletic population and to raise awareness among health care providers of the possibility of this life- and organ-threatening injury.

Background:

An 18-year-old, previously healthy female collegiate soccer athlete sustained a direct blow from an opponent''s knee between the left and right upper abdominal quadrants while attempting to head the ball. She initially presented with only minimal nausea and discomfort, but this progressed to abdominal pain, tenderness, spasm, and vomiting. She was referred to the emergency department, where she was diagnosed with a pancreatic laceration.

Differential Diagnosis:

Duodenal, hepatic, or splenic contusion or laceration; hemorrhagic ovarian cyst.

Treatment:

The patient underwent a distal pancreatectomy and total splenectomy.

Uniqueness:

Pancreatic injuries, particularly those severe enough to warrant surgical intervention, are extremely rare in athletes.

Conclusions:

Recognition of a pancreatic injury can be very challenging outside the hospital setting. This is problematic, because a delay in diagnosis is a significant source of preventable morbidity and mortality after this rare injury. Thus, early identification depends on a high index of suspicion, a thorough examination, and close observation. It is imperative that athletic trainers and other health care professionals be able to identify this condition so that referral and management can occur without delay.Key Words: abdomen, blunt trauma, cholangiopancreatography, pancreatectomy, splenectomyInjuries to the pancreas from blunt trauma are relatively uncommon and rarely occur during athletic training and competition.^1–3 However, these injuries are associated with high morbidity and mortality because they are difficult to detect and diagnosis is often delayed.⁴ Identification of a serious intra-abdominal condition is often challenging, as many injuries may not be apparent during the initial assessment.^1,5 Furthermore, the mechanisms of injury often result in associated damage that may divert an athletic trainer''s attention from a potentially life- or organ-threatening intra-abdominal condition. We present this case of a pancreatic laceration in a collegiate female soccer athlete to inform health care professionals in the sports setting about this uncommon but life-threatening condition. This case is unique in that this injury rarely occurs in athletes, but it was severe enough to warrant removal of the spleen and a a large section of the pancreas.     

Hip Pain in a High School Football Player: A Case Report

OBJECTIVE: To describe the evaluation, diagnosis, and conservative treatment of a 15-year-old male high school football player with an avulsion fracture of the ischial tuberosity. BACKGROUND: Avulsion fracture of the ischial tuberosity is a rare and often missed diagnosis. A literature review offered limited information concerning the evaluation and conservative treatment of such an injury. DIFFERENTIAL DIAGNOSIS: Avulsion fracture of the ischial tuberosity. TREATMENT: The athlete's treatment goal was to return to football and weight lifting without surgical intervention. Treatment initially focused on controlling pain and normalizing gait. The athlete then advanced to a progressive resistance exercise program and functional sporting drills as he improved in hip range of motion, strength, and neuromuscular control. He returned to unrestricted sporting activities 14 weeks after the injury. UNIQUENESS: Avulsion of the ischial tuberosity is a rare injury. Most published case reports have recommended surgical intervention for this injury, with little information describing conservative treatment. CONCLUSIONS: Sports medicine practitioners must obtain an accurate history, perform a thorough physical examination, and obtain appropriate radiographs in order to correctly diagnose an ischial tuberosity avulsion fracture. Furthermore, they should consider conservative treatment for minimally displaced ischial tuberosity avulsion fractures. Should the athlete not show significant functional gains within a month of conservative treatment, the health care provider should consider surgical treatment.     

Frostbite in an Adolescent Football Player: A Case Report

Objective:

To present the case of vascular compromise of a finger from a confluent circumferential blister due to an inappropriately applied commercial cold pack in a high school athlete and to describe the mechanism of iatrogenic injury, acute surgical management, rehabilitation, and pathophysiology of frostbite and constriction injuries.

Background:

A 17-year-old male football player presented with a frostbite and constriction injury to the index finger secondary to prolonged use of a cooling pack after a mild traumatic injury to the digit. He developed a prolonged sensory deficit from thermal injury, as well as acute vascular compromise requiring urgent operative intervention.

Differential Diagnosis:

Frostbite and constriction injury to the index finger.

Treatment:

Emergency surgical decompression and occupational therapy.

Uniqueness:

Frostbite injuries can occur iatrogenically because of inappropriate use of cooling devices or gel packs. Fingers are commonly injured extremities that are particularly susceptible to frostbite and compression injuries. To our knowledge, no case of vascular compromise from the blister constriction of digits has been reported.

Conclusions:

Patients and their caregivers must be educated about how to properly use cooling devices. Clinicians need to fully evaluate patients with iatrogenic frostbite injuries, giving particular attention to neurovascular status, and must recognize the need for surgical release of constriction syndrome to prevent substantial morbidity.Key Words: constriction syndrome, freezing, cryotherapy, vascular compromise, hand injuries, ice packsFrostbite injuries are common in colder climates and during winter recreational activities. The most frequently involved areas are the distal and terminal structures, such as the fingers, toes, nose, and ears. With the wide acceptance of the rest, ice, compression, and elevation protocol, iatrogenic frostbite has become a risk that cannot be ignored. Thermal injuries have been described in the literature secondary to the use of ice packs and other cooling objects and devices.^1–3 We present the case of a teenaged athlete who developed vascular compromise of a finger from a confluent circumferential blister due to an inappropriately applied commercial cold pack on the football field. To our knowledge, no case of vascular compromise from the blister constriction of digits has been reported in the literature. The patient''s legal guardian provided written informed consent for this case report.     

Splenic Artery Avulsion in a High School Football Player: A Case Report

OBJECTIVE: To present the case of a high school football player who sustained avulsion of 2 branches of the splenic artery from his spleen as he was tackled and landed on the football. BACKGROUND: A high school football player was tackled and fell onto the football, left side first. He was examined by a certified athletic trainer and an internist. On evaluation, he had a positive Kehr sign, exquisite left upper abdominal quadrant tenderness, and complaint of nausea. He also exhibited signs of the onset of shock, including diaphoresis, a rapid pulse, and hypotension. He was immediately transported by ambulance to the local emergency facility. DIFFERENTIAL DIAGNOSIS: Splenic rupture, splenic laceration, splenic artery avulsion, or ruptured viscus. TREATMENT: Emergency surgery was performed, with removal of 2800 mL of blood and ligation of the 2 arterial branches avulsed from the spleen. The patient fully recovered within 6 weeks and was cleared to resume all sports activities. UNIQUENESS: Injury to the spleen in football is a known yet very uncommon injury. Even more unusual is the avulsion of splenic artery branches from the spleen. CONCLUSIONS: It is critical that athletic trainers and team physicians have an understanding of the mechanisms, signs, and symptoms of splenic injury. Because the spleen is a highly vascular organ, severe hemorrhage can be fatal in just minutes if not recognized and appropriately treated.     

Pneumomediastinum and Pneumopericardium in an 11-Year-Old Rugby Player: A Case Report

Objective:

Pneumomediastinum and pneumopericardium are rare occurrences in young athletes, but they can result in potentially life-threatening consequences.

Background:

While involved in a rugby match, an 11-year-old boy received a chest compression by 3 players during a tackle. He continued to play, but 2 hours later, he developed sharp retrosternal chest pain. A chest radiograph and an echocardiograph at the nearest emergency department showed pneumopericardium and pneumomediastinum.

Differential Diagnosis:

Sternal and rib contusions, rib fractures, heartburn, acute asthma exacerbation, pneumomediastinum, pneumopericardium, pneumothorax, traumatic tracheal rupture, myocardial infarction, and costochondritis (Tietze syndrome).

Treatment:

Acetaminophen for pain control.

Uniqueness:

To our knowledge, this is the only case in the international literature of the simultaneous occurrence of pneumomediastinum and pneumopericardium in a child as a consequence of blunt chest trauma during a rugby match.

Conclusions:

Pneumomediastinum and pneumopericardium may be consequences of rugby blunt chest trauma. Symptoms can appear 1 to 2 hours later, and the conditions may result in serious complications. Immediate admission to the emergency department is required.Key Words: retrosternal chest pain, compression trauma, youth athletesPneumomediastinum (PM) and pneumopericardium (PP) are conditions in which air is present in the mediastinal and pericardial spaces, respectively. The mediastinum is the central compartment of the thoracic cavity and contains the heart and great vessels, trachea, esophagus, phrenic and cardiac nerves, thoracic duct, thymus, and lymph nodes. It extends from the sternum in the front to the vertebral column in back. The pericardium is a double-walled sac that contains the heart and the roots of the great vessels. The pathogenesis of PM and PP during a thoracic compression is probably an increase in intra-alveolar pressure; alveolar overdistention results in rupture of alveolar walls, allowing air to travel through the pulmonary interstitium along the perivascular sheaths to the lung hilum and mediastinum and the pericardial reflection.^1–3 Pericardial connective tissue is discontinuous at the lines of reflection of the parietal pericardium near the ostia of the pulmonary veins, creating a site of potential weakness where microscopic dissection of air into the pericardial sac is possible.^1,2,4–6Pneumomediastinum can be spontaneous, occurring without an evident primary cause, or secondary to underlying and predisposing conditions, such as asthma, bronchiolitis obliterans, tobacco smoke, illegal drug ingestion, or blunt thoracic trauma. In the case of trauma, PM is more serious due to the likely association with other injuries and the higher risk of complications.^7,8 In a series of 986 children admitted to the trauma center of an emergency department, PM accounted for 0.6% of thoracic injuries.⁹Pneumopericardium is typically secondary to recent heart surgery or to blunt or penetrating trauma,¹⁰ but it can also occur with infectious pericarditis from gas-producing organisms or from a fistula formation between the pericardium and an adjacent air-containing organ.¹¹In children, PM and PP are rarely reported simultaneously^12–15 and even less often as complications of trauma during sports.^11,16 In the latter condition, PP is secondary to PM when great forces applied to the chest provoke the passage of air from the mediastinal space to the pericardial space.¹⁷ We report a case of chest pain secondary to PM and PP in a child as a result of blunt chest trauma during a tackle in a rugby match.     

Postfixed Brachial Plexus Radiculopathy Due to Thoracic Disc Herniation in a Collegiate Wrestler: A Case Report

Objective:

To present the unique case of a collegiate wrestler with C7 neurologic symptoms due to T1–T2 disc herniation.

Background:

A 23-year-old male collegiate wrestler injured his neck in a wrestling tournament match and experienced pain, weakness, and numbness in his left upper extremity. He completed that match and 1 additional match that day with mild symptoms. Evaluation by a certified athletic trainer 6 days postinjury showed radiculopathy in the C7 distribution of his left upper extremity. He was evaluated further by the team physician, a primary care physician, and a neurosurgeon.

Differential Diagnosis:

Cervical spine injury, stinger/burner, peripheral nerve injury, spinal cord injury, thoracic outlet syndrome, brachial plexus radiculopathy.

Treatment:

The patient initially underwent nonoperative management with ice, heat, massage, electrical stimulation, shortwave diathermy, and nonsteroidal anti-inflammatory drugs without symptom resolution. Cervical spine radiographs were negative for bony pathologic conditions. Magnetic resonance imaging showed evidence of T1–T2 disc herniation. The patient underwent surgery to resolve the symptoms and enable him to participate for the remainder of the wrestling season.

Uniqueness:

Whereas brachial plexus radiculopathy commonly is seen in collision sports, a postfixed brachial plexus in which the T2 nerve root has substantial contribution to the innervation of the upper extremity is a rare anatomic variation with which many health care providers are unfamiliar.

Conclusions:

The injury sustained by the wrestler appeared to be C7 radiculopathy due to a brachial plexus traction injury. However, it ultimately was diagnosed as radiculopathy due to a T1–T2 thoracic intervertebral disc herniation causing impingement of a postfixed brachial plexus and required surgical intervention. Athletic trainers and physicians need to be aware of the anatomic variations of the brachial plexus when evaluating and caring for patients with suspected brachial plexus radiculopathies.Key Words: neuropathy, burner, stinger, cervical spine, thoracic spineInjury to the brachial plexus, or brachial plexopathy, is one of the most common upper extremity injuries in athletics, especially collision sports, such as football, hockey, and wrestling. The incidence in football players has been reported to be as high as 49%,¹ but the true incidence may be higher because the symptoms typically are transient and many patients do not report their symptoms to health care providers. Patients with brachial plexus injuries typically present with unilateral numbness, muscle weakness, and burning or stinging pain radiating down the upper extremity.^2–6 Symptoms typically last only a few minutes but may persist for hours, days, or longer.In the medical literature, researchers^7–12 commonly describe the brachial plexus as formed by the combination of spinal nerve roots from the C5–T1 spinal cord levels. Whereas the brachial plexus has numerous anatomic variations, 2 of the most common are known as prefixation and postfixation. Prefixation occurs when the C4 nerve root has an increased contribution to the plexus and the T1 nerve root has substantially less or no contribution. Conversely, postfixation occurs when the T2 nerve root has increased contribution and the C5 nerve root has diminished contribution. Prefixation is much more common than postfixation.^11,13–17Intervertebral disc herniation within the brachial plexus is a serious injury because it may impinge on the nerve roots, causing radiculopathy or partial paralysis. Intervertebral disc herniation that impinges on the brachial plexus occurs almost exclusively in the cervical spine. Thoracic intervertebral disc herniations are much less common than cervical and lumbar disc herniations. High-level thoracic disc herniations, which occur from T1–T4, are exceedingly uncommon.^18–26We present the case of a 23-year-old male collegiate wrestler who sustained what appeared to be a C7 brachial plexus traction injury but ultimately was diagnosed with a T1–T2 thoracic disc herniation impinging a postfixed brachial plexus that required surgical intervention. Given the rarity of T1–T2 disc herniation, we believe this case illustrates the importance of understanding the common anatomic variations of the brachial plexus to aid in proper diagnosis and appropriate treatment of these conditions, especially when the response to treatment does not progress as anticipated.     

Bulbar Palsy as the Initial Manifestation of Multiple Myeloma: A Case Report

Multiple Myeloma (MM) is a neoplastic disorder derived from the malignant proliferation of monoclonal plasma cells. It is characterized by the overproduction of immunoglobulins (Ig). We report a rare case in which bulbar palsy was the initial manifestation of IgG-MM. A 66-year-old woman initially presented with progressive dysphagia and dysarthria for half a year. Physical examination demonstrated a deviation of the uvula, difficulty in protruding tongue, and bilateral tongue atrophy. Laboratory assessments revealed anemia and prominent monoclonal elevation of IgG levels both in serum and cerebrospinal fluid (CSF). The diagnosis of IgG-MM was confirmed by the identification of plasmacytosis in bone marrow aspiration and biopsy and elevation of γ-M protein in serum protein electrophoresis (SPEP). Therefore, the patient began to receive the chemotherapy with PAD (bortezomib-doxorubicin-dexamethasone) regimen. Her condition had been under control. MM as a hematological malignancy can affect cranial nerves and present as chronic progressive bulbar palsy.     

Unique Treatment Regimen for Effort Thrombosis in the Nondominant Extremity of an Overhead Athlete: A Case Report

Objective:

To advise athletic trainers on the potential for effort thrombosis to occur in nonthrowing athletes and to underscore the importance of early recognition and treatment.

Background:

An 18-year-old offensive lineman presented with a 1-day history of diffuse shoulder pain with no specific history of injury; swelling and erythema involved the entire left upper extremity. He was immediately referred to the team physician, who suspected deep vein thrombosis and sent the athlete to an imaging center. Duplex ultrasound was obtained on the day of presentation, and he was admitted to the hospital that evening.

Differential Diagnosis:

Deep vein thrombosis, thoracic outlet syndrome, shoulder tendinitis.

Treatment:

Anticoagulation with heparin was administered at the hospital, and he was sent home the next day on subcutaneous enoxaparin sodium, followed by a 5-mg daily dose of oral warfarin sodium. Oral anticoagulants were continued for a total of 4 weeks. The athlete began upper body lifting and was released 5 weeks postinjury to gradually return to football without restrictions.

Uniqueness:

Effort thrombosis is typically seen in the dominant arm of athletes, and the current treatment protocol calls for thrombolysis or surgical intervention. This athlete, whose position required repeated elevation of his arms in forward flexion, sustained the injury in his nondominant arm, was treated with anticoagulation only, and had a full return to football. At 18-month follow-up, he had no recurrence of symptoms.

Conclusions:

Early recognition and treatment of athletes with effort thrombosis is paramount to a successful clinical outcome and prompt return to play.     

Radio Frequency Ablation in Drug Resistant Chemotherapy-induced Peripheral Neuropathy: A Case Report and Review of Literature

Chemotherapy-induced peripheral neuropathy (CIPN) is a frequently encountered complication. It can result from a host of agents. Various modalities of treatment have been advocated, of which a novel method is radio frequency ablation. A 63-year-old male, a case of carcinoma prostrate with bone metastases, presented with tingling and numbness in right upper limb. He was given morphine, gabapentin and later switched to pregabalin, but medications provided only minor relief. Initially he was given stellate ganglion block, then radiofrequency ablation of dorsal root ganglion was done, but it failed to provide complete relief. Pulsed radiofrequency ablation (PRF) was then done for 90 seconds; two cycles each in both ulnar and median nerve. After the procedure the patient showed improvement in symptoms within four to five hours and 80% relief in symptoms. We conclude that PRF can be used for the treatment of drug resistant CIPN.     

Acute Subdural Hematoma in a High School Football Player After 2 Unreported Episodes of Head Trauma: A Case Report

OBJECTIVE: To discuss the association between 2 unreported episodes of head trauma and an acute subdural hematoma in a high school football player; to address the role of the sport health care team in secondary schools when caring for an athlete with head trauma; and to recognize the importance of educating athletes and coaches about this condition. BACKGROUND: A previously healthy athlete experienced 2 unreported episodes of head trauma during a single game. The athlete was conscious and oriented to person, time, and place, but he vomited and complained of severe headache, nausea, and vertigo. During transfer, the athlete appeared to have a seizure. DIFFERENTIAL DIAGNOSIS: Subdural hematoma, epidural hematoma, intracerebral hemorrhage, second-impact syndrome, cervical spine injury, or epilepsy. TREATMENT: Computed tomography scan indicated fluid over the left frontal temporal fossa. Conservative treatment was begun, and the fluid resolved without incident. UNIQUENESS: A single episode of blunt trauma has been thought to cause an acute subdural hematoma. However, multiple concussions can also result in this condition. CONCLUSION: Single or multiple episodes of head trauma can lead to an acute subdural hematoma. This case study reflects the importance of proper education in the recognition and care of head trauma and return-to-play guidelines for athletes and coaches. A sport health care team in all secondary schools can provide the immediate and appropriate intervention for such injuries.     

Longitudinal Assessment of Noncontact Anterior Cruciate Ligament Injury Risk Factors During Maturation in a Female Athlete: A Case Report

Objective:

To present a unique case of a young pubertal female athlete who was prospectively monitored for previously identified anterior cruciate ligament (ACL) injury risk factors for 3 years before sustaining an ACL injury.

Background:

In prospective studies, previous investigators have examined cross-sectional measures of anatomic, hormonal, and biomechanical risk factors for ACL injury in young female athletes. In this report, we offer a longitudinal example of measured risk factors as the participant matured.

Differential Diagnosis:

Partial or complete tear of the ACL.

Measurements:

The participant was identified from a cohort monitored from 2002 until 2007. No injury prevention training or intervention was included during this time in the study cohort.

Findings:

The injury occurred in the year after the third assessment during the athlete''s club basketball season. Knee examination, magnetic resonance imaging findings, and arthroscopic evaluation confirmed a complete ACL rupture. The athlete was early pubertal in year 1 of the study and pubertal during the next 2 years; menarche occurred at age 12 years. At the time of injury, she was 14.25 years old and postpubertal, with closing femoral and tibial physes. For each of the 3 years before injury, she demonstrated incremental increases in height, body mass index, and anterior knee laxity. She also displayed decreased hip abduction and knee flexor strength, concomitant with increased knee abduction loads, after each year of growth.

Conclusions:

During puberty, the participant increased body mass and height of the center of mass without matching increases in hip and knee strength. The lack of strength and neuromuscular adaptation to match the increased demands of her pubertal stature may underlie the increased knee abduction loads measured at each annual visit and may have predisposed her to increased risk of ACL injury.