Cortical Irregularity Research Articles

Distal radial osteochondroma causing expansile lysis and ulna fracture in a dog.

To describe the diagnosis, management, and outcome of a dog with a right distal radial osteochondroma that penetrated the ulna, causing expansile lysis and fracture. A 9-month-old entire female German Shorthaired Pointer. The dog had a 2-month history of weight-bearing lameness of the right forelimb and a 2-week history of a progressively enlarging, firm swelling on the distolateral antebrachium. Computed tomography was used to characterize the lesion and for surgical planning. A distal ulnar ostectomy removed the affected ulnar segment, and the radial osteochondroma was excised with rongeurs. The dog was sound at 2, 16, and 45 weeks postoperatively. Radiographs at 45 weeks showed a persistent ulnar ostectomy gap with irregular but smoothly marginated edges and focal cortical irregularity at the site of radial osteochondroma excision. There was no evidence of osteochondroma recurrence. This is a newly recognized presentation of an osteochondroma penetrating the cortex of an adjacent bone in a dog resulting in expansile lysis and cortical fracture. Computed tomography was important in diagnosis and surgical planning, and surgical treatment was successful in removing the osteochondroma and ulnar lesion. This case provides long-term radiographic and clinical follow-up after osteochondroma excision and contributes to the current knowledge on prognosis following osteochondroma excision in dogs.

Imaging of the Pediatric Knee.

During normal development, imaging findings in the immature knee joint may mimic pathology or indicate transient sites of weakness, prone to injury. This article reviews the development of the knee joint, age- and maturation-dependent imaging considerations, and various developmental variants that can be encountered, subdivided into those that involve the tibiofemoral and patellofemoral compartments, soft tissues, and osseous components. The tibiofemoral compartment section reviews the focal periphyseal edema zone (FOPE), ossification variants of the femoral condyles, distal femoral metaphyseal cortical irregularity from periosteal traction, and the metaphyseal subperiosteal stripe, which should be distinguished from pathologic mimickers such as endochondral ossification dysfunction, osteochondritis dissecans (OCD), fibroosseous lesion, periosteal and subcortical pathologies. The patellofemoral compartment section includes a review of partite patella, dorsolateral defect, variant trochlear morphology, and maturation-dependent sites of transient weakness that are prone to injury from repetitive overuse (Sinding-Larsen-Johansson syndrome and Osgood-Schlatter disease) and avulsion fractures (patellar sleeve and tibial tubercle avulsions). Finally, soft tissue (discoid lateral meniscus, meniscal flounce, anterior cruciate ligament variants) and osseous components (meniscal ossicle, fabella, and cyamella) are reviewed.

Tumor-Like Distal Femoral Cortical Irregularities of the Knee in Adolescent Competitive Alpine Skiers: Longitudinal Assessment Over 48 Months

Background: Tumor-like distal femoral cortical irregularities (DFCIs) are a frequent incidental finding on knee magnetic resonance imaging (MRI) and are common in young competitive athletes. Purpose: To assess and compare the morphology and prevalence of DFCIs in competitive alpine skiers over 48 months during adolescence. Study Design: Case series; Level of evidence, 4. Methods: Adolescent competitive alpine skiers were prospectively recruited in 2018 and received bilateral 3-T MRI of the knee at baseline and after 48 months. All MRIs were evaluated for the presence and location of DFCIs, which were marked at 1 of 3 anatomic positions: (1) the femoral attachment of the medial head of the gastrocnemius muscle, (2) the lateral head of the gastrocnemius muscle, or (3) the attachment of the adductor magnus aponeurosis. The size of the DFCI was measured by 2 radiologists independently. The measurements were compared using the Wilcoxon signed-rank test, the interclass correlation coefficient (ICC), and Cohen Kappa. Results: A total of 63 athletes (mean age at follow-up, 19.6 ± 1.2 years; n = 25 female) were included in the study. At baseline, DFCIs were detected in 84 out of 126 knees (67%). At the 48-month follow-up, DFCIs were found in 88 out of 126 knees (70%), with multiple DFCIs in 3 knees and no significant difference between male and female patients (n = 24 male, n = 19 female; P = .71). No significant increase was detected for the number (P = .21) and size of the DFCIs between the baseline and the 48-month follow-up (mean size: baseline, 3.7 ± 0.8 mm; 48-month follow-up: 3.6 ± 0.9 mm; P = .66). The interrater agreement for the mean size measurements of DFCIs was good to excellent (ICC 0.88). Conclusion: DFCIs remain a frequent finding on knee MRI in competitive alpine skiers after skeletal maturation and do not disappear during adolescence. The DFCI size was constant in athletes aged between 15 and 19 years. Moreover, DFCIs should not be mistaken for a pathologic finding.

The relationship between kinesiophobia, balance, and upper extremity functions in patients with painful shoulder pathology.

Poor balance ability may contribute to shoulder pathology in patients with existing shoulder pathologies or vice versa. The relationship between kinesiophobia and chronic shoulder pain intensity has been researched, although the conclusions are conflicting. To our knowledge, no study in the literature explores the association between kinesiophobia and balance in patients with shoulder pain. To investigate the relationship between kinesiophobia, upper extremity functions, and balance abilities in patients with shoulder pain. Cross-sectional observational study. Physical medicine and rehabilitation hospital. Not applicable. A total of 44 patients with shoulder pain were included in the study. The pain severity was assessed using a visual analog scale (VAS). The Tampa Scale for Kinesiophobia (TSK), Berg Balance Scale (BBS), and Shoulder Pain and Disability Index (SPADI) were used to assess the patients. Ultrasound was used to diagnose underlying shoulder joint problems. Static and dynamic postural control was evaluated. The most common pathologies detected by ultrasound were supraspinatus tendinitis/rupture (77.3%), cortical irregularity (68.2%), and bursitis (63.6%). TSK score did not correlate with age, body mass index, symptom duration, or VAS score in rest (all p > .05), but it was associated with scores on the BBS (r = -0.437, p = .003), SPADI-pain (r = 0.474, p = .001), SPADI-disability (r = 0.355, p = .018), SPADI-total (r = 0.405, p = .006), and VAS in activity (r = 0.331, p = .028). According to multiple linear regression analysis, BBS score, SPADI-total score, and anterior-posterior sway length were significant predictors of TSK (r = 0.645, r2 = 0.416). According to the findings of this study, the main risk factors for high levels of kinesiophobia are poor balance, severe pain, and disability. In addition to mechanical causes of shoulder pain, diagnosing and intervening on underlying balance issues and psychosocial causes of shoulder pain will improve treatment success.

Detection of Sternum Fracture with POCUS Despite Normal Computed Tomography Findings: A Case Report

Sternal fractures are extremely rare in children. It often develops after high-energy chest trauma. Many methods other than ultrasonography are used in the diagnosis of sternal fractures. However, Point-of-care ultrasound (POCUS) can outperform other methods due to its ease of use, less radiation and fast results. A thirteen-year-old male patient was brought due to chest pain that started after blunt chest trauma after falling from a height. In her initial evaluation in the trauma room, the patient's respiratory and cardiovascular examinations were found to be normal. On palpation, there was local tenderness in the middle 1/3 of the sternum. No pathology was detected in E-FAST. The portable chest radiograph was normal. POCUS was performed after the patient did not respond to analgesic treatment and had local sensitivity on the sternum. A sternal fracture was detected. Suspicious cortical irregularity was detected in repeated chest X-ray and thorax CT was reported as normal. When CT was re-evaluated, a wet tree fracture was observed in the sternum body. The patient was discharged without any complications. In this article, the importance of diagnosing a sternal fracture case whose computed tomography was reported as normal with POCUS and integrating rapid, noninvasive and radiation-free ultrasonography into the physical examination will be discussed in the management of these patients.

Sonographic pathoanatomy of greater trochanteric pain syndrome.

To identify and highlight pertinent US features that could serve as imaging biomarkers to describe different patient phenotypes, within Great Trochanteric Pain Syndrome (GTPS) clinical diagnosis. Using ultrasound we evaluated eighty-eight clinically diagnosed patients with GTPS, for tendon matrix changes and calcium deposits in the gluteus medius (superoposterior and lateral aspects) and in the gluteus minimus. Peritrochanteric examination included fascia lata, trochanteric bursa, cortical irregularities and the presence of enthesophytes. The association of pathological changes with pain and functionality was evaluated using multivariate regression models. Out of the 88 patients, 86 examinations (97.7%) detected gluteus medius tendinopathy, and 54 patients (61.4%) had gluteus minimus tendinopathy in addition. Calcium deposits were present in 97.7% of patients, associated with tenderness (p = 0.009), and most often located in the gluteus medius rather than in the gluteus minimus (p = 0.014); calcifications were associated with tendon thickness (p = 0.042), hypoechogenicity (p = 0.005) and the presence of partial tears (p = 0.030). Bursa swelling occurred in 36 patients (40.9%); multivariate regression models predicted less pain in patients with bursa distension (p = 0.008) and dysfunction in patients with gluteal muscle atrophy (p = 0.001) and loss of fibrillar pattern in the gluteus medius (p = 0.002). GTPS involves both degenerative calcifying gluteal tendinopathy and alterations in the peritrochanteric space associated with physical function and pain. The severity of GTPS can be assessed using ultrasound imaging biomarkers.

Skeletal Fluorosis.

A 27-year-old man with polysubstance abuse including methamphetamine, fentanyl, and 1.5 years of electronics compressed gas duster inhalation presented following an assault. Radiologic imaging performed for suspected fractures revealed periosteal reaction, cortical thickening with increased bone density, and ligament and tendon ossification, which were not present on imaging obtained 3 years before presentation. A bone scan was subsequently performed revealing a metabolic superscan with cortical irregularity. Further investigation revealed skeletal fluorosis from electronics compressed gas duster inhalation. Skeletal fluorosis may be considered when these osseous findings are encountered.

Demonstrating the relationship of ultrasonographic parameters with disease activity and pain in lateral epicondylitis.

To evaluate the relationship of ultrasonographic evaluation parameters with pain, muscle strength and disease severity in lateral epicondylitis (LE). 64 people were included in present retrospective, cross-sectional study. Activity and rest pain was questioned with Visual Analog Scale (VAS). Also, Patient Rated Tennis Elbow Evaluation (PRTEE) and the maximum grip strength were evaluated. Hypoechoic region, neovascularity, cortical irregularity, enthesopathy and peritendinous fluid or bursitis were evaluated by ultrasonography. 48 of the patients were female and 16 were male. Mean age was 48.53 ± 6.12, body mass index was 27.70 ± 4.75. 55 (85.9%) hypoechoic region, 31 (48.4%) neovascularity, 21 (32.8%) cortical irregularity, 19 (29,7%) enthesopathy, and 18 (28.1%) peritendinous fluid or bursitis were detected by ultrasonography. When the ultrasonographic findings and clinical findings of the patients were compared, no significant difference was found between the hypoechoic region, cortical irregularity, enthesopathy and clinical findings (P > .05), while the extension grip strength was found to be significantly lower in patients with neovascularity (P = .045). In addition, patients with peritendinous fluid or bursitis, were found to be significantly lower in both flexion (P = .033) and extension (P = .023) grip strength, while PRTEE function (P = .021) subgroup and total (P = .038) scores were significantly higher. Hypoechoic region, cortical irregularities and enthesopathy were not evaluated to be associated with disease severity, pain and muscle strength. Neovascularity was found to be associated only with extension grip strength. Peritendinous fluid or bursitis was found to be associated with both flexion and extension grip strength and disease activity, but not associated with pain.

Temporo-frontal and parotidial hidradenocarcinoma: A case report

Introduction: Hidradenocarcinoma is a very rare malignant tumor of the sweat glands. Diagnosis is based essentially on histological and immunohistochemical studies. Standard treatment is surgery combined with radiotherapy if there is a prognostic factor for local recurrence. We report a case treated in our department. Observation: A 24-year-old female patient with no specific pathological history consulted the Joliot Curie Institute of the Dantec Hospital for a forehead nodule that appeared in 2012 and was painless, evolving towards February 2021 into two right temporo-maxillary masses progressively increasing in volume. Examination revealed two tumors of stony consistency, with smooth, ulcerated surface, infiltrated center, raised borders, budding, not bleeding on contact, painless, the largest measuring approximately 16cm, located at the temporofrontal and right parotid level with extension to the right auricle associated with homolateral periorbital edema and right retroauricular and submental adenopathies, the largest measuring 3x2cm. Parotid skin biopsy revealed nodular tumour masses in the deep dermis, composed of a proliferation of medium- to large-sized epithelial cells, sometimes clear with central nuclei and numerous atypia and abnormal mitoses. Epidermoid differentiation can be seen in places. The stroma is fibrino-hyaline. The appearance was suggestive of a hidradenocarcinoma. The cervical CT scan revealed an inhomogeneous tissue process, strongly enhanced after well-limited contrast injection, in close contact with the right parotid gland. Similar homolateral parietofrontal lesions were noted, as well as a spiky homolateral frontoparietal appearance with cortical irregularity. The extension work-up was negative. Conclusion: Hidradenocarcinoma is a very rare malignant tumour with a high risk of locoregional and distant recurrence, mainly in lymph nodes. Its prognosis is poor.

Extensor indicis proprius to extensor pollicis longus transfer in spontaneous rupture of extensor pollicis longus following non displaced fracture distal end radius

Exact incidence of extensor pollicis longus (EPL) ruptures following distal radius fracture is not known. Peculiarly it’s common in nondisplaced fracture of the distal radius with an incidence of EPL rupture of 0.2-5%. Cortical irregularities from distal radius fractures or osteophytes easily abrade the tendon, causing gradual attrition and ultimately rupture. Compromised blood supply is also related to EPL rupture which is supported by microcirculatory anatomic studies. We present a case of 49 year old female who presented with spontaneous rupture of the EPL following a nondisplaced fracture of the distal radius managed by extensor indicis proprius (EIP) transfer. EIP transfer gives promising outcome. Optimum tension of the tendon is crucial for good functional outcome. We recommend suturing the tendon with thumb in extension and wrist in neutral position for optimum tension of tendon to avoid extensor lag and to prevent loss of IP flexion.

Periventricular nodular heterotopia associated with a "transmantle band sign" in patients with epilepsy.

Previous studies using advanced magnetic resonance imaging (MRI) techniques have documented abnormal transmantle bands connecting ectopic nodules to overlying cortex in patients with periventricular nodular heterotopia (PNH). We describe a similar finding using conventional MRI techniques. Patients were identified by means of a full-text search of radiological reports. All scanning was performed using conventional sequences at 3 Tesla (3T). Scans were reviewed by three neuroradiologists, and we characterized imaging features based on type of PNH and cortical irregularities associated with the transmantle band. A total 57 PNH patients were reviewed, of whom 41 demonstrated a "transmantle band" connecting the nodule to the overlying cortex. One or more periventricular heterotopic nodules was present in all 41 patients-this was bilateral in 29 of 41 (71%) and unilateral in the remaining 29%. In many cases there was more than one such band, and in some cases this band was nodular. In 19 of the cases, the cortex to which the band connected was abnormal, showing thinning in 4 cases, thickening in 5 cases, and polymicrogyria in another 10. The transmantle band can be seen frequently in both unilateral and bilateral cases of PNH and can be visualized with conventional 3T MRI sequences. The band highlights the underlying neuronal migration issues at play in the pathogenesis of this disorder, but its underlying role in the complex, patient-specific epileptogenic networks in this cohort has yet to be determined and warrants further investigation.

Pseudotumor deltoideus: An unusual and rare case treated in rural coal mine hospital

Abstract Pseudotumor deltoideus is a relatively recently coined term to describe the condition of the spectrum of eccentric bone irregularities around the deltoid tubercle region of the humerus. Usually, these patients complain of varying degrees of pain, swelling, and discomfort in and around the deltoid tuberosity region of the humerus. The radiological findings of these patients are characterized by relative cortical lucency in and around the deltoid tuberosity of humerus, cortical irregularity, and adjacent eccentric marrow abnormality in computed tomography and magnetic resonance imaging scans. Most probably, these are previously less-reported anatomical variations of the deltoid tuberosity region of the humerus. Advanced imaging studies and extended follow-up suggest that this clinical entity has got an indolent process, which can be managed conservatively. The purpose of this presentation is to highlight this lesser known and reported cause of shoulder and arm pain and to make this cause be considered while formulating a management protocol.

Incidental findings involving the temporomandibular joint on computed tomography and magnetic resonance imaging.

The temporomandibular joint (TMJ) is frequently imaged in head and neck computed tomography (CT) and magnetic resonance imaging (MRI) studies. Depending on the indication for the study, an abnormality of the TMJ may be an incidental finding. These findings encompass both intra- and extra-articular disorders. They may also be related to local, regional or systemic conditions. Familiarity with these findings along with pertinent clinical information helps narrow the list of differential diagnoses. While definitive diagnosis may not be immediately apparent, a systematic approach contributes to improved discussions between clinicians and radiologists and better patient management.

Achilles Pain - Track And Field

HISTORY: An 18-year-old, female, Division 1 collegiate track and cross-country athlete presented mid-season with acute on chronic, right posterior ankle pain after running. She was treated the season prior for insertional Achilles tendinopathy with protected weight bearing, manual therapy, eccentric strengthening, night splints, oral and topical NSAIDs, nitroglycerin patches and intra-tendinous prolotherapy. Her pain returned this season with running or direct contact of the Achilles tendon. PHYSICAL EXAMINATION: On inspection there was bilateral pes planus and slight swelling of the Achilles tendon 1-2 cm proximal to the insertion with tenderness to palpation. She had full ankle range of motion with mild pain only on end range of passive dorsiflexion. There was a non-antalgic gait pattern and no pain with toe and heel walking or with heel pumps. Ankle strength was normal and sensation to light touch was intact throughout. DIFFERENTIAL DIAGNOSIS:1. Achilles tendinopathy, recalcitrant2. Achilles paratenonitis3. Retrocalcaneal bursopathy4. Posterior ankle impingement TEST AND RESULTS: Diagnostic musculoskeletal ultrasound showed a normal appearing Achilles tendon without fusiform swelling, hypoechogenicity, fiber disruption, neovascularization or cortical irregularities FINAL/WORKING DIAGNOSIS: Achilles paratenonitis TREATMENT AND OUTCOMES:1. Referral to sports physical therapy for a progressive tendon loading program and return to run program using a weight assisted treadmill2. Despite strength and flexibility gains, the patient was unable to return to run without pain3. We performed an ultrasound guided, percutaneous Achilles paratenon brisement with saline to dissect the tight, adhesive paratenon from the tendon itself4. Additionally, during the same procedure, we performed an ultrasound guided, percutaneous, Achilles tendon scraping to disrupt peritendinous neovessels and neonerves5. After 1 week of protected rest, patient returned to physical therapy and was able to complete a return to run program and return to sport without pain within 1 month.

Ultrasonographic imaging findings of the shoulder in patients with Parkinson disease

BackgroundShoulder disorders, including frozen shoulder, bursitis, and rotator cuff lesions, are common musculoskeletal problems in patients with Parkinson disease (PD). Because musculoskeletal ultrasound (US) can clearly image shoulder joints, we aimed to evaluate shoulder joints using US in patients with PD and healthy participants and correlation between US and PD severity. MethodsThis is a prospective case-control study. 50 patients with PD and 50 healthy subjects from the outpatient department were administered US for bilateral shoulders. For data analysis, we chose the more severely affected side in the PD group for matching with the corresponding shoulder in the control group according to age, sex, and body mass index. Pain and disability were measured using the Visual Analogue Scale (VAS) for pain, Shoulder Pain and Disability Index (SPADI), and the Shoulder Disability Questionnaire (SDQ). ResultsThe PD group had higher VAS pain scores during activity (p = 0.003) and rest (p < 0.001), as well as the SPADI and SDQ scores (p < 0.001). In US findings, biceps long head tendon sheath effusion (p = 0.001), humeral head cortical irregularity (p = 0.012), and abnormality in the supraspinatus tendon (p = 0.003) were significantly greater in the PD group. Intra-group analysis in the PD group demonstrated a significant difference in passive flexion (p = 0.019) and supraspinatus tendinopathy (p = 0.033) on US examination during different disease stages. ConclusionsPatients with PD had more supraspinatus tendinopathy on US findings than control subjects. The lesion was significantly associated with disease severity. Clinical trial numberNCT02702232.

The role of adding Hyaluronic Acid in the grafting process for the repair of experimentally induced tibial defect in dogs model

The study was designed to determine the role of adding hyaluronic acid as a supportive filling material to improve grafting process of experimentally defective tibial bone in dog model. Eighteen local breed dogs of both sexes weighted 18± 0.4 kg and aged (12± 0.6Months) were randomly allocated in two equal groups. In the first group, twelve dogs underwent experimental tibial bone defect (2.5×0.7 cm ) and replaced with deprotenized lamb ribs. The second group were treated as that for the first, but supported by adding 1% hyaluronic acid, to their grafts. The bone in both groups was firmly fixed by cerclage wire. All dogs were; followed-up clinically, radiologically and macroscopically at (14, 30 and 60 days after the intervention. In all study dogs the systemic infections, signs of seromas, hematoma and sever lameness were not developed along the period of the study . Grossly, dogs in the second group at 60 days showed an increase in the size of the filler of bone at the edges and in the mid of the defect, improvement and acceleration in the bone healing, and formation of bone bridges compared to the first group. Radiological finding exhibited complete healing of the fixated bone segment with the surrounding area; however, some cortical irregularities denoted chronic periosteal reaction and callus formation in the treatment with hyaluronic acid. In conclusion, the study indicated that hyaluronic acid with xenograft materials exhibited remarkable beneficial effects on improvement of the tibial bone defect augmentation

Test Characteristics of Chest Ultrasonography for Rib Fractures Following Blunt Chest Trauma: A Systematic Review and Meta-analysis

Chest ultrasonography has been reported as an accurate imaging modality and potentially superior to chest radiographs in diagnosing traumatic rib fractures. However, few studies have compared ultrasonography to the reference standard of computed tomography (CT), with no systematic reviews published on the topic to date. Our objective was to summarize the evidence comparing the test characteristics of chest ultrasonography to CT in diagnosing rib fractures. This study was performed and reported in adherence to PRISMA guidelines. We searched 5 databases plus gray literature from inception to October 2021. Two independent reviewers completed study selection, data extraction, and a QUADAS-2 risk of bias assessment. Summary measures were obtained from the Hierarchical Summary Receiver Operating Characteristic model. From 1,660 citations, we identified 7 studies for inclusion, of which 6 had available 2×2 data for meta-analysis (n= 663). Of the 6 studies, 3 involved emergency department-performed ultrasonography and 3 radiology-performed ultrasonography. Chest ultrasonography had a pooled sensitivity of 89.3% (95% confidence interval [CI], 81.1 to 94.3) and specificity of 98.4% (95% CI, 90.2 to 99.8) compared with CT imaging for the diagnosis of any rib fracture. The finding of a fracture on ultrasonography, defined as an underlying cortical irregularity, was associated with a+likelihood ratio (LR) of 55.7 (95% CI, 8.5 to 363.4) for CT diagnosed rib fracture, while the absence of ultrasonography fracture held a -LR of 0.11 (95% CI, 0.06 to 0.20). We were unable to detect a difference in test characteristics between emergency department- and radiology-performed ultrasonography (P=.11). The overall risk of bias of included studies was high, with patient selection identified as the highest risk domain. Chest ultrasonography is both sensitive and highly specific in diagnosing rib fractures following blunt trauma.

Aging and entheses: An ultrasonographic probing of degenerative enthesopathy in a cohort of 147 healthy subjects.

To investigate the prevalence and features of degenerative enthesopathic changes in a large cohort of healthy individuals by musculoskeletal ultrasound (MSUS) and their relation to age and other demographic features. In this cross-sectional study, 147 healthy subjects (1470 entheses) were examined by MSUS according to the Outcome Measures in Rheumatology guidelines: Achilles tendon, plantar fascia, patellar, and quadriceps insertions of both lower limbs. The mean age (±SD) of the participants was 43.68 (±14.53) years and 57.1% were female. Enthesopathy has been detected in at least 1 area in 113 subjects (76.87%). Thickening (21.6%) and hypoechogenicity (15.3%) were the most frequent inflammatory findings while enthesophyte (10.13%) was the most prevalent structural one. Age and male gender were significantly correlating with inflammatory (rs =.341, P=.001/r=.310, P=.001), structural (rs =.354, P=.001/r=.166, P=.04) and total scores (rs =.406, P=.001/r=.302, P=.001). More inflammatory changes were noticed in the age group 36-55years. Body mass index had a positive correlation with inflammatory (rs =.290, P=.001) and total scores (rs =0.298, P=.001) but not with structural lesions (rs =.154, P=.062). Thickening, hypoechogenicity, cortical irregularities, and enthesophytes are frequent degenerative features of enthesopathy. These findings need to be redefined to be more specific for spondyloarthritides. Enthesopathy should be interpreted with caution in the light of the clinical picture, especially in elderly and obese male patients.

Bilateral Superomedial Scapular Pain And Swelling In A Young Basketball Player

HISTORY: A fifteen year old otherwise healthy basketball player developed pain and swelling over bilateral superomedial scapula after starting a new weight lifting program. The team’s strength coach, unfamiliar with training high school athletes, instructed performance of Romanian dead lifts with >100 lbs. He described tight, aching pain rated at 4/10 in severity. Denied neck or upper limb radicular pain, focal weakness, sensory loss, and constitutional symptoms. He rested from weight lifting and at time of presentation ten days later, the swelling had resolved. He and family had questions regarding diagnosis and return to play. Coaches prohibited his interaction with teammates due to lack of participation in assigned weight training. PHYSICAL EXAMINATION: He was 6’8” tall, weighed 180 lbs. No swelling, skin changes, atrophy, or winging. Mildly tender to palpation at insertion of bilateral levator scapulae and middle trapezius bilaterally. Normal, symmetric, and pain free cervical and shoulder ROM. Normal strength, sensation, reflexes. DIFFERENTIAL DIAGNOSIS: 1) Muscle strain 2) Traction apophysitis 3) Scapulothoracic bursitis 4) Dorsal scapular nerve entrapment TEST AND RESULTS: Limited diagnostic ultrasound of the periscapular region was performed in clinic using an 18-5 MHz linear array transducer. This revealed cortical irregularities at insertion of the left levator scapulae. This was associated with hyperemia on doppler, increased vascular flow on SMI, and partial beam penetration of the cortex. Sonopalpation tenderness over levator scapulae insertion bilaterally. FINAL WORKING DIAGNOSIS: Traction apophysitis of bilateral levator scapulae TREATMENT AND OUTCOMES: 1) Rest from weight lifting, ice PRN. 2) Educational letter written to coaching staff. 3) Physical therapy included 3D biomechanical analysis and EMG, flexibility for shoulder, cervical and thoracic regions with strengthening of posterior scapular stabilizers and core musculature and proprioception activities. Progression targeted sport specific, age-appropriate weight training for in-season play. 4) Return to play if pain ≤2/10 in severity. 5) At two month follow-up, he made strength gains, improved mechanics, and is fully practicing in workouts and engaged in Nationally Sponsored AAU Basketball Circuit competition.

Shoulder Pain - Dodgeball

HISTORY: 39-year-old right-handed man presented to clinic for right shoulder pain. Symptoms were present for 4-5 months prior and began several days after playing in a dodgeball tournament. There was no trauma or clear inciting event. Pain was localized to the top of the right shoulder and worse with reaching across the body and with overhead activities. The 3-4 weeks prior to presenting to clinic he noticed a lump and swelling over the top of the shoulder and clavicular region that was not painful to touch. His pain was rated overall 3/10 intensity. PHYSICAL EXAM: Full range of motion of the shoulder in abduction, flexion without pain. Negative empty can test, Hawkins and Neers tests on the right. Speeds test negative on the right. Fullness and bony prominence noted at the distal clavicle on the right shoulder. No focal tenderness at the AC joint. Mild discomfort with scarf test on the right. DIFFERENTIAL DIAGNOSIS: 1. Acromioclavicular joint sprain 2. Acromioclavicular joint arthralgia 3. Distal clavicle osteolysis 4. Osteoid osteoma. TESTS AND RESULTS: Ultrasound right shoulder: Cortical irregularity of the distal right clavicle. XR right shoulder: Distal clavicular ill-defined lytic lesion with apparent cortical breakthrough superiorly and possibly inferiorly. MRI right shoulder: Indeterminate 3.6 cm expansile enhancing lesion with fluid. Biopsy right clavicle with USP6 genotype testing: consistent with an aneurysmal bone cyst FINAL/WORKING DIAGNOSIS: Aneurysmal bone cyst in the distal clavicle TREATMENT AND OUTCOMES: 1. Patient referred to orthopedic oncology and underwent biopsy 2. Underwent aspiration of aneurysmal bone cyst with injection of doxycycline 3. 2 months post-operatively continued to have pain and tightness in the shoulder 4. 5 months post-operatively reported resolution in shoulder pain and improved mobility, interval sclerosis noted of aneurysmal bone cyst on imaging