“Doc,I can’t walk now!”

1. “Doc,I can’t walk now!” Rick Horak, MD Primary Care Sports Medicine Fellow ASMI SEACSM 11 Feb 2012

2. 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

3. Medical History • PMHx: Negative, especially for any bleeding or clotting disorders • Medications: Periactin PRN • Allergies: None • FHx: Negative • SHx: No tobacco or ETOH

4. Physical Exam • General: WD WN 16 yo male • MMSE: Alert and Oriented x 4 • Vitals: 6 feet, 175 pounds

5. 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

6. 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

7. 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

8. Questions

9. 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

10. Differential Diagnosis Continued • Congenital, Developmental Disorders • Hip osteochondrosis • Capital Epiphysitis • Anatomic, Structural Disorders • Lumbar Herniated Disk Syndrome • Hamstring tightness • Slipped Capital Epiphysitis • Meralgia Paresthetica

11. IMAGING

14. Imaging

17. Initial Working Diagnosis • Deep right thigh bruise

18. 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

19. 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

20. 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

21. Musculoskeletal Exam Continued • Strength and Tone: • No atrophy • Limited knee extension against resistance • Gait: • Limited weight bearing secondary to pain • Neurological: • Sensation intact throughout

22. Questions

23. Differential Diagnosis • Hematoma • Tendon Rupture • Myositis Ossificans

24. Treatment Plan • Continue using crutches provided by the ER • Obtain MRI of the right thigh

25. MRI: T1 Axial

26. MRI: T1 Sagittal

27. MRI: T2 Axial

28. MRI: T2 Coronal

29. MRI: T2 Sagittal

30. 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

31. 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

32. 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

33. Final Plan • Release to all sports without restrictions