S206 S290
MSK & SPORTS MEDICINE POSTER HALL: CASE REPORTS
Poster 232:
Trigger Point Injection and Botulinum Toxin Relieving
Thoracic Outlet Syndrome: A Case Report
Rishi Vora (MedStar Georgetown/National Rehabilitation Hospital,
Washington, DC, USA), Thomas Heckman, DO
Disclosures:
Rishi Vora: I Have No Relevant Financial Relationships To
Disclose
Case/Program Description:
A 25-year-old female pharmacist pre-
sented with right arm pain, weakness, paresthesias and skin color
changes that worsened with overhead activity. MRI of the brain and
brachial plexus along with Doppler ultrasound studies did not find a
specific etiology. While suspecting thoracic outlet syndrome, her
vascular surgeon referred her to seek less invasive options prior to
considering resection of her first rib.
Setting:
Outpatient Pain Management.
Results:
Trigger point injections directed to the right anterior scalene
provided significant improvement of her mixed vascular and neuro-
genic symptoms and improved the function of her right arm. Later a
total of 100 units of botulinum toxin A between sternocleidomastoid,
upper trapezius, levator scapulae and scalenes were injected and also
provided significant relief of symptoms.
Discussion:
Literature regarding trigger points and Botox injection
in thoracic outlet syndrome is limited. Here, the trigger point in-
jections in the anterior scalene muscle helped resolved outlet
obstruction. Later botulinum toxin A injections were also injected
to adjacent musculature that also provided relief. While physical
therapy and surgical options are available, a quicker recovery was
made through the use of these injections. This case highlights the
usage of a minimally invasive technique to improve function and
reduce disability.
Conclusions:
Trigger point therapy could be a possible treatment for
thoracic outlet syndrome. Given the possible myofascial etiology of
thoracic outlet syndrome, trigger points may be a causative factor.
The anterior scalene can be implicated in thoracic outlet syndrome
providing a possible location to direct such therapy. Trigger point in-
jections and Botox are not commonly used for thoracic outlet syn-
drome, but can provide a simple and definitive treatment. No standard
currently exists for quantity or frequency of botulinum toxin A in-
jections and warrants further investigation.
Level of Evidence:
Level V
Poster 233:
Pellegrini-Stieda Syndrome: Novel Ultrasound
Diagnosis and Percutaneous Lavage Treatment: A
Case Report
Isaac P. Syrop, MD (NY Presby Hosp/Columbia/Cornell, Chappaqua,
NY, United States), Peter Moley, MD
Disclosures:
Isaac Syrop: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
A 57-year-old woman presents with left
knee pain. Her knee pain, located on the medial side, began 2 weeks
following a slip and fall. Described as sharp and aching, her pain ranges
from 0 to 7, exacerbated by knee flexion. Palpation reveals local
tenderness overlying the left medial femoral condyle, with no pain
overlying the medial joint line. There are no signs of knee laxity or
malalignment.
Setting:
Outpatient Physiatry.
Results:
Plain film imaging of the left knee is normal. Ultraso-
nography of the left knee reveals a hyperechoic ovoid-shaped
calcific deposit located within and underlying the proximal MCL,
adjacent to the margin of the medial femoral condyle. MRI of the
left knee is significant for minimal remodeling of the MCL proxi-
mally with a rounded focus of signal void, measuring approxi-
mately 5 7 mm, along the far posterior margin of the ligament,
the appearance of which is most consistent with hydroxyapatite
deposition.
Discussion:
Based on ultrasonography, and corroborated with MRI, the
diagnosis of Pellegrini-Stieda syndrome (PSS) is made and the patient is
treated with lavage, aspiration and a corticosteroid injection.
Following the procedure, the patient reports a 75% pain reduction, and
at 2 weeks reports a 90% pain reduction. First described by Augusto
Pellegrini in 1905 and Alfred Stieda in 1908, PSS is the radiographic
finding of a calcification at the origin of the MCL after a history of
trauma around the knee. In this case report, the presentation of
medial knee pain 2 weeks following direct impact to the medial left
knee, correlated radiographically with hydroxyapatite deposition
along the proximal posterior MCL, is consistent with a typical pre-
sentation of PSS.
Conclusions:
This case is the first report documenting the utility of
ultrasound in the diagnosis of PSS as well as the first report of using
ultrasound-guided percutaneous lavage as a successful treatment.
Level of Evidence:
Level V
Poster 234:
Treatment of First Metacarpophalangeal Joint
Instability and Snapping Thumb Using Ultrasound-
guided Prolotherapy and Hydrodissection: A Case
Report
Sheng-Chun Kung, MD (Chi Mei Medical Center, Tainan, East Dist.,
Taiwan, Province of China), Daniel Chiung-Jui Su, MD, Willy Chou, MD
Disclosures:
Sheng-Chun Kung: I Have No Relevant Financial Re-
lationships To Disclose
Case/Program Description:
A 28-year-old, breast-feeding women
presented with left radial styloid process pain and snapping sensa-
tion when extended left thumb for 4 months. Ultrasound (US)
evaluation showed swollen over both left abductor pollicis longus
(APL) and extensor pollicis brevis (EPB) tendons. The dynamic US
images showed rubbing at intersection of radial extensor tendons
with APL and EPB. Present of bifid APL tendons is noted and there is
a snapping phenomenon when the EPB tendon glided over APL
tendon during thumb extension and abduction. She received phys-
ical therapy for 2 months and intersection syndrome improved, but
snapping thumb persisted with pain. Follow-up US examination
revealed superficial radial nerve entrapment and still snapping
phenomenon. US-guided hydrodissection with dextrose 5% was
performed over distal superficial radial nerve, APL and EPB tendons.
The effect of hydrodissection lasted for 2 days then pain scale
returned to 7/10. On the next follow-up, US-guided prolotherapy
with dextrose 15% was performed over left MCP joint and ulnar
collateral ligament of thumb due to laxity of left thumb with dorsal
displaced metacarpal end of MCP joint.
Setting:
Medical Center.
Results:
Prolotherapy was done two times in 1 month. At 1 month
postinjections, the patient reported complete resolution of pain.
There was no recurrence at 6-month follow-up.
Discussion:
Multiple APL tendons is an anatomic variation which in-
creases the risk of de Quervain disease. US-guided hydrodissection was
proven to successfully relieve the snapping phenomenon. In our case,
the superficial radial nerve was entrapped by adhesive APL and EPB
tendons, however, the effect of hydrodissection did not maintain. The
result of injection is prolonged after performing regenerative medi-
cine over the loosened MCP joint, and the response was great in our
case.
Conclusions:
US-guided prolotherapy combined with hydrodissection
is an efficacious treatment for chronic de Quervain disease caused by
first MCP joint laxity and superficial radial nerve entrapment.
Level of Evidence:
Level V
S206
Abstracts / PM R 9 (2017) S131-S290