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gracilis transfer to LUE for elbow flexion with tenodesis of FDP. The
patient returned for electromyography of the free gracilis transfer.
Setting:
Level I Trauma Center, Inpatient Rehabilitation Facility.
Results:
Muscle atrophy was noted in left upper arm and forearm. The
patient had full ROM to shoulder, elbow, wrist, and fingers. Patient had
0/5 strength for all muscle units below elbow and reported no
sensation below the elbow to light touch with absent reflexes. Elec-
tromyography was performed in at three sites in the muscle, proximal
(15 1cm from antebrachial fossa), middle (9x1cm from antebrachial
fossa), and distal (5 1cm from antebrachial fossa). Spontaneous ac-
tivity was noted with fibs and positive sharp waves along with poly-
phasics at all sites, consistent with reinnervation. Ultrasound was then
performed and showed the gracilis transfer was seen intact in the
upper arm with healthy muscle belly. Other forearm muscles were
noted to have significant muscular atrophy.
Discussion:
Correlation between electromyography and ultrasound is
important for assessing reinnervation after free muscle transfer. Elec-
tromyography may demonstrate reinnervation or no activity, while
musculoskeletal ultrasound images the important anatomical structures.
Conclusions:
Together, these tools can provide information regarding
the success of neurotized, functional free muscle transfers and may
help guide further treatment or diagnose early free flap failures.
Level of Evidence:
Level V
Poster 242:
Novel Techniques to Diagnose and Treat Popliteal
Artery Entrapment Syndrome
Marc P. Gruner, DO (WA Hosp Cntr/Georgetown Univ), Mark Kasmer,
MD
Disclosures:
Marc Gruner: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
This is a 19-year-old female runner that
presented with bilateral lower leg pain and paresthesias during running.
Multiple providers evaluated this patient for 6 years, having had tests such
as x-ray, MRI, bone scan, angiography, and compartment pressure testing.
At her initial visit, we confirmed the diagnosis of dynamic popliteal artery
entrapment syndrome (PAES). We used dynamic ultrasound to demon-
strate complete loss of blood flow through the popliteal artery during
sustained plantar flexion immediately following symptom onset invoked
by treadmill running. Treatment options discussed with this patient
included partial gastrocnemius surgical resection, botulinum toxin in-
jection to the gastrocnemius, and activity modification. Discussing with
multiple physicians, we decided to perform Botox injections.
Setting:
Outpatient Sports center.
Results:
Under ultrasound guidance, we injected 60 units of Botox
into the right medial and lateral gastrocnemius; we injected 40 units
each into the less symptomatic left medial and lateral gastrocnemius.
The patient was held out of competition until symptom-free during
running, which was 6 weeks. The symptoms returned 6 months later,
two additional Botox injections were performed with resolution of
symptoms.
Discussion:
This case illustrates the use of ultrasound for the diag-
nosis and treatment of PAES. Diagnostic ultrasound may be equally
efficacious and significantly more cost effective than other imaging
used to diagnose PAES. Additionally, ultrasound has dynamic capa-
bility, including provocative testing, as well as Doppler, which quan-
titatively measures blood flow. There are few cases of PAES treated
successfully with Botox injections. This patient achieved complete
symptom resolution for 3-9 months after each injection. Further
research, not only in diagnosis and treatment, but also more stan-
dardized return to sport protocol are necessary to determine effec-
tiveness of Botox injections as a treatment for PAES.
Conclusions:
Dynamic ultrasound may be a safe, more cost-effective
option to accurately diagnose PAES. Additionally, Botox could be an
alternative to surgery for these patients.
Level of Evidence:
Level V
Poster 243:
Hereditary Neuropathy with Liability to Pressure
Palsy (HNPP) Presenting as Shoulder Weakness: A
Case Report
Anupam Sinha, MS DO (Rothman Inst, Mount Laurel, New Jersey,
United States), Madhuri Dholakia, MD
Disclosures:
Anupam Sinha: I Have No Relevant Financial Relation-
ships To Disclose
Case/Program Description:
A 25-year-old man presented with
complaint of several years of left shoulder weakness. This had been
painless until about 6 months ago when he developed left anterior
shoulder pain, worsened with weightlifting. He denied radicular pain
or weakness of the other limbs.
Physical examination revealed 4/5 strength in the left biceps and
triceps, 3/5 strength in the left deltoid, and 3/5 strength in the left
shoulder external rotators. There was mild left scapular winging. Re-
flexes were intact. Long tract signs were negative.
Setting:
Outpatient orthopedic practice.
Results:
Nerve conduction studies revealed abnormal median,
ulnar, and radial sensory responses; abnormal sural sensory
response; abnormal left median and ulnar motor responses; and
abnormal left peroneal motor response. Electromyography revealed
denervation potentials in the left infraspinatus and supraspinatus
muscles. The remainder of the needle examination was normal. The
patient was diagnosed with acute left suprascapular neuropathy
with an underlying sensory motor demyelinating peripheral poly-
neuropathy. The patient was referred to neurology for further
evaluation. Additional bloodwork and genetic testing was performed
revealing a mutation of the PMP22 gene, consistent with a diagnosis
of HNPP.
Discussion:
HNPP is characterized by repeated focal pressure neu-
ropathies with the initial presentation occurring between the ages of
20 to 40. Some affected individuals also have signs of a peripheral
neuropathy. HNPP is confirmed with recurrent focal compression
neuropathies and family history consistent with autosomal dominant
inheritance. Mutation of the PMP22 gene is seen in 80% of cases.
Peroneal, ulnar, median, and radial nerve palsies are most common.
Treatments consist of temporary splinting and bracing of the affected
area, along with activity modification to prevent pressure on vulner-
able areas of nerve compression.
Conclusions:
We present a rare case of HNPP presenting as supra-
scapular neuropathy. Clinicians should be aware of this diagnosis and
consider it in patients who present with isolated nerve weakness.
Level of Evidence:
Level V
Poster 244:
Hydrodissection of Achilles Tendon and Fat Pad as a
Treatment of Chronic Achilles Tendinopathy: A Case Report
Ray A. Stanford, DO (New York University), Dallas Kingsbury, MD
Disclosures:
Ray Stanford: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
A 44-year-old man presented to a sports
medicine clinic with 4 months of right heel pain. Patient reported
symptoms started after sliding to second base while playing baseball.
Heel pain initially improved, then later the pain returned and per-
sisted through the patient’s season of flag football. The pain was
described as constant, achy, and deep; worsened with plantar flexion.
Pain at worst is 9/10 on push off during walking. The pain is specifically
located at the Achilles enthesis and does not radiate. The patient
reported a history of multiple minor ankle sprains. On physical exam,
patient had tenderness to palpation at right posterior calcaneus at
enthesis as well as the superficial distal Achilles tendon. Otherwise,
patient had full strength and range of motion. Focused MSK ultrasound
showed: large calcaneal enthesophytes with Achilles tendinosis both
midportion and insertion, positive power Doppler signal, slight
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Abstracts / PM R 9 (2017) S131-S290