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thickening of superficial Achilles bursa, no tendon tear. Patient was
treated initially with NSAID and home exercise program. 4 weeks later
patient returned without symptomatic improvement, and elected to
have an ultrasound-guided hydrodissection of the Achilles tendon and
fat pad. The procedure involved injecting 3mL ropivicaine deep to the
Achilles tendon superficial to the Kaeger’s fat pad. Next 12mL sterile
saline was injected to hydrodissect the tendon from the fat pad.
Setting:
Sports Medicine Clinic.
Results:
2 weeks after the procedure the patient reported a 70%
decrease in pain.
Discussion:
Histologic analysis of Achilles and patellar tendinopathy
have demonstrated pathologic angiogenesis stemming from the adja-
cent fat pads. These new blind-ending neovessels are paralleled by
neo-nerves which may contribute to tendinopathic pain. Hydro-
dissection of the tendon from the fat pad disrupts the neo-innervation,
and therefore may improve pain.
Conclusions:
Ultrasound guided hydrodissection of Achilles tendon
and fat pad is a viable option for treating chronic Achilles
tendinopathy.
Level of Evidence:
Level V
Poster 245:
Lumbar Fat Herniation as an Etiology of Low Back
Pain: A Case Report
Christopher J. Rizik, DO (Wm Beaumont Hosp, Royal Oak, MI, United
States), Evan Halchishick, DO
Disclosures:
Christopher Rizik: I Have No Relevant Financial Re-
lationships To Disclose
Case/Program Description:
An 86-year-old man presented with
complaint of left sided low back pain. He reported a focal, non-
radicular, high intensity pain. Symptoms presented without preceding
overt trauma, and worsened over a period of months. X-ray of the
lumbosacral spine and CT abdomen/pelvis failed to demonstrate an
acute correlative process to his symptoms. He exhibited focal tender-
ness to palpation just inferior to the posterior rib angles of the lower left
sided ribs. Additionally, a prominent soft tissue mass was visualized over
the posterior lateral torso, and coincided with the area of maximal
tenderness. A focused re-reading of the obtained CT imaging study by
the Radiology department led to an interpretation of lumbar fat herni-
ation, with inflammatory changes at the stump of the hernia.
Setting:
Acute hospital setting, regular medical floor.
Results:
On physical exam, the patient demonstrated intact active
range of motion, sensation, strength, and reflexes throughout the lower
extremities. Long tract signs were negative. Therewas no provocation of
pain symptoms with palpation or percussion of the midline lumbar spine
or sacroiliac joints. A diagnosis of Rib Tip Syndrome was considered.
However, the lumbar fat herniation was designated the most likely
etiology of pain. General Surgery was consulted and recommended
outpatient follow up for anticipated surgical removal.
Discussion:
This patient presented with severe pain that was assessed by
different physicians toinvolve the abdomen, flank, and back. Therewas no
clinical or radiographic evidence to implicate the axial spine as the
correlative agent of pain. A nodular soft tissue mass was visualized and
palpated, and sat over the area of maximal tenderness. A posterior lumbar
fat hernia pain is a known, but rarely seen, etiology of acute back pain.
Conclusions:
We report a case of progressive, focal low back pain
with an underlying etiology of posterior lumbar fat herniation.
Level of Evidence:
Level V
Poster 246:
Calcific Bursitis of the Illiopsoas Bursa Causing Left
Groin Pain in an Active Runner
Marc P. Gruner, DO (WA Hosp Cntr/Georgetown Univ), Simon M. Willis,
MD, Luis A. Guerrero, MD
Disclosures:
Marc Gruner: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
A 35-year-old woman presented with left
groin pain that began after a long flight from Paris, France to Wash-
ington, D.C. The pain initially started as soreness in her left groin, but
progressively worsened over the next few days prompting a visit to the
ER. After a negative pelvic exam and slightly elevated C-reactive
protein, a computed tomography (CT) scan of the abdomen and pelvis
demonstrated calcific iliopsoas bursa without other major pathology.
She was subsequently seen in the sports medicine clinic with increased
pain, radiating cephalad and caudally in the distribution of the left hip
flexor tendon. She reported that the pain was aggravated with left hip
flexion.
Setting:
Outpatient Academic Sports Medicine Center.
Results:
Ultrasound (US) of the hip demonstrated a hyperechoic re-
gion in the iliopsoas bursa with no joint effusion. Under US guidance,
the calcific bursa was fenestrated multiple times using a 3.5-inch
spinal needle while injecting a mixture of 40 mg Kenalog and 4 cc of 1%
Lidocaine, with complete pain resolution after completion of the
procedure.
Discussion:
Iliopsoas bursitis etiology usually is secondary to hip joint
degenerative changes or tendinopathy of the iliopsoas. The bursa
communicates with the hip joint in up to 15% of the population and a
hip effusion can cause an iliopsoas bursitis. Calcification within the
bursa is very rare and etiology unclear. Multiple etiologies of calcifi-
cation include repetitive micro trauma, local trauma, ischemia, sec-
ondary diseases (renal disease, collagen diseases, vitamin D overload,
and autoimmune conditions). In our patient, it is likely multifactorial
in how the patient’s bursa was calcified. Calcific lavage has worked
very well for calcific tendinosis, but this case demonstrates successful
treatment within the bursa.
Conclusions:
This case illustrates how ultrasound can be effective
diagnostic and therapeutic tool to treat calcific iliopsoas bursitis.
Level of Evidence:
Level V
Poster 247:
Isolated Lateral Collateral Ligament Tendinopathy
and Rupture - Two Cases of a Rare Injury Pattern: A
Case Report
Alan Schleier, DO (New York University Medical Center, New York, NY,
United States), Baruch Kim, Resident, Yu M. Chiu, DO,
Wayne L. Stokes, MD
Disclosures:
Alan Schleier, DO: I Have No Relevant Financial Re-
lationships To Disclose
Case/Program Description:
We describe 2 cases of isolated lateral
collateral ligament injuries. Our first case is a 32-year-old man who
presented with worsening atraumatic right knee pain for 2 months.
The pain was focal and located along lateral aspect of the knee. Pa-
tient works at the airport handling baggage and also is an avid
skateboarder. Physical examination revealed focal tenderness along
the LCL and pain without laxity during varus stress testing. We also
report a 19-year-old female college soccer player who presented after
a twisting injury to her right knee. She admitted to experiencing a
“popping” sensation at the time of injury, and noted persistent pain
despite conservative treatment measures. On physical examination,
there was evidence of mild effusion and varus laxity with tenderness
over the LCL.
Setting:
Outpatient Sports Medicine Clinic.
Results:
Case 1: ultrasound revealed focal thickening and hypoechoic
texture of the distal LCL, consistent with sprain. Case 2: MRI of the
right knee revealed evidence of an isolated tear of the LCL.
Discussion:
For case 1, we believe the patient’s isolated LCL injury is
due to repetitive stress, specifically increased varus stress during
skateboarding, combined with repetitive rotational forces placed on
the knee during baggage handling. In case 2, we believe the patient’s
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Abstracts / PM R 9 (2017) S131-S290