S211 S290
isolated LCL injury is primarily due to the reported twisting injury
while playing soccer in addition to the cumulative rotational stresses.
Conclusions:
We are reporting cases of isolated LCL injuries which are
known to be rare. These two cases demonstrate that isolated LCL in-
juries may occur as a result of both acute and chronic stress patterns.
Level of Evidence:
Level V
Poster 248:
Dynamic Ultrasound in the Diagnosis of Retrocalcaneal
Bursitis Causing Posterior Ankle Impingement with
Dorsiflexion: A Case Report
Julia Reilly, MD (Spaulding Rehabilitation Hospital/Harvard Medical
School, Charlestown, MA, United States, Charlestown, MA, United
States), Robert Diaz, MD, Minna J. Kohler, MD
Disclosures:
Julia Reilly: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
This patient presented with persistent
right posterior ankle pain for 6 weeks worsened with ankle dorsiflexion.
She had increased her activity level in prior months by participating in
Zumba exercises. One month prior to presentation, she was clinically
diagnosed with Achilles tendinopathy by an orthopedist. Symptoms did
not improve with Physical Therapy and anti-inflammatory medications.
Examination was notable for pain with passive ankle dorsiflexion and
tenderness to palpation along her posterior ankle at the level of the
Achilles tendon insertion/retrocalcaneal bursa region without visible
swelling. Diagnostic ultrasound revealed moderate retrocalcaneal
bursitis without Achilles tendinopathy, enthesitis, or erosions. Dynamic
view of posterior ankle in dorsiflexion showed bursal impingement on
the Achilles tendon, reproducing patient’s symptoms. Due to persistent
pain, an ultrasound-guided retrocalcaneal bursa corticosteroid injec-
tion was performed. Her ankle was immobilized in an aircast boot for 2
weeks and repetitive ankle activity was limited after immobilization.
Setting:
Tertiary Rheumatology Musculoskeletal Ultrasound Clinic.
Results:
At 8-weeks post-injection, the patient reported significant
improvement in her ankle pain and tenderness. Follow-up ultrasound
revealed reduction in bursal thickening with no further impingement.
Discussion:
Diagnostic ultrasound with dynamic maneuvers can
accurately diagnose the etiology of posterior ankle pain. Ultrasound
with clinical correlation identified the pain to arise from the retro-
calcaneal bursa, and dynamic views confirmed impingement and
reproduced pain with dorsiflexion. Retrocalcaneal bursitis is not often
considered in the differential diagnoses of posterior ankle impinge-
ment symptoms. In this case, corticosteroid injection provided tar-
geted therapy to the bursa. Injection to the tendon is contraindicated
with her previous suspected diagnosis of Achilles Tendinopathy.
Conclusions:
Dynamic ultrasound can improve the diagnostic accu-
racy of posterior ankle pain. With clinical correlation, the pain
generating structure can be visibly identified, and dynamic maneuvers
can confirm impingement symptoms. This case highlights how point-of-
care ultrasound can expedite diagnostic accuracy and guided treat-
ment in posterior ankle pain.
Level of Evidence:
Level V
Poster 249:
Ultrasound Guided Tarsal Tunnel Injection for
Diagnosis and Treatment of Tarsal Tunnel Syndrome:
A Case Report
Rohan Kapoor, MD (WA Hosp Cntr/Georgetown Univ)
Disclosures:
Rohan Kapoor: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
Our patient is a 54-year-old man who
presented to clinic with bilateral foot pain. The pain started at the
hallux of both feet and over time spread through the dorsal aspects.
He denied any inciting event or trauma in the past. Extensive workup
was completed by his Orthopedist, including EMGs, arteriogram, MRI,
and bone scan, but results were unremarkable. Past treatment
included a physical therapy course and had multiple lumbar epidural
steroid injections preformed with no improvement.
Setting:
Outpatient Musculoskeletal Clinic.
Results:
Although EMG was negative for tarsal tunnel syndrome,
strong clinical suspicion was present. Ultrasound guided tarsal tunnel
injection of Lidocaine was performed with good relief of his symptoms
helping our team make a diagnosis. This was followed by a cortico-
steroid injection. Follow up visits at 1 month proved this intervention
provided greater than 80 percent improvement of his pain.
Discussion:
Tarsal tunnel syndrome is caused by compression of the
components of the tarsal tunnel under the flexor retinaculum at the
level of the ankle or below. Diagnosis is typically made with history,
clinical exam, EMG studies, and imaging. In our case EMG studies and
imaging were inconclusive. Clinical suspicion was high for nerve
entrapment under the flexor retinaculum even with negative studies.
In office ultrasound guided anesthetic injection was a valuable diag-
nostic tool that assisted us in coming to a diagnosis. Ultrasound guided
injection in the tarsal tunnel can be of both diagnostic as well as
therapeutic value.
Conclusions:
With strong clinical suspicion, negative EMG and imaging
may not rule out tarsal tunnel syndrome. Ultrasound-guided injection
to the tarsal tunnel can have both diagnostic and therapeutic value.
Level of Evidence:
Level V
Poster 250:
Congenital ACL Deficiency and Advanced Knee Osteoarthritis
Gregory R. Kelley (WA Hosp Cntr/Georgetown Univ)
Disclosures:
Gregory Kelley: I Have No Relevant Financial Relation-
ships To Disclose
Case/Program Description:
A 60-year-old man with no known ortho-
pedic history presented to our outpatient musculoskeletal clinic with
several years of bilateral knee pain made worse with weight bearing.
He was mostly wheelchair bound for community distances, partly from
weakness resulting from a prior stroke and partly from severe knee
pain. Given bilateral ligamentous laxity on physical exam including a
positive Lachman test, an MRI was ordered which, along with his se-
vere tricompartmental arthritis, showed bilateral ACL deficiency and
medial meniscus degeneration. His pain did not respond well to con-
servative measures such as steroid injection, viscosupplementation, or
physical therapy.
Setting:
Musculoskeletal clinic.
Results:
Per patient request, the patient was referred to orthopedic
surgery for consideration of bilateral knee replacement given his sig-
nificant osteoarthritis, failure to respond to conservative measures,
and functional limitation.
Discussion:
Congenital ACL deficiency has been described in or-
thopedic literature as a rare occurrence that can manifest as an
isolated occurrence or as part of a syndrome with other structural
and anatomic skeletal defects. Generally, ACL reconstruction is
considered if symptomatic knee instability is present; however,
there are no significant studies comparing the outcomes of surgical
versus nonsurgical treatment of congenital ACL absence (partly
given his rarity). It is also unclear to what degree surgical inter-
vention in these patients may delay or halt the development of
osteoarthritis. Until further studies clarify this, a reasonable man-
agement may include physical therapy to enhance stabilizing
muscular forces around the knee, an exercise regimen that limits
compressive knee forces and close follow-up for clinical or radio-
graphic evidence of further knee compromise.
Conclusions:
While our patient was not a good candidate for recon-
structive surgery, there is still debate how to best manage congenital
ACL deficiency in the absence of overt clinical instability as well as its
role in the development of future knee arthritis.
Level of Evidence:
Level V
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Abstracts / PM R 9 (2017) S131-S290