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“Doc,I can’t walk now!”
Rick Horak, MDPrimary Care Sports Medicine Fellow
ASMISEACSM
11 Feb 2012
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
Medical History
• PMHx: Negative, especially for any bleeding or clotting disorders
• Medications: Periactin PRN• Allergies: None• FHx: Negative• SHx: No tobacco or ETOH
Physical Exam
• General: WD WN 16 yo male• MMSE: Alert and Oriented x 4• Vitals: 6 feet, 175 pounds
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
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
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
Questions
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
Differential Diagnosis Continued
• Congenital, Developmental Disorders– Hip osteochondrosis– Capital Epiphysitis
• Anatomic, Structural Disorders– Lumbar Herniated Disk Syndrome– Hamstring tightness– Slipped Capital Epiphysitis– Meralgia Paresthetica
IMAGING
Imaging
Initial Working Diagnosis
• Deep right thigh bruise
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
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
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
Musculoskeletal Exam Continued
• Strength and Tone:– No atrophy– Limited knee extension against resistance
• Gait:– Limited weight bearing secondary to pain
• Neurological:– Sensation intact throughout
Questions
Differential Diagnosis
• Hematoma• Tendon Rupture• Myositis Ossificans
Treatment Plan
• Continue using crutches provided by the ER• Obtain MRI of the right thigh
MRI: T1 Axial
MRI: T1 Sagittal
MRI: T2 Axial
MRI: T2 Coronal
MRI: T2 Sagittal
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
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
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
Final Plan
• Release to all sports without restrictions