“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