1. Doc,I cant walk now! Rick Horak, MD Primary Care Sports Medicine Fellow ASMI SEACSM 11 Feb 2012

2. 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

3. Medical History PMHx: Negative, especially for any bleeding or clotting disorders Medications: Periactin PRN Allergies: None FHx: Negative SHx: No tobacco or ETOH

4. Physical Exam General: WD WN 16 yo male MMSE: Alert and Oriented x 4 Vitals: 6 feet, 175 pounds

5. 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

6. 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

7. 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

8. Questions

9. 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

10. Differential Diagnosis Continued Congenital, Developmental Disorders – Hip osteochondrosis – Capital Epiphysitis Anatomic, Structural Disorders – Lumbar Herniated Disk Syndrome – Hamstring tightness – Slipped Capital Epiphysitis – Meralgia Paresthetica

11. IMAGING

14. Imaging

17. Initial Working Diagnosis Deep right thigh bruise

18. 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

19. 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

20. 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

21. Musculoskeletal Exam Continued Strength and Tone: – No atrophy – Limited knee extension against resistance Gait: – Limited weight bearing secondary to pain Neurological: – Sensation intact throughout

22. Questions

23. Differential Diagnosis Hematoma Tendon Rupture Myositis Ossificans

24. Treatment Plan Continue using crutches provided by the ER Obtain MRI of the right thigh

25. MRI: T1 Axial

26. MRI: T1 Sagittal

27. MRI: T2 Axial

28. MRI: T2 Coronal

29. MRI: T2 Sagittal

30. 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

31. 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

32. 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

33. Final Plan Release to all sports without restrictions