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Athletes’ Knowledge of Concussions and the Decision to Seek Treatment
Jarem, O, Vosloo, J, Scriber, K; Ithaca College, Ithaca, NY
Context: Between 1.6 and 3.8 million sport related concussions (SRCs) are recorded annually; however this
may be an underestimate. Reasons for underreporting are of interest to sports medicine professionals and
educators, as failing to report this injury has potentially devastating consequences. Objective: To investigate
the prevalence of failure to report SRCs, reasons for failing to report, and to whom SRCs are reported to in
college athletics. Knowledge of symptoms and demographic differences were also examined. Design:
Retrospective, anonymous survey Setting: Online survey Participants: Six hundred and eighteen (618) NCAA
Division I and Division III soccer and lacrosse athletes from the northeast United States responded to the
survey; 603 (97.6%) completed all sections. Participants (female n=358, male n=243) aged between 18-25
(M=19.8; SD=1.3) and averaged 9.8 (SD=3.9) years of athletic participation. Interventions: Survey assessed
knowledge, concussion history, and reporting behavior. Forty Division I and Division III coaches from
men’s/women’s soccer/lacrosse teams were contacted via email to participate. Coaches’ subsequently
forwarded the survey link to their athletes, who had six weeks to participate. Descriptive statistics recorded
demographic information and knowledge quiz scores. Independent t-test compared the quiz scores in athletes
with prior SRC experience to athletes with no history of concussions. Chi-square analysis compared athletes
(Division I/Division III, soccer/lacrosse, male/female) on their likelihood of reporting SRCs. Main Outcome
Measures: Dependent variables in the study included prevalence of athletes with previous concussions,
reporting behavior, reasons why athletes failed to report and to whom they reported. Results: 42.3% of the
participants who sustained at least one concussion had failed to report this injury once, compared to the 57.7%
who reported their injury diligently. Reasons for failure to report included: “Didn’t want to be pulled out of the
game or practice” (43.2%, n=163), “Didn’t think it was serious enough” (40.6%, n=153), “Didn’t know it was a
concussion” (32.6%, n=123), “Didn’t want to appear weak,” (23.9%, n=90), and “Didn’t want to let down
teammates/coach” (22.3%, n=84). Athletes reported SRC to athletic trainers (74.1%), Parents (68.3%), Coaches
(59.0%), and Teammates (28.0%). Chi-square tests revealed no significant differences between gender on
failure to report a SRC, but significant differences between sport type (χ2 (1)=6.74, p<.01), and division level
(χ2 (1)=5.05, p<.05) indicates increased likelihood of failure to report in lacrosse/Division III. Athletes with
(M=17.13, SD=2.04) and without (M=16.60, SD=2.16) previous experience with concussions scored relatively
high on SRC knowledge quiz. Conclusions: Collegiate athletes are more knowledgeable of concussions than
previously believed; other factors may influence the decision to report (including a conscious choice to
withhold symptoms). Significantly more Division III/lacrosse athletes are likely to fail to report SRCs than
Division I/soccer athletes. Word Count: 454 words.
Impact Of Helmet Design And Work Setting On Time And Movement During Lacrosse Helmet
Facemask Removal By Certified Athletic Trainers
Boergers R, Cabell L, Pinto-Zipp G, Sisto S: Seton Hall University South Orange, NJ
Context: The 2009 NATA Position Statement on Acute Management of the Cervical Spine-Injured Athlete,
states that guidelines for management of the lacrosse athlete can not be made until there is evidence regarding
ease and safety of facemask (FM) removal. Athletic trainer work setting and helmet design may influence
removal time and head/neck movement. Knowledge of helmet design differences may help athletic trainers
provide effective acute management of suspected cervical spine injured athletes. Objective: The purpose of
this study was to assess the influence of work setting and helmet design on time and head/neck movement
during the FM removal process. Design: 2 x 5 factorial design with random assignment of helmet type was used
to assess the main and interactive effects of the independent variables [setting: (college, high school)] and
[helmet: (Triumph, CPX, Pro7, XR, Venom)] on time and head/neck movement in 3 planes. Setting:
University biomechanics lab. Patients or Other Participants: Twenty-four (12 high school, 12 college)
certified athletic trainers (age 35.8 ± 8.9) with at least 1 year experience working with lacrosse athletes.
Interventions: Subjects completed 1 trial of FM removal for each of the 5 different helmets worn by a human
model. Three dimensional kinematic data of the head/neck relative to the trunk were collected using a Vicon
motion capture system. The helmet was stabilized between the subject’s knees while removing the FM with an
electric screwdriver. Helmet testing order was randomized to control for ordering effect. Separate 2 x 5
repeated measures ANOVA were used to evaluate main and interactive effects of work setting and helmet
design on removal time and head/neck movement. Pairwise comparisons using a Bonferroni correction were
used post hoc. Main Outcome Measures: The dependent variables were removal time (sec), and maximal
head/neck movement (deg) in relationship to the trunk measured in three planes. Results: There was no
significant main effect of work setting on any of the outcome measures. There was a significant main effect of
helmet design on time. Mean removal times ranged from 31.09 – 79.02 sec. Four helmets (Triumph, CPX, XR,
Venom) took significantly less time to remove than the Pro7 helmet. The Triumph, CPX, XR took significantly
less time than Venom. The Triumph and CPX took significantly less time than the XR (p < .05). Significant
differences existed between maximal movement in the sagittal plane (p <.05). Maximal sagittal plane
movement in the Triumph helmet (7.08° ± 3.59°) was significantly more than the Pro7 (4.30° ± 2.39°). There
were no significant differences between helmets for maximal frontal and transverse plane movement. There
were no significant interactive effects on any of the outcomes. Conclusion: Helmet design affected time and
maximal head/neck movement. Work setting did not affect outcome measures. Word Count: 450
There are No Sex Differences in the Landing Biomechanics of Youth Soccer Athletes
Stephenson LJ*, DiStefano LJ†, Padua DA‡: ‡ University of North Carolina, Chapel Hill, North Carolina,
*Stony Brook University, Stony Brook, New York, †University of Connecticut, Storrs, Connecticut.
Context: Postpubertal females have been shown to have different landing biomechanics than males, which may
put them at increased risk for ACL injury. Limited knowledge is available regarding sex differences and landing
biomechanics in younger populations. Objective: To determine if there are sex differences in youth soccer
athletes’ landing biomechanics. Design: Cross-sectional. Setting: Research laboratory. Participants: Sixty
healthy soccer athletes (females: n=25, age=10±1 years, height=140.34±6.48cm, mass=33.06±5.03kg; males:
n=35, age=10±1 years, height=143.03±6.23cm, mass=34.42±5.34kg) volunteered to participate. Interventions:
One set of three trials of a jump-landing task was performed during a single test session. The task required
participants to jump forward from a 30cm high box placed a distance of half their height away from a force
plate, land with their dominant foot on the force plate, and immediately jump for maximal vertical height. An
optical three-dimensional motion analysis system and a force plate measured lower extremity kinematics and
kinetics. Main Outcome Measures: Dependent variables included sagittal and frontal plane knee angles at
initial contact and peak values over the stance phase. Peak vertical (VGRF), posterior (PGRF), and anterior
(AGRF) ground reaction forces (PGRF), internal knee extension moment, and external knee valgus moment
over the stance phase were also measured. Forces were normalized to body weight and moments were
normalized to body weight and height. Separate one-way analyses of variance were performed on the
dependent variables to assess group differences between males and females (α≤.05) and descriptive statistics
were used to identify mean values. Results: No significant differences were observed (P>0.05) in our main
outcome measures. A descriptive analysis of kinematic variables revealed that at initial contact participants
landed with 17.96±6.3° of knee flexion and 0.537±3.77° of knee valgus and peaked at 76.23±9.11° of knee
flexion and 5.51±8.21° of knee valgus during the jump landing task. Descriptive analysis of normalized peak
kinetic variables revealed VGRF=3.59±0.786%BW, AGRF=0.383±0.253%BW, and PGRF=-1.32±0.318%BW.
Conclusion: Male and female prepubertal soccer players are not significantly different in their biomechanical
landing strategies and tend to land in an extended knee position. This suggests that injury prevention programs
should be implemented in this age group to encourage proper landing technique before sex differences emerge.
Word Count: 353
Quadriceps Performance Profiles and Associations to Subjective Outcome Measures in Patients 12-36
Months Post-Ipsilateral Hamstring Tendons Anterior Cruciate Ligament Reconstruction.
Vairo GL*, Miller SJ*, McBrier NM†, Sebastianelli WJ‡, Sherbondy PS‡, Buckley WE*: Athletic Training
& Sports Medicine Research Laboratory, *Department of Kinesiology, ‡Department of Orthopaedics and
Rehabilitation, The Pennsylvania State University, University Park, PA; †Health Science Department, Lock
Haven University of Pennsylvania Clearfield Campus, Clearfield PA
Context: Primary harvest of the ipsilateral hamstring tendons autograft for anterior cruciate ligament (ACL)
reconstruction has become prevalent among orthopaedic surgeons. We previously reported knee flexor deficits
in patients following this operative technique. However, limited evidence exists in related patients for ensuing
quadriceps performance, which is a predictor to knee health-related quality of life (HRQL) post-ACL
reconstruction. Objective: Our primary aim was to profile knee extensor responses to ipsilateral semitendinosus
and gracilis (STG) autograft ACL reconstruction in physically active patients that demonstrated hamstrings
performance insufficiencies 12-36 months following surgery. Based on prior research, we hypothesized patients
would display quadriceps performance deficits for the involved leg compared to uninvolved and healthy
matched control legs. A secondary aim was to explore associations among subjective outcome measures and
objective quadriceps performance. Design: Retrospective cohort, Level 2b evidence. Setting: A controlled
research laboratory. Patients or Other Participants: Fifteen (1 man, 14 women) patients (age = 21.2 ± 2.6
years, height = 1.7 ± 0.1 m, mass = 68.7 ± 12.6 kg, Tegner = 6.9 ± 1.6) 27.5 ± 10.9 months post-surgery were
matched to 15 (1 man, 14 women) healthy matched control participants (age = 21 ± 1.1 years, height = 1.6 ± 0.1
m, mass = 67.4 ± 10.3 kg, Tegner = 6.3 ± 1.3). Interventions: The independent variable was the operative
technique. Isokinetic strength and endurance were measured at angular velocities of 60 º/s and 240 º/s
respectively using reliable methods. Subjective measures included the reliable Knee Outcome Survey (KOS)
and Knee Injury and Osteoarthritis Outcome Score (KOOS). Respective one-tail dependent and independent ttests were calculated to determine within patient and between participant differences. Correlation coefficients
were computed among the KOS and KOOS to quadriceps performance. P < 0.05 denoted statistical
significance. Main Outcome Measures: Dependent variables included: normalized peak moment and total
work; time to peak moment; angle of peak moment; KOS and KOOS subscale scores. Results: Data were
normally distributed. Patients demonstrated a significant difference for angle of peak moment with the involved
(73.0 ± 11.9 ˚) compared to uninvolved (77.4 ± 12.1 ˚) leg (P = 0.022). Patients also displayed a significant
correlation among the KOOS Sports subscale score and extensor strength (r = -0.533, P = 0.041) for the
involved leg. All other measures were insignificant (P > 0.05). Conclusions: The shallower angle of extensor
peak moment may be attributed to hamstrings antagonistic deficits to quadriceps induced knee extension
associated with donor-site morbidity. An inverse relationship among the KOOS Sports subscale score and
extensor peak moment indicates patients perceived better subjective athletic outcomes with lesser quadriceps
strength in the presence of hamstrings weakness. Our findings advocate continued investigation for determining
factors associated with knee HRQL in ACL reconstructed patients. Word Count: 450. Funded by the
Pennsylvania Athletic Trainers’ Society, Inc. Supported Research Grant
Influence of a Two Week Faculty Led Short Term Study Aboard Program on Athletic Training and
Exercise Science Student’s Attitudes Toward Cultural Awareness
Guyer, MS, Matthew, TD: Springfield College, Springfield, Massachusetts
Context: Current and prospective athletic training and exercise science students often ask if they can take a
semester off to study abroad. Unfortunately, pre-professional curriculums seldom allow students the opportunity
to study abroad for a semester due to the academic rigor and clinical demands. Objective: The purpose of this
study was to evaluate how a two-week faculty lead short term study aboard (FL-STSA) program would
influence the students’ perceptions and recollections about their attitudes toward four categories identified as
the essential elements of "cultural awareness". Design: Pre-post FL-STSA survey. Setting: A fifteen week on
campus course was followed by a two-week aboard program in Ireland. Participants: Participants (N = 27)
included Athletic Training (n = 12) and Exercise Science (n = 15) undergraduate students from 2 institutes of
higher education in Western Ma. Intervention: The International Awareness and Activities Survey ([IAAS]
Chieffo & Griffiths, 2004) was utilized to examine student attitudes after a FL-STSA program. Pre-test data
were obtained before the overseas portion of the trip and Post-test data were obtained at the completion of the
study abroad experience. Main Outcome Measure: The IAAS is designed to measure student perceptions and
recollections about their attitudes toward four categories identified as the essential elements of "cultural
awareness": (1) intercultural awareness; degree to which students were conscious of similarities and differences
between their culture and host cultures, (2) personal growth and development; mature attitudes and actions and
openness to new experiences, (3) functional knowledge; learning or expressing a desire to learn information or
skills relevant to travel in general or to a specific host site and (4) global interdependence; students’ awareness
of the interconnectedness of national, international and supra-national systems. Scores on the IAAS range from
5 (strongly disagree) to 1 (Strongly agree). To obtain subscale scores, items were summed and then averaged.
Repeated Measures t-tests were used to examine the differences in pre and post test scores for each subscale.
Results: Significant (p < .05) mean differences were found for all subscales, intercultural awareness (p < .001),
personal growth and development (p < .001), functional knowledge (p < .001) and global interdependence (p =<
001). For all subscales, percent improvement from pre to post test ranged from 18% - 34%. Conclusions:
Participants in the FL-STSA significantly improved their attitude toward global awareness. A two week FLSTSA program is a sufficient amount of time to influence student attitudes and beliefs. Word Count: 398
Comparing Instructional Methods in the Knowledge Acquisition of Musculoskeletal Anatomy in Athletic
Training Students
Rothbard, M: Southern Connecticut State University, New Haven, CT
Context: The importance and difficulty of teaching and learning musculoskeletal anatomy has been
documented previously. Little is recorded about the selection and implementation of instructional strategies to
improve knowledge acquisition of anatomy in athletic training students (ATS). Objective: To compare the
effect of traditional instructional methods (lecture, models, and charts) with traditional instructional methods
plus a computer based instruction (CBI) simulation program on knowledge acquisition of musculoskeletal
anatomy in undergraduate ATS. Design: A quasi-experimental, pre-test post-test counterbalanced comparison
design. Participants were randomly assigned to one of two conditions. Group one received traditional
instructional methods only for lower extremity course content and traditional instructional methods plus the CBI
simulation for upper extremity course content. Group two participated in reverse order. Setting: A 3-credit
undergraduate Anatomy and Physiology I course at a public university. Participants: A convenience sample of
24 ATS was used. Students were eligible to participate if seeking a Bachelor of Science degree, and no prior
university-level A&P coursework. A majority of participants (70.8%) were 19 years of age or younger and had
earned 0-29 credits (77.1%). There were slightly more men (56.3%) than women (43.8%). Interventions: A
CBI simulated cadaver dissection program consisting of dissection, animation, imaging, and self testing
modules. Main Outcome Measures: Student scores on pre and post-test upper and lower extremity multiple
choice and practical examinations (split half correlation coefficient =.784). T-tests and repeated measures
ANOVA with alpha levels of .05 were used to determine significant differences between the two conditions.
Results: For the lower extremity there was a significant main effect for written and practical examination scores
(F=263.24, P<.001) and a significant test score by intervention interaction (F=15.60, P<.001). Post hoc testing
revealed that test scores were significantly greater (t=2.75, p=.012, ES=1.12) in the CBI group (M=36.67,
SD=5.55) compared to the traditional group (M=30.67, SD=4.69).There were no significant differences in the
pre-test scores (t=-.529, p=.602) between the CBI (M=19, SD=4.69) and traditional (M=19.92, SD=3.75)
groups. For the upper extremity there was a significant main effect for written and practical examination scores
(F=246.33, P<.001) and a significant test score by intervention interaction (F=196.02, P<.001). Post hoc testing
revealed that test scores were significantly greater (t=3.17, P=.004, ES=1.29) in the CBI group (M=39,
SD=3.16) compared to the traditional group (M=31.42, SD=7.66).There were no differences in the pre-test
scores (t =-.219, P=.829) between the CBI (M=18.67, SD=4.4) and traditional (M=19.17, SD=6.59) groups.
Conclusions: Both groups of participants had increases in pre-post test scores; however, participants utilizing
traditional instructional methods plus CBI had greater post-test scores. The addition of a CBI simulated cadaver
dissection improved knowledge acquisition of lower and upper extremity musculoskeletal anatomy in
undergraduate ATS. Further work is needed to determine why this effect occurred. Word Count: 448
Continuing Education Among Athletic Trainers: A Qualitative Study
Samdperil, G: Sacred Heart University, Fairfield, CT
Context: Continuing education (CE) is intended to promote ongoing competence, in the areas of knowledge
and clinical skills, as well as to increase expertise that enhances professional practice. CE provides Certified
Athletic trainers (ATs) the opportunity for professional growth through intellectual engagement in meaningful
learning through formal activities (e.g., conferences, symposiums, and workshops). Furthermore, CE helps
foster a change in clinical decision making and clinical behaviors resulting in a change in patient care.
Objective: The purpose of this study is to examine ATs participation in continuing education and its perceived
impact on clinical practice. Included in this study is an analysis of the selection process, motivation factors to
participate, and barriers preventing participation are evaluated. Furthermore, job setting characteristics which
positively or negatively influence implementation of new information into clinical practice were also evaluated.
Design: A descriptive study with a qualitative design was followed with formal interviews and the collection of
fieldnotes. Setting: Individual interviews were conducted at each of the participant’s work sites, except for one
which was conducted at the researcher’s institution. Patients or Other Participants: The 15 participants for
this study consisted of five representatives from each of the three primary employment settings for athletic
trainers: colleges/universities, secondary schools and sports medicine clinics. Only currently practicing athletic
trainers were selected to participate in the process. All participants had been certified for a minimum of 3 years
and a maximum of 10 years. Data Collection and Analysis: Interviews were recorded and transcribed
verbatim. Analysis of the data, using Atlas 5.1 to code transcripts and identify emerging trends among the
participants and subgroups, was used. Results: Findings revealed three emerging trends among all group
participants that impacted participation in continuing education including: 1) timing of CE activity, 2) content
relevance to current job setting, and 3) the perceived value and culture of continuing education at the work
setting. Among the sub-groups, trends were identified in the areas of financial reimbursement, perceived value
of professional development by employer, and the ability to meet learning goals and objectives through CE
activities. Conclusion: Universally, the most profound influence found to determine participation in CE
activities was timing. Athletic trainers, regardless of work setting, felt an obligation to be at work, despite the
reason for absents. For those who did not receive financial support from their employer (all public high school
athletic trainers) cost was a major barrier. Many selected on-line CE learning opportunities to minimize cost and
impact on the employment setting. Most athletic trainers discussed the need to attend CE activities during the
summer months to decrease or eliminate any impact on their employer. Word Count: 450
Comparison of Time and Difficulty during Football Helmet and Facemask Removal
Beltz EM, Day MA, Decoster LC, Swartz EE, Mihalik, JP: University of New Hampshire (Durham, NH),
New Hampshire Musculoskeletal Institute (Manchester, NH), University of North Carolina, Chapel Hill,
NC.
Context: Sports medicine professionals presented with a potentially spine-injured athlete must effectively
manage the situation to avoid iatrogenic sequelae. This is complicated in football where protective equipment
inhibits airway access. Current guidelines for managing such injuries recommend removing the facemask rather
than the helmet. However, previously published studies have not directly compared helmet and facemask
removal. Objective: To compare time, split time and difficulty of facemask (FMR) and helmet removal (HR) in
two different helmet styles. A secondary objective was to compare these variables during HR with air bladders
either inflated or deflated. Design: Repeated measures. Setting: Controlled laboratory. Participants: 22
certified athletic trainers (15 males, 7 females 33.9±10.5 yrs, 11.4±10.0 yrs certified, 172±9.4 cm, 76.7±14.9
kg). All participants were free from upper extremity or CNS pathology for 6 months and signed an IRBapproved consent. Interventions: Independent variables consisted of removal technique, helmet type, and
bladder deflation status. After familiarization, participants conducted 2 successful trials of 6 conditions in
random order. Conditions consisted of FMR and HR on two helmets: Riddell Revolution™ and Riddell
VSR4™. Trials involving HR were completed with participants either deflating (D) accessible air bladders or
leaving bladders inflated (I). Helmets and facemasks were removed from a live model who wore properly fitted
helmets and shoulder pads. The modelʼs head was stabilized by the participant and an investigator. RPE
(modified Borg CR-10 scale) was reported by the participant after each trial. Repeated-Measures ANOVAs
with Bonferroni correction were conducted to compare time, split time and RPE for FMR and HR. Paired t-tests
were used to compare collapsed FMR and HR data for each dependent variable. Alpha=P< 0.05. Main
Outcome Measures: Total time and split time required for FMR and HR, and the level of difficulty. Because
HR involves more steps than FMR, split times reflect time required for chinstrap and cheek-pad removal before
actual HR. Results: Regardless of helmet, FMR (37.97±5.24s) was faster (p=0.001) and easier (1.93±0.85)
(p<0.001) than HR (96.13±23.15s, RPE 3.71±1.18). FMR in the Revolution (33.64±7.46s) was faster (p=0.008)
than VSR4 (42.3±6.96s). HR-I in the Revolution (51.98±20.43s) was faster (p<0.001) than HR-D
(67.40±16.63s). Review of split times collected revealed 65.5% and 87.1% of HR time for Revolution and
VSR4, respectively, was spent performing tasks required before actually removing the helmet. Inflation status
did not affect time or difficulty during VSR4 HR. Conclusions: Removing a facemask provides for faster and
easier airway access than removing a helmet in the Revolution® and VSR4helmets, validating current
recommendations. Overall, removal was easier and faster in the Revolution® than in the VSR4, indicating that
recent helmet designs improves time to airway access. Word Count: 432
Cervical Spine Motion during American Football Equipment removal Protocols: A Challenge to the Allor-Nothing Endeavor
Jacobson BR, Cendoma M, Gdovin J, Cooney KM, Bruening DA: * Mercyhurst College, Erie, PA, +
Shriner’s Hospital, Erie,PA
Context: The all-or-nothing endeavor related to equipment-laden athletes has recently been instituted within
the NATA position statement with regard to acute management of the cervical spine injured athlete. However,
research used to support the statement has not considered alternative protocols or measured spine movement
throughout the equipment removal process. Objective: To determine the amount of cervical spine movement
produced by BOC athletic trainers upon implementation of the all-or-nothing endeavor and to compare these
findings to an alternative pack-and-fill-protocol. Design: Crossover study. Setting: Controlled laboratory
setting that was similar to an on-field evaluation site in order to mimic real life scenarios with regard to the
injured athlete. Participants: Eight male collegiate athletes and four selected BOC athletic trainers. The
targeted population was football athletes all which met the availability of the study and provided anatomical
differences which gave enough variability to the research in regards to body composition. The athletic trainers
recruited for the study were all certified and proficient in their skill set and only required a ten-minute session
prior to performing the removal protocols to provide more accuracy to the study. Interventions: Four different
equipment removal protocols were employed and compared. Motion capture analysis was used to track the
motion of the head relative to the sternum as the ATCs performed the removal protocols. Main Outcome
Measures: Cervical spine motion (head relative to sternum); measured as translations and rotations. 4x4
ANOVAS with repeated measures were used to compare discrete motion variables (changes in position and
total excursions) among protocols and athletic trainers. Results: Removal of the helmet and shoulder pads
resulted in a mean 1.4 cm drop in head positioning, compared with a mean 0.1 cm drop when pack-and-fill was
employed (p=0.002). Total angular and linear excursions during equipment removal were also different
between the same two protocols, with pack-and-fill showing 3.7 degrees less angular movement (p=0.034) and
1.8 cm less vertical movement (p<0.001) than shoulder pad removal. Conclusion: The pack-and-fill method
resulted in less overall motion than removal of the helmet and shoulder pads together when compared to the
NATA statement regarding the all-or-none principle. These findings have the potential to replace the all-ornothing endeavor. The methods used in this study may be applied to future research on sport specific or
manufacture/model specific equipment to assess the potential benefits of the pack-and fill method with other
protective athletic equipment. Another future direction is the investigation of the entire treatment process from
initial assessment through spine boarding and transportation.
446 words
Cam Type Femoroacetabular Impingement with Labral Tear in A Collegiate Ice Hockey Player: A Case
Study
Adelman DA, Geisler PR, Kelly E. Ithaca College: NY
Background: Femoroactebular Impingement (FAI) is a relatively new concept for sports medicine practitioners
that’s seen increased prevalence over the last 15 years. FAI can be a debilitating disorder for athletes and a
complex diagnosis for clinicians, particularly those involved in sports such as hockey, soccer, or basketball that
require constant cutting and acceleration/deceleration movements. We present a case of a Cam FAI in a 20year-old Division I Men's Ice Hockey player in December 2009. The athlete initially complained of soreness in
the right hip that manifested as pain with skating and resisted hip flexion. He was initially diagnosed with a hip
flexor strain and treated conservatively with light stretching, ice, and rest; but did not respond well to
conservative care. The case was managed surgically in June 2010, and rehabilitation was implemented to
effectively return the athlete to normal function and competition. Differential Diagnosis: Cam or pincer-type
FAI, hip flexor strain, adductor strain/tendinopathy, athletic pubalgia, femoral neck stress fracture, and pubic
symphysis. Treatment: With the aid of radiographic and magnetic resonance imaging (MRI), the pathology
was diagnosed as bilateral cam-type FAI. The decision to undergo arthroscopic surgery was made based on
debilitating pain levels in the right hip, and his desire to fully participate the following season with minimal
limitations. Surgical intervention involved right hip arthroscopy to improve joint congruency, labral resection,
and osteochondroplasty to remove the osseous cam deformity on the femoral head-neck junction. The decision
was made to delay surgery on the left hip because symptoms were not as severe or functionally limiting. A
rehabilitation program was then established to eliminate pain, improve ROM, increase hip musculature strength,
and restore sport specific function. Uniqueness: This particular case was unique in that FAI is a relatively new
concept that involves activity-specific dynamic hip motion, and because it presented in an acute fashion, rather
than an expected slow, insidious onset. The bilateral considerations also make management of this case unique
because of the tolerable symptoms in the left hip, and the decision to delay surgery on the left hip until post
season. Conclusion: After reviewing the case and literature related to FAI prevalence, the management of this
case was appropriate given the athletes eventual return to play after 14 weeks, and his successful progression
from initial injury to unlimited status. It also demonstrates the complex clinical evaluation challenges and the
need for effective clinical reasoning and differential diagnosis skills. Effective surgical intervention and
rehabilitation goals were essential in the successful management of this case. The athlete continued with
rehabilitation on the right hip throughout the season, and was scheduled to undergo corrective arthroscopic
surgery on his left hip post season. Word Count: 443
Thoracolumbar Pain in a Female Collegiate Gymnast
Almeida M, Stobierski R, Rothbard M, Hannah C: Southern Connecticut State University, New Haven,
Connecticut
Background: A 22 y/o female gymnast complained of immediate severe sharp thoracolumbar pain without the
presence of radiating pain, unusual sounds, or sensations secondary to landing on her thoracolumbar spine
forcing spinal hyperflexion after failing to perform a full twisting front tuck somersault from the balance beam.
The patient was unable to walk and reported that pain was aggravated by movement and alleviated by rest.
Visual inspection revealed patient apprehension for movement without the presence of swelling or deformity.
Physical examination elicited palpable tenderness over the thoracolumbar spinous processes with associated
spinal extensor muscle spasm. Range of motion was severely restricted by pain and spasms and subsequently
not performed. Neurological screening was able to rule out associated spinal cord injury. The patient’s medical
history was not significant for traumatic injuries to the spine or surrounding area. Differential Diagnosis:
vertebral body compression fracture, spinous process fracture, transverse process fracture, vertebral arch
fracture, spinal ligament sprain, facet casulary sprain, erector spinae (iliocostalis, longissimus, and spinalis)
strain, and internal organ derangement. Treatment: After initial evaluation, emergency medical services was
summoned, the patient was immobilized with a full backboard, and transported to a local emergency medical
facility for further evaluation. Thoracolumbar radiographs were obtained and revealed a decreased anterior
border vertebral height without subsequent interspinal space increases. She was diagnosed with a T12 and L1
compression fracture and was placed in a thoracolumbar sacral orthosis (TLSO). Early rehabilitation consisted
of spinal immobilization to relieve pain, spasms, and soft tissue restrictions for 12 weeks. Status post 12 weeks,
the patient was removed from the TLSO and a more aggressive rehabilitation program was implemented which
included restoring hip muscle balance, flexibility, strength, and muscular endurance. Status post 18 weeks, the
patient was functionally stable and core stabilization and strengthening with application for gymnastic activities
was incorporated into the rehabilitation program. Status post 26 weeks, the patient was discharged from
rehabilitation; however, she was unable to return to competitive gymnastics due to the exceptional physical and
mental demands of the sport. Uniqueness: Thoracolumbar spinal fractures are very rare in athletics. Common
causes are high velocity high-energy impacts such as car accidents. Other susceptible populations are older
individuals with osteoporosis or spinal tumors, and in younger individuals with a history of steroid use.
Specifically, in this case, the young and otherwise healthy patient suffered a career ending injury. Also, the
mechanism of injury was very unique. The dismount caused her torso to remain in motion, forcing the spine in
hyperflexion, resulting in the fracture. Furthermore, this pathology did not affect ligamentous stability or cause
secondary spinal cord injury. Lastly, based on the literature, management for this pathology required an
additional 6 weeks of non-operative bracing due to a lack of complete osseous healing. Conclusion: In the sport
of gymnastics, when situations go awry in the air, gymnasts are instructed to perform a tuck and roll maneuver
to ensure a safe landing to prevent injury. Unfortunately, the gymnast could not complete this maneuver in
sufficient time, causing injury. The mechanism of injury in this case is very important to recognize in order to
identify the clinical presentation, give appropriate immediate care, and provide proper post-injury management.
Thoracolumbar fracture management can include non-operative bracing for neurologically intact pathologies.
Disability from this pathology can last up to 6 months. With no neurologic damage, patients may return to full
athletic participation provided they are free of pain during activity and core stability and strength is adequate to
meet the specific demands of the participant’s activity. Word Count: 583
Knee Pain in Collegiate Football Player
Armenti B, Reppe K, Rothbard M, Nelson C: Southern Connecticut State University, New Haven,
Connecticut
Background: A 22 year old male defensive end reported sharp anteromedial left knee pain upon making a
tackle during a game. Visual inspection during the on site evaluation revealed a lateral patellar dislocation. The
team physician relocated the patella on the field. The patient was placed in a functional patellar stabilization
brace, and was cleared to return to competition. Upon returning to the game, the patient demonstrated a positive
antalgic gait. He limped off the field complaining of severe knee pain. A second examination on the sideline
revealed positive edema and ecchymosis, medial joint tenderness, and limited active ROM. Valgus stress test
was negative at 0°; however, at 30° a positive test elicited a soft end feel. The patellar apprehension and glide
tests were positive for patellar instability. Medical history was not significant for traumatic injuries to the
involved knee or surrounding area. Differential Diagnosis: patellar dislocation, patellar instability, patellar
fracture, patellar tendon tear, medial patellofemoral ligament sprain, osteochondral lesion, femoral
osteocondylar contusion, medial mensical tear, and medial collateral ligament sprain. Treatment: The patient
was iced, elevated, wrapped with a compression bandage, placed into a straight leg knee immobilizer, instructed
to ambulate utilizing non-weight bearing crutch gait pattern, and diagnosed with a patellar dislocation and
medial collateral ligament sprain by the team orthopedic surgeon. An MRI was ordered. The results indicated a
lateral patellar dislocation, anterolateral distal femoral contusion with no osteochondral lesion of the patella, and
a grade III medial petellofemoral ligament (MPFL) sprain. The patient was placed on a rehabilitation program
prior to surgery consisting of thermal agents, ROM exercises, and massage to reduce pain and edema. Status
post two weeks the patient underwent MPFL reconstruction. During surgery, a patellar bone fragment was
discovered within the edema and removed. The initial post-operative rehabilitation program consisted of wound
management, use of a rehabilitative patellar stabilization brace, electrotherapy, and therapeutic exercise
program to decrease pain and edema, and increase neuromuscular coordination, proprioception and range of
motion. Four weeks post-reconstruction, a more aggressive rehabilitation program was implemented to further
improve proprioception and range of motion and restore muscular strength, endurance, and power. Thirteen
weeks postreconstruction, the patient progressed to jogging on a treadmill to restore cardiovascular endurance.
Sixteen weeks post-reconstruction, the patient was functionally stable and was prescribed sport-specific
activities that included team conditioning drills to restore speed, agility, and power. The patient was cleared by
the team physician and fully returned to athletic activities approximately 24 weeks post- reconstruction. His
return to activity did not elicit any pain or apprehension. Uniqueness: MPFL ruptures in conjunction with
medial collateral ligament pathologies are unique in athletics. Specifically, in this case, the injury was difficult
to diagnose on initial evaluation because the reported symptoms and obvious deformity overshadowed the
Ligamentous involvement. Furthermore, the MRI did not reveal the displaced fragment of the patella, which
would indicate the requirement of surgical intervention. Conclusion: Patellofemoral injuries are a common
knee pathology and can affect prepubescent children through adults. The MPFL secures the patella to the
medial aspect of the knee and is frequently injured as a result of a lateral subluxation. Predisposing factors
relevant to this case included hypermobility caused by hamstring and iliotibial band tightness. Prompt
recognition and management of acute patellofemoral pathologies are crucial for reducing further stress on other
joint structures. Tearing of the MPFL can lead to decreased mechanical knee extensor mechanism efficiency,
degrading of the femoral and patellar articular surfaces, and mechanical and anatomical instabilities. Surgical
intervention reduces the risk of recurrence by over 30% and is usually indicated to diminish joint
pathomechanical and functional limitations. Word Count: 598
Collegiate Men’s Lacrosse Player With An Adductor Avulsion Fracture
Barandica S, Cleaves G, Wujciak D: Kean University, Union, New Jersey
Background: An 18-year-old male lacrosse player suffered an avulsion fracture on the right pubic symphysis
and inferior pubic ramus over the insertion of the adductor muscles. Mechanism of injury: Athlete planted foot
and turned while running causing pain and a popping sensation in his groin. Initial assessment revealed point
tenderness over adductors and its insertion over right pubic symphysis. Upon initial assessment no edema,
ecchymosis or paresthesia was found. Neurological assessments were normal. Hip active and passive ROM was
full, pain noted with last few degrees of hip abduction. Strength was full for all knee motions and hip motions
except for hip external rotation and adduction, which were 4+/5. Special Tests: MMT was positive for pain with
resisted hip adduction. Initial Treatment/Advice: Ice bag application for 20 minutes and rehabilitation was
advised. Differential Diagnosis: Adductor Strain, Gracilis Strain, Adductor Avulsion Fracture, Stress Fracture,
and Sports Hernia. Treatment: Athlete did not follow up for rehabilitation until eleven days after the initial
evaluation. At that point he was unable to fully participate in practice due to weakness with adduction and hip
internal and external rotation. At this point athlete complained of point tenderness at the insertion of the
adductor longus into the symphysis pubis. ROM was full and strength was 4/5 with hip adduction and internal
and external rotation, all other motions were 4+/5. Treatment consisted of cryotherapy to manage the pain and
strengthening exercises. X-rays were taken twenty days post injury to rule out avulsion fracture. Impression of
x-ray report showed no bony abnormalities and unremarkable adjacent soft tissues. Follow up with team
physician concluded that athlete had an adductor strain/apophysitis, he was advised to continue rehabilitation
and to participate as tolerated. If the athlete did not improve or pain increased he would need a period of rest.
Athlete continued participation and his strengthening exercises in our rehabilitation clinic until his season
ended. Athlete’s progressive rehabilitation consisted of ice (20 minutes), SLR hip flex, ext, add and abd (no
weight up to 2lbs), ball squeezes (2-3 second hold), manual resistance (IR/ER 3x10), seated hip flex (3x10),
Monopolar E-Stim (20 minutes) and SwimEx warm-ups. Athlete went home for the summer and pain
continued. He followed up with his own physician who ordered an MRI which confirmed diffuse marrow
edema as a result of stress response. Localized swelling was apparent on MRI where adductors insert at the
right pubic bone suggesting a strain or partial avulsion. Detailed examination of MRI and original x-rays along
with signs and symptoms confirmed partial avulsion of the adductors. Athlete continued rehabilitation at a
physical therapy facility for the summer and returned once school started. Athlete is currently receiving
prolotherapy by our team physicians and is unable to continue his rehabilitation regiment at this time.
Uniqueness: An adductor avulsion fracture is commonly misdiagnosed as an adductor strain. If mistreated it
can lead to chronically persistent injuries that can end up being career threatening. Signs of this injury include
limping, pain with passive and active muscle stretching, tenderness to palpation of adductor muscles and
insertion point over pubic symphysis. Conclusion: An adductor avulsion fracture is a musculoskeletal injury
occurring typically in adolescents as a result of an unexpected explosive muscle contraction and is characterized
by a sudden onset of hip pain. Detailed history of the injury and x-rays are helpful in accurate and early
diagnosis of ischial injuries. Rehabilitation approach should be structured and monitored to prevent further
injury and timely return to activity. Word Count: 598
Laryngeal Fracture and Dysphonia in 21 Year Old Male Colligate Football Player
Creveling HC, Janik GK, Hand A: King’s College, Wilkes Barre, PA
Background: A 21-year-old male football player was injured during a collegiate football game. The athlete
came in to the AT room after the game complaining of pain in this throat. The patient stated that he got
“clothlined” by an opponent to the throat and his chinstrap additionally came down and hit his throat. He
continued to play fully and did not report the injury to anyone. The patient had a noticeable deepened and raspy
change in his voice. Patient showed no signs of apparent distress. He also complained that he had little pain
with swallowing and breathing, but otherwise felt good. Differential Diagnosis: Neck Stain, Neck Contusion,
Vocal Cord Contusion, Laryngeal Fracture, Thyroid Cartilage Fracture. Treatment: Athlete was instructed to
keep ice on his throat and if signs and symptoms got worse to go to the emergency room immediately. He was
also instructed to follow up at the bruise clinic the next morning. The following day the symptoms continued,
but did not worsen, and the athlete was sent to an urgent care facility, the patient was diagnosed with an anterior
neck stain and contusion and was cleared to return to play. No x-rays were taken even with the concern of a
fracture from the athletic trainers in the referral. The patient returned to limited practice, but the athletic trainer
was still concerned that symptoms persisted so the patient was sent to have a second opinion with an ENT
doctor the following day. The athlete was diagnosed with a vocal cord hematoma and was sent for a CT scan to
rule out a thyroid cartilage fracture. He was held out of practice because of the concern that the hematoma could
rupture and possibly suffocate the athlete. The CT scan revealed that there was a vertical displaced fracture on
the thyroid cartilage on the left side, which overlapped by 6mm. There was also minimal edema on the left
vocal cord. Following the first diagnosis the physician recommended that the athlete’s treatment was to use a
moist heat pack for his neck before practicing. After the second opinion the athlete was not allowed to
participate in sports for 6 weeks and was recommended to see a speech therapist due to the concern of his
deepened voice. The doctor reported no need for surgery because the fracture was minimal. The follow up
appointment reveled noticeable improvement and the athlete was informed that he could return to play 12/1
which was about 2 months; allowing the fracture time to heal correctly. Uniqueness: Laryngeal fractures are
not commonly seen in athletics, the injury is normally seen in patients that are in traumatic accidents. In this
cases the laryngeal fractures presented with little pain in the actually throat, with dysphonia being the primary
sign and symptom. Conclusions: Athletic trainers should be aware of the possibility of laryngeal fractures and
the signs and symptoms with neck pain and dysphonia. In this case the athlete was first diagnosed with a neck
contusion. The possibility of significant side effects, including a catastrophic event could have occurred, such as
suffocation, if returned to play was allowed. Athletic trainers should be confident to get a second opinion when
signs and symptoms do not correspond with the original diagnosis. In this case the athlete was diagnosed with a
larynx fracture and edema to the vocal cords, was misdiagnosed initially and was only determined after
concerns by the athletic trainer. Word Count: 569
Cervical Neuropathy in a Division I Football Player
Galeazzi, B. DiNapoli, D. Cordone, J. Straub, SJ. Quinnipiac University, Hamden CT, Yale University,
New Haven CT
Background: 21 year old outside linebacker spear tackled an opposing athlete causing left lateral cervical
flexion and depression of the shoulder. Athlete was face down on field and initially had a short loss of
consciousness. The athlete stated numerous times he was unable to feel his right arm. Strength assessment
indicated normal strength in the left arm but on the right side the athlete was limited to grip strength in right
hand. The athlete had a previous medical history of a herniated lumbar disc at L4/L5 region and also had a
history of left shoulder contusion and abnormally-formed glenoid fossa. The athlete was spine boarded and
transported to the local Emergency Department Differential Diagnosis: cervical spine fracture, cervical spine
ligamentous sprain, spinal cord injury, concussion, shoulder dislocation or fracture. Treatment: A CT scan of
brain and neck read unremarkable and thus ruling out cervical spinal injuries. The athlete had persistent deficits
in his right arm (deltoids, biceps, infraspinatus) but recovered some sensation and function in fingers and was
presumed to have suffered a brachial plexus injury. The athlete spent a week in the hospital for further
examinations and additional neurology consultation. The final diagnosis was a right brachial plexus injury,
specifically a C5 nerve root avulsion and a partial C6 nerve root avulsion. The initial treatment plan called for
edema reduction and occupational/physical therapy. Medications were prescribed for pain and causalgia. Over
the subsequent four month period, minimal recovery was noted. The patient was informed of surgical options
and risks and ultimately consented to surgery. The pre-surgical plan was for a right supraclavicular exploration
of C5-6 with inoperative testing. The plan included nerve grafting within the shoulder; axillary nerve, through
posterior division upper trunk and suprascapular nerve with sural nerve grafts from either one or both legs as
necessary. Surgery was performed at approximately 5 months status-post. The actual reconstruction consisted of
a sural nerve graft that ran from the C5 nerve root to supraspinatus nerve and to posterior division of upper
trunk of the right brachial plexus and a double Oberlin’s procedure. At follow-up appointment 5 months S/P
reconstructive surgery, EMG indicated minor reinnervation to the supraspinatus and no reinnervation to deltoid
or elbow flexors. He also demonstrated nearly full antigravity elbow flexion and mild gravity eliminated
external rotation of shoulder. The patient did demonstrate anti-gravity elbow flexion with shoulder internally
rotated. Gravity eliminated position was full with a smooth arc of motion. Numbness and pain were still
present. The patient was referred to Hand Therapy to assist with re-education of shoulder and elbow flexion.
The goal is to continue to re-educate and strengthen and be able to lift a 5 lb backpack with right hand by
1/1/12. Home Exercise Program was given. Uniqueness: While 65% of collegiate football athletes are reported
to suffer brachial plexus injuries at some point in in their careers the more common mechanism of avulsion of
C5 and C6 Nerve Roots is motorcycle accidents. The reported incidences of brachial plexopathies with nerve
root avulsions in football are limited. Conclusions: While brachial plexus injuries are common is football, the
avulsion of a nerve root is rare. Conservative treatment options may be long due to the lengthy time period of
nerve regeneration. When conservative measures fail, nerve grafting must be considered. Complete recovery
may be difficult; clearly defined limited functional activities may be more appropriate long-term goals. WORD
COUNT 563
Abnormal Heart Rhythm in Collegiate Female Basketball Player
Hallissey H, Wright T, Rothbard M, Dale A: Southern Connecticut State University, New Haven,
Connecticut.
Background: A 21-year-old female basketball guard presented with an unstable heart rhythm that was
identified after volunteering in an exercise physiology experimental study. Physical examination identified a
slight pause in between heartbeats. The patient stated that this occurred regularly, but did not report it staff. She
was subsequently removed from participation and referred to campus health cardiac conditions and the preparticipation physical examination performed by her primary care physician did not reveal any cardiac
abnormalities. Differential Diagnosis: congenital heart defect (atrial/ventricular septal defect), heart muscle
condition (myocarditis, cardiomyopathy), heart murmur (mitral valve prolapse/regurgitation/stenosis, aortic
stenosis/sclerosis/regurgitation), Arrythmia (Supraventricular tachycardia, proxysmal supraventricular
tachycardia, sinus tachycardia, bundle-branch block, atrial fibrillation). Treatment: After the initial
consultation with the primary care physician, she was referred to a cardiologist. The cardiologist ordered a 24hour Holter test which indicated a heart rate of 38-126 bpm with an average of 65 bpm. Also, the 24-hour
Holter test revealed a 1o and 2o atrioventricular block, a disruption of nerve conduction in the heart that resulted
in pauses, as well as 341 isolated premature ventricular contractions, which were asymptomatic and occurred
mostly during sleep. Furthermore, the 24-hour Holter test revealed 5 episodes of tachycardia, 33 episodes of
bradycardia, and 130 pauses greater than 2 seconds, with the longest pause being 2.2 seconds. Further
diagnostic testing included an electrocardiogram to evaluate the electrical activity and an echocardiogram to
evaluate the ventricles and valve functions. The electrocardiogram was within normal limits; however, the
echocardiogram revealed minor mitral valve regurgitation with normal mitral valve appearance, trace tricuspid
valve regurgitation with normal appearance, and trace pulmonic valve regurgitation with normal appearance.
Upon completion of diagnostic testing, the cardiologist diagnosed the condition as 1o and 2o atrioventricular
block with mild mitral valve regurgitation. After discussing the diagnoses, the patient was not prescribed
medication and was subsequently cleared for unrestricted activity pending careful monitoring by the athletic
trainer. Uniqueness: Cardiac conditions are unique in collegiate athletes and can jeopardize and life. Despite
being diagnosed with 1o and 2o atrioventricular block with mild mitral valve regurgitation, the patient was able
to participate for an entire season. This case is also unique because she did not present with significant
symptoms during the season, did not notify any medical professionals when she noticed any abnormal heart
rhythms, and was cleared for unrestricted activity pending careful monitoring by the athletic trainer.
Conclusion: If a cardiac condition is present, it will most often be found during the pre-particiaption screening
process. In this instance however, the condition was not identified during the pre-participation screening and the
athlete participated without identification of the condition. Although many medical organizations do not support
advanced cardiovascular screening for athletic participation, more thorough cardiac screenings may be
necessary for athletic trainers to adequately identify and prevent sudden cardiac pathologies that may arise.
Advanced cardiovascular screenings could be performed during pre-participation screenings to ensure safe
participation. Additionally, athletic participants should be educated about the warning signs and symptoms of
cardiovascular conditions so that they may feel comfortable reporting them to their athletic trainer or other
appropriate health care providers. As such, this case demonstrates that athletic trainers will have exposure to
patients suffering from cardiovascular conditions and should be able to identify, educate, and monitor
participants with cardiac symptoms which may include sweating, pallor, palpitations, anxiety, exertional or nonexertional chest pain, dizziness, nausea, dyspnea, hypertension, hypotension, epigastric pain, as well as being
asymptomatic. Word Count: 584
Stress Injury of the Second Metatarsal in a Collegiate Football Offensive Lineman Following Previous
Excision of a Tarsal Coalition: A Case Report
Harpham J, Hummel C: Ithaca College, Ithaca, NY
Background: The subject is a twenty-one year old collegiate football offensive lineman with a history of an
excised cuboid-navicular tarsal coalition at the age of fifteen. A tarsal coalition is a congenital pathology in
which two or more of the tarsal bones fail to separate during development. This results in limited gliding and
rotation of the affected tarsals, causing an increase in stress of these joints and a decrease in the function of the
longitudinal arch. Six years post-operation, the subject reported a sharp pain in his right midfoot following
practice without any frank mechanism of injury. The athletic training staff’s physical examination revealed
point tenderness along the second metatarsal and observable biomechanical faults including pes planus, a
dropped second metatarsal, and callus formation along the longitudinal arch and second metatarsal. Differential
Diagnosis: The differential diagnosis included midfoot sprain, Lisfranc joint injury, Morton’s neuroma, and
stress injury (fracture/reaction). Treatment: Further evaluation by the team physician, which included an Xray and magnetic resonance imaging (MRI), led to the diagnosis of a stress injury to the second metatarsal.
Initial treatment included pain-free partial weight bearing in a walking boot, along with the following modality
treatments: vasopneumatic cryotherapy, interferential electrical stimulation, pulsed ultrasound, contrast bath,
and deep oscillation therapy. Custom-made orthotics were utilized and the subject progressed pain-free through
various strengthening exercises. He started a functional return (jogging, lineman drills) when he was able to
perform a pain-free single leg heel raise and full squat. He was able to return to full activity four weeks after
diagnosis. Uniqueness: The uniqueness of this case involves an athlete with a rare congenital pathology
affecting just one to fourteen percent of the population. Even fewer cases have been reported of a coalition
between the cuboid and navicular. While there are case reports and studies noting the increased likelihood of
biomechanical problems, there are none linking a metatarsal stress injury to a previous tarsal coalition excision.
Conclusions: Currently, the surgical success of tarsal coalition excisions is based on the clinical outcomes of
decreased pain and increased functionality. More long-term studies should be done to examine if the prevalence
of metatarsal stress injuries increases with a previous tarsal coalition excision. Furthermore, it would be
beneficial to examine the effects of custom-made orthotics and general foot and ankle rehabilitation exercises
on long-term functional outcomes. Word Count: 416
Diagnosis of Nonsustained Ventricular Tachycardia in an 18-Year-Old Female College Softball Player: A
Case Study
Hodson, VE. Springfield College, Springfield, Massachusetts, Athletic Training Education Program
Background: An 18 year old female college softball player took herself out of practice complaining of chest
pain. Her face was flushed, and she was unsteady and hunched over. Her pertinent medical history included
occasional headaches and numbness and tingling down into her hands and feet with activity. She was seen by a
pulmonologist three years prior to the incident and he concluded that nothing was out of the ordinary.
Evaluation revealed pain on the left side of her sternum and tightness in her chest. Two sets of vital signs were
taken 20 minutes apart. Pulse and blood pressure were elevated but consistent with her level of activity at the
time. She was taken out of practice for the day and referred to a cardiologist and a physician. Differential
Diagnosis: Respiratory distress, cardiopulmonary pathology or tachycardia. Treatment: The cardiologist gave
the patient an event monitor and cleared her for practice. Upon returning to practice, the athlete experienced
shortness of breath and a feeling of tightness in her heart. Her face was pale but her lung and cardiac
auscultation were normal. She was removed from practice and rested. Two days later, the patient complained
of right lateral neck pain that radiated down her arms and hands. She was also experiencing sharp pain in her
arms and left elbow. At this point, the patient was taken out of practice until further diagnosis. A little over a
week later, the patient was referred to an electrophysiologist. An echocardiogram, stress echocardiogram
(ECG), and MRI were ordered at this time, and the patient was restricted from activity. The echocardiogram,
stress echocardiogram, and the MRI results all came back normal. The event monitor results however indicated
that the athlete experienced one bout of asymptomatic ventricular tachycardia and was therefore diagnosed with
nonsustained ventricular tachycardia (NSVT). The patient was given information about her condition and what
should be done when episodes occur. She was cleared for full participation, but with the stipulation that if her
heart rate exceeds 150 bpm, EMS must be activated. As a precaution, an Automated External Defibrillator
(AED) was always present and taken to every game and practice. The patient finished her season with few
minor episodes and continued her softball career the following seasons. Uniqueness: Nonsustained ventricular
tachycardia is an arrhythmia that can be life threatening. NSVT can lead to ventricular fibrillation, asystole, or
even death. The tachycardia is nonsustained because it lasts no longer than 30 seconds. However, with some
episodes, the heart rate can reach a level where defibrillation is the only viable treatment. While preparedness
for an emergency situation is of the utmost importance, no daily treatment is necessary for NSVT. A similar
condition is Supraventricular tachycardia. Unlike NSVT, Supraventricular tachycardia is rarely life threatening
and can be treated with physical maneuvers such as the Valsalva maneuver. Conclusions: In the case of this
athlete, a life threatening condition could have easily been diagnosed as a brief episode of breathing difficulty.
When patients are experiencing any type of chest pain, regardless of the severity, it is important for the athletic
trainer to consider all potential pathologies. Athletic trainers and athletes, as in this situation, need to have a
good relationship so athletes will be willing to seek help when they need it. Word Count: 511
Hip Pain in a Men’s Collegiate Lacrosse Athlete
Iasilli Z, McCaffrey M, Norkus S; Quinnipiac University, Hamden, CT
Background: This report presents the case of a unique pathophysiological injury involving the hip of a 19 YO,
male lacrosse athlete. The athlete has an extensive history involving the lower extremities. In 2010, the athlete
had a right hip flexor strain, femoral acetabular impingement, labral tear, and heterotopic ossification of the hip.
He had a right hip arthroscopy with excision of the heterotopic ossification, debridement of a labral tear, and
peripheral compartment arthroscopy with osteoplasty of the femoral neck. The athlete was unable to participate
in the 2010 fall season. At the commencement of the 2011 season, the athlete was recovering from a right knee
meniscectomy, which he sustained playing indoor lacrosse. His rehabilitation progressed and he was cleared to
play at the beginning of March. The athlete was gradually re-introduced into practice and was fully
participating by early April. Towards the end of April, the athlete began complaining of low back and hip pain.
Upon evaluation, it was noted that the athlete had an SI rotation. Muscle energy was used to correct the rotation
and the athlete seemed to experience relief. However, the following day the pain recurred. A more extensive
evaluation of the entire lower extremity revealed positive FABERs, posterior shear, and hip scouring tests. Due
to pain, he also presented with limited hip flexion and iliopsoas weakness. Differential Diagnosis: Labrum
injury, iliopsoas strain, trochanteric bursitis, iliopsoas tendonitis. Treatment: Following the evaluation, the
athlete was removed from play and referred to his surgeon, whom he saw at the conclusion of the school year.
At that time, he received a cortisone injection into the iliopsoas which provided temporary relief. At a follow
up appointment in July, the surgeon identified a significant amount of scar tissue from the first surgery which
had been restricting iliopsoas ROM. The athlete was instructed to begin rehabilitation focusing on
strengthening of the lower extremity, balance, and core stability. After a few weeks of therapeutic exercise, the
athlete began experiencing increased pain. He sought a follow up appointment with his physician, who ordered
a hip MRA. The MRA identified a partial-thickness detachment of the posterior/superior right acetabular
labrum, a non-displaced acute stress fracture involving the parasymphyseal right pubis, and arthritic changes of
bilateral sacroiliac joints. After receiving the MRA report, a right hip arthroscopy with lysis of adhesions,
chondroplasty acetabulum, iliopsoas tendon release, and peripheral compartment arthroscopy was scheduled.
Post-op, the athlete was instructed to start rehabilitation after one week and was NWB for the first two weeks.
The athlete is currently progressing in his rehabilitation process with the goal of returning to full play by the
spring season. Uniqueness: Hip joint injuries represent a minute amount of injuries experienced in athletics
and an even smaller amount sustained in collegiate lacrosse. The extensive history of the athlete is unique and
the variety of injuries sustained simultaneously is rare. In addition, this athlete did not present with the
common signs and symptoms of an acetabular labral tear, which typically presents with groin pain, snapping or
clicking sensations, and limited range of motion throughout most hip motions. Conclusion: After reviewing the
MRA report, it was determined that the athlete had right hip labral tearing, arthrofibrosis, and iliopsoas
tendonitis. Due to the number of structures involved, the athlete did not present typically. This case represents
the importance of a comprehensive approach to assessment in which the entire lower extremity is assessed, as it
is possible for more than one injury to be present. Word Count: 575
Diagnosis of Paradoxical Vocal Fold Movement (Pvfm) In a 21-Year Old Female College Lacrosse
Player: A Case Study
Itchkavich-Levasseur, M, & Barbato, C L : Springfield College, ATEP, Springfield,
Massachusetts
Background: A 21-year-old female lacrosse player reported to the athletic training room complaining of
shortness of breath. The patient stated that she thought she might be developing asthma. The patient was
complaining of wheezing and coughing and difficulty breathing while exercising. Symptoms were not present
during rest however. The patient’s physician prescribed her an Albuterol asthma inhaler. The patient stated that
the inhaler was not working to control her breathing problems. She also indicated that she had more trouble
breathing when taking the inhaler. Her medical history was not indicative of severe pulmonary pathology. The
patient presented with no swollen lymph nodes, no deformity, and normal and equal breath sounds during both
rest and exercise. Differential Diagnosis: Tracheomalacia, irritable larynx syndrome, exercise-induced asthma,
thyroid tumors, and chronic obstructive pulmonary disease (COPD). Treatment: The patient was referred to a
pulmonary specialist the following week. The patient received x-rays and MRIs of her chest. Both tests came
back negative for any abnormalities. Next, an endoscopy was performed to evaluate the larynx. The results of
the endoscopy showed that there was an abnormality within the vocal cords. A speech test was then performed
to further evaluate the larynx. All of the tests were performed in a time span of just over one year. During this
time, the patient continued to participate in college sports. The pulmonologist eventually diagnosed the patient
with Paradoxical Vocal Fold Movement (PVFM). PVFM is a very rare breathing disorder that is often
misdiagnosed as asthma. The disorder is characterized by adduction of the vocal folds during inspiration
resulting in labored breathing. The pulmonologist cleared the patient to for full activity. The patient continued a
rehabilitation program on her own. The rehabilitation program consisted of larynx relaxation techniques and
practicing proper breathing techniques while talking and exercising. Uniqueness: PVFM is often
misdiagnosed as asthma due to the similarities in symptoms. Very little research exists on the topic of PVFM,
therefore the disorder is somewhat misunderstood. In extreme cases, airway intervention is necessary. This
case was considerably milder. PVFM attacks are often triggered by exercise or periods of stress. The disease is
approximately 4 times more prevalent in females than in males. Numerous cases have been documented in
males however, and in the male population, PVFM is often observed in conjunction with asthma. Many athletes
with PVFM can continue to participate in sports as long as they are aware of their limitations. Conclusions:
This case study presents the signs, symptoms, and causes of PVFM in order to help health care professionals to
better understand this rare disorder. As PVFM is often misdiagnosed, it is important for health care
professionals to be aware of this disorder in order to properly diagnose and treat PVFM. Word count: 454
Acute Traumatic Multi-joint Injuries in a Division I Female Soccer Athlete.
Klics ME, Passarette AM, Mitchell BJ, Stephenson LJ: Stony Brook University, Stony Brook, New York
Background: An 18 year old Division I female soccer forward with no previous history of injury to her left
side collided with a goalie during game play. Athlete was unable to report a detailed mechanism of injury
(MOI). The athlete presented to the athletic trainer complaining of pain from her left knee to her left ankle with
immediate moderate swelling and no associated discoloration or deformity. Palpation revealed severe
tenderness along all medial knee structures, lateral knee structures, patellar tendon, medial and lateral hamstring
tendons, in the popliteal fossa, along the tibia, fibula, and the bilateral ankle ligaments. Neurological symptoms
such as tingling and mild numbness were also reported that radiated into the foot and toes. Neurologic
symptoms subsided after approximately 10 minutes. She was placed in an immobilizer and was non-weight
bearing (NWB). Differential Diagnosis: Grade II medial collateral ligament (MCL) sprain, patellar
subluxation, proximal tibia fracture, medial ankle sprain, lateral ankle sprain, fibular head fracture with
associated Peroneal Nerve involvement. Treatment: Athlete received an MRI, which revealed a compression
fracture of the anterior medial tibial plateau, near complete tear of the MCL, and increased signal in the
posterior cruciate ligament (PCL). Radiographic exam of the ankle revealed no fractures. Athlete was NWB
for four weeks and engaged in a rehabilitation program to decrease pain and swelling and increase range of
motion at the knee and ankle. At five weeks post injury substantial improvements have been observed. Pain
has decreased from 9/10 to 1/10 in the knee and ankle, and active range of motion for knee flexion has
increased to 120°. Two weeks of immobilization resulted in left side atrophy, which has been resolved with
isometric and isotonic exercises. The ankle sprain has recovered to a fully functional level. Uniqueness: This
athlete sustained substantial injuries to the knee and ankle joints as a result of one MOI. Typically, high forces
and velocities, such as those in a motor vehicle accident, cause these types of injuries but this mechanism
displayed fairly low forces and velocities in comparison. The presentation of the injury is also unique due to the
pain pattern and remarkable sensitivity to palpation of the entire lower leg. Due to the unique presentation of
these injuries, radiographic imaging was required to confirm the extent of the injuries sustained in the knee and
ankle. Based on the diagnosis of an MCL sprain, it is assumed that a valgus force was applied to the knee. In
addition, it can be assumed that there was an associated rotational mechanism that caused the compression of
the femur on the tibia and subsequently the anterior medial tibial plateau fracture. It is interesting to note that
the anterior cruciate ligament (ACL) was not damaged with the rotational mechanism, as this is the most
common mechanism of an ACL sprain. Conclusions: It is possible for multi-joint injuries to occur in an
athletic environment as a result of one MOI. Athletic movements are by nature multiplanar, and subsequently
athletes are at risk for sustaining multiple injuries as a result of one mechanism. A comprehensive examination
that includes radiographic imaging is necessary to rule out differential diagnoses, and should include the joints
above and below the injury site so that an accurate diagnosis can be reached. Word Count: 539.
Acute Achilles Tendon Rupture in Collegiate Football Player
Lentini, J, Cleaves G, Howland K E: Kean University, Union, NJ
Background: A 25 year-old male football player suffered an acute Achilles tendon rupture. Mechanism of
injury: athlete felt a pop posterior aspect of left ankle when tackling; athlete felt “like someone hit him on back
of ankle”. Initial assessment found palpable defect in distal 1/3 of Achilles tendon with palpable pain noted
posterior-medial calcaneous and superior portion Achilles tendon and musculotendonis unit of calf;
neurological assessment WNL. Active dorsiflexion, inversion, and eversion WNL but weak active
plantarflexion of left ankle was apparent. Special Tests: Thompson Test found complete absence of
plantarflexion with calf squeeze. Initial treatment: Jones’ compression wrap with posterior splint and crutches.
Athlete advised RICE and acetaminophen as directed for pain. Appointment with orthopedic surgeon was made
for 2 days after injury and surgery was scheduled 5 days post-injury. Differential Diagnosis: Ankle fracture,
ankle sprain, Achilles tendon strain/tendonitis, acute Achilles tendon rupture. Obvious palpable defect and
positive Thompson Test indicate acute Achilles tendon rupture. Treatment: Surgery to repair tendon
performed 5 days post-injury. Pre-surgery treatment included two sessions of RICE and light pulsed electrical
stimulation to decrease swelling and pain. Uniqueness: Typically, Achilles tendon rupture occurs more
commonly in males 30-50, years old and who are participating in recreational sports, or the “weekend warrior”.
In this case, the athlete is a 25-year-old male who ruptured his Achilles tendon during an intercollegiate football
game. Previous history reports two separate complaints (8/2009 and 1/2010) of pain felt in his Achilles tendon
during sprinting activities. Palpable pain was consistently reported in medial attachment site of Achilles tendon
posterior calcaneous and on medial calcaneal tubercle. In January 2010, the athlete complained of specific pain
during push off when running and jumping. Weakness with plantarflexion and crepitus in posterior ankle was
noted; Physician’s assessment was tendonosis of the Achilles tendon; treatment of RICE, electrical stimulation,
stretching, balance and eccentric manual resistive exercises were implemented for approximately 2 months.
Therapy was discontinued due to summer break. Athlete returned to the 2010 and 2011 football season without
any complaints of Achilles tendon pain or dysfunction. Therefore, is there an association of previous Achilles
tendon pathology to the acute Achilles tendon rupture? Conclusion: Spontaneous, acute ruptures are closely
related to sports activity, in which the activity involves a sudden and aggressive stretch to the triceps surae
group, while simultaneously contracting the calf eccentrically. The interplay of increased mechanical stress to
the Achilles tendon during the explosive activity and possible intratendonis degeneration may have increased
the risk of acute Achilles tendon rupture. Schepsis et al discussed pathologic degenerative changes in region of
tendon rupture was found in 50% of 292 patients and that the acceleration/deceleration mechanisms have been
reported in approximately 90% of sports-related Achilles tendon ruptures². A recent study reported
histopatholgical differences in patients undergoing surgery to repair acute Achilles tendon compared to cadaver
samples of intact Achilles tendon¹. Significantly, the study found a marked difference in abnormal collagen
cells in the ruptured Achilles tendon, including the proximal and distal intact portions. The authors
hypothesized the collagen abnormality in the Achilles tendon could result in an increase risk to tendon rupture
because the tendon is less resistant to tensile forces. Abnormal changes in the collagen matrix of the Achilles
tendon may influence the elastic component of the tendon, inhibiting the tendon’s ability to overcome excessive
mechanical stress. Therefore, previous history of Achilles tendonosis may have predisposed this athlete to the
acute rupture, which is an uncommon injury for his age population. Word Count: 596
Os Acromiale in a High School Wrestler
Morelli ND ATC*, Sterner RL PhD ATC: Rowan University Glassboro, NJ. *Ithaca College Ithaca, NY
Background: A seventeen-year-old male high school wrestler was thrown to the mat during a wrestling match
and landed directly on his right acromial process in a fully abducted and externally rotated position. He
experienced immediate pain, point tenderness, and decreased range of motion due to pain. A percussion test to
his acromion was positive, thereby indicating that all other special tests were contraindicated due to the
possibility of a fracture. After the evaluation, it was decided that diagnostic testing was warranted. An MRI
revealed a stress fracture to the acromion along with a predisposing pathology called os acromiale. Os
acromiale is a congenital condition where one of the acromion’s epiphyseal plates fails to fuse together. This
underlying pathology has been found to be a predisposition for many shoulder pathologies. Differential
Diagnosis: Acromioclavicular sprain, fracture to the clavicle, labral pathologies, and rotator cuff pathologies.
Treatment: An MRI revealed a stress fracture-like pathology to his acromion. The supervising physician
diagnosed os acromiale as a predisposing condition for the stress fracture. This patient was placed in a sling for
seven days to protect the shoulder from extraneous movements. During this time, he was treated for pain
modulation using interferential electric stimulation and ice. On day eight, light range of motion exercises,
increasing in five-degree increments every two days, was added to the rehabilitation program. Two weeks post
injury the patient began some light biceps and triceps strengthening exercises and proprioceptive neuromuscular
facilitation drills to strengthen and coordinate movements within the shoulder complex (within a pain-free range
of motion). The athlete responded well to the rehabilitation so a functional progressive rehabilitation program
was implemented at week three. This injury occurred at the end of the wrestling season; therefore the patient
was unable to participate in any of the remaining practices or matches. However, he was able to return to
functional activity one month after the injury occurred and was back to full activity 6 weeks post injury.
Uniqueness: A stress fracture to the acromion is a rare pathology by itself, but to also have congenital os
acromiale makes this case more unique. Os acromiale has been found to only affect about 8% of the
population. This pathology is normally associated with rotator cuff tears and labral pathologies, however in this
situation a stress fracture preceded the diagnosis of os acromiale. Conclusions: Os acromiale is a rare condition
that has been shown to predispose the shoulder to different injuries. Since it is impossible to tell if an individual
has os acromiale without diagnostic imaging, there is no way to prevent secondary pathologies from occurring.
If a patient presents with repetitive shoulder pathologies, os acromiale could be an alternative diagnosis. After
the diagnosis, athletic trainers can use preventative braces and implement more functional rehabilitation
techniques to teach proper biomechanics. If correct biomechanics are used this will decrease the likelihood of
chronic shoulder pathologies. Word Count: 505
Pubic Symphysis Sprain in a Division III Collegiate Men’s Basketball Athlete
Ouellette CL, Stiller-Ostrowski JL, Welch M; Lasell College, Netwon, MA
Background: A 21-year old male collegiate basketball athlete presented with pelvic pain after demonstrating a
hip rotation mechanism while participating in a game. Athlete jumped for a lay-up and on his way down had
feet taken out from under him causing right innominate to strike floor before left. On-court evaluation revealed
no pelvic fracture or lumbosacral involvement; no history of injury to the lower extremity. Athlete complained
of sharp pain (8/10) alongside the posterior aspect of lower back and pain over the right ischium. Palpations of
the iliac crests, spinous processes L4- S2 and PSIS’s were painfree. No palpable deformity was present. No
noises or sensations were reported. The certified athletic trainer removed athlete from court with walking
assistance to athletic training facility. Off-court evaluation revealed pain described as “achy” as 7/10 (versus
sharp) during palpation of the right ischium; no other structures elicited pain when palpated. Reevaluation 24
hours post-injury indicated new present clinical symptoms. Athlete complained of deep anteriomedial pelvic
“achy” pain (8/10) with no posterior pain. Severe pain was present over right ASIS, right AIIS, right inguinal
ligament and bilateral pubic bones. Based on clinical findings, athlete was given immediate referral to the
emergency room for diagnostic testing and further evaluation due to a lack of range of motion and increased
pain scale. Differential Diagnosis: Ischial Contusion, Inguinal Ligament Sprain, Adductor Insertion Strain,
Right Innominate Up-Slip, Osteitis Pubis, Athletic Pubalgia, Pubic Symphysis Sprain. Treatment: The
emergency room physician ordered a plain film radiograph. Based on evaluation and diagnostic findings,
athlete was diagnosed with a contusion to the pubic symphysis and pubic symphysis sprain. Following this
diagnosis, certain pertinent evaluation findings were retrospectively identified. Several predisposing factors
(excessive lumbar lordosis, an anterior pelvic tilt, a decreased and differential Q-angle bilaterally) were noted
which may have contributed to his mechanism of injury. Discontinuation of physical activity was advised;
athlete limited to activities of daily living for three days. Athlete followed conservative rehabilitation protocol
designed by the team physician and athletic trainer. The rehabilitation phase started day three post-injury and
consisted of preheating the area using a moist hot pack, followed by straight-leg raises bilaterally to reduce
athlete’s apprehensiveness toward and engage in AROM, single-leg stance balance training (bilaterally),
progressive resistance exercises in hip flexion, extension, abduction and adduction using a theraband.
Cryotherapy post-rehabilitation. Days seven through ten post-injury consisted of functional testing including
both cardiovascular exercise (resistance bike: level 5, and light jogging/ running on the treadmill: 10-20
minutes, 5.5-7.4 mph) and functional activity protocol (28-meter: sprints, backwards running, karaoke/
grapevine (both directions), powerskips, side-shuffles (both directions) on the basketball court). Athlete was
cleared for full return-to-play status ten days post-injury, with the condition of activity ceasing if pain presented.
Rehabilitation continued once athlete returned to participation. Uniqueness: Injury to the pubic symphysis is
relatively uncommon in athletics due to the anatomy of the joint as well as the mechanisms required for
structural damage to occur. Consequently, acute injuries to the pubic symphysis are more susceptible to being
overlooked by Athletic Trainers. A lack of research regarding this injury contributes to the motive for
misdiagnosis; this case report will serve as a guide to ensure the proper diagnosis in the next case. Conclusions:
Although pubic symphysis sprains occur infrequently, acute injuries to the pubic symphysis should be treated
with caution and must not be overlooked. It is imperative that Athletic Trainers be alert to clinical evaluation
findings that may point to this diagnosis. Delayed recognition and diagnosis may lead to increased functional
limitations and prolonged pain. Timely diagnosis and treatment are essential to ensure speedy recovery. Word
Count: 597
Persistent Knee Pain In A Collegiate Track And Field Athlete
Polakowski J, Rothbard M, Davis C: Southern Connecticut State University, New Haven, Connecticut
Background: A 22-year old male multi-event intercollegiate track and field athlete presented with moderate
persistent left anterior knee pain secondary to various athletic activities without any unusual sounds or
sensations. The patient reported being able to perform ADLs, running, and lower extremity conditioning
exercises; however, the pain significantly increased with these activities. Visual examination revealed a slight
deformity in the patellar tendon, as well as a medially rotated patella at rest between the femoral condyles.
Physical inspection elicited palpable tenderness and edema over the patellar tendon and specifically, the inferior
patellar pole. Functional inspections including ROM, special, and neurological testing were WNL; however,
active and resisted extension and passive flexion were painful. The patient’s medical history was significant for
bilateral Osgood-Schlatter’s Disease at age 13, which required extensive rest and a gradual return to activity.
Throughout high school, the patient was able to participate in athletic activities without significant left knee
pain. The patient was not currently taking any medication; however, reported being hypersensitive to all
NSAIDs. Differential Diagnosis: Infrapatellar tendinopathy, fat pad impingement, patellofemoral instability,
patellar malalignment, infrapatellar bursitis; patellar osteochondrosis, osteochondritis dissecans, osteogenic
sarcoma, patellar tendon calcification. Treatment: After the initial evaluation, the patient received conservative
treatment encompassing ice, compression, and elevation and was referred to the team physician who ordered
radiographs. Radiographs revealed a 4.5 cm bony calcification disconnected from the tibial tuberosity that
appeared to have grown into the patellar tendon. The patient was diagnosed with a non-union patellar tendon
calcification derived from Osgood-Schlatter’s Disease with inferior pole patellar tendinopathy and infrapatellar
bursitis as a secondary diagnosis. The physician attributed the tendinopathy and bursitis to the size, location,
and instability of the calcification. The patient was removed from activity for one week to control the
inflammation and pain and was prescribed a neoprene sleeve to assist with compression, patellar alignment, and
patellar stability. Following initial rest, a rehabilitation program consisting of partial weight bearing isotonic
exercises and aquatic therapy was implemented to restore and improve muscular strength and cardiovascular
fitness. After one week of the conservative therapeutic exercise program, a progressive rehabilitation program
was incorporated emphasizing calf and eccentric extensor mechanism strengthening, core stabilization and
strengthening, and quadriceps and hamstring flexibility. The patient also returned to limited team activities that
included running, but no jumping. Status post four weeks, the patient reported being pain free and was
conditionally cleared by the team physician for unrestricted athletic activities, pending continuation of
rehabilitation. The patient continues to address core and lower extremity strength and flexibility deficiencies.
Uniqueness: Osgood-Schlatter’s disease is a traction apophysitis causing a tibial osteochondrosis that
traditionally responds well to restricted activity, stretching, and NSAIDs. A long-term sequella of the condition
is typically a thickening and prominence fusion of the tibial tubercle; however, this case is unique because a 4.5
cm non-union calcification formed at the tibial tuberosity which appeared to have grown into the patellar tendon
itself, and the calcification size, location, and instability resulted in poor static control of the patella. Also, this
calcific instability in the tendon contributed to the secondary patellar tendinopathy and bursitis. Conclusion:
Skeletally mature individuals may continue to be symptomatic from pathologies associated with OsgoodSchlatter’s disease. An unstable patellar tendon attachment on the tibial tubercle resulting from a non-union
secondary to Osgood-Schlatter’s disease contributed to the development the patient’s disability. Unfortunately,
a calcification within the patellar tendon formed during the bony fusion of the tibial tuberical caused lingering
symptoms. In addition to the initial treatment of rest and a gradual return to activity, management should
include core, calf, and knee extensor mechanism stretching, strengthening, and patient education. Word Count:
598
Brachial Plexus Neuropathy Specific to the Long Thoracic Nerve in a Men’s Basketball Player
Putorti E*, Gray C†: *Cayuga Medical Center, Ithaca, NY; †Ithaca College, Ithaca, NY
Background: A 19-year-old male Division III basketball player presented to the athletic training room with
difficulty forward flexing his right shoulder due to pain and weakness. He complained of upper trapezius
muscle pain with active lateral neck flexion, and point tenderness over the medial border and inferior angle of
the scapula. He could not recall a known mechanism of injury (MOI). Upon initial examination there was
obvious scapular dyskinesis, winging scapula, and serratus anterior weakness when the shoulder was actively
flexed or abducted above 45o. Differential Diagnosis: Long thoracic nerve palsy, brachial plexus injury,
cervical disc pathology, cervical stenosis, upper extremity nerve entrapment, rotator cuff tear, glenoid labrum
tear. Treatment: The athlete was referred to the team physician who performed an examination, and ordered
neck and shoulder x-rays along with nerve conduction velocity testing. All tests were normal. He was diagnosed
with acute brachial plexus neuropathy of the long thoracic nerve/Parsonage-Turner Syndrome. He was
prescribed a course of prednisone and referred to an orthopedic surgeon who recommended conservative
treatment involving a period of rest and avoiding overhead activities, while managing pain and spasm with
modalities. After several weeks the pain improved, and exercises focusing on the rotator cuff at 0 degrees were
performed as well as concentrating on shoulder retraction when performing activities. At 4 weeks post-injury,
there was an increase in pain-free AROM of the shoulder and exercises at 90 degrees were added with a focus
on neuromuscular control and scapular stabilization. By 6 weeks the athlete was able to begin controlled drills
in practice that involved shooting, rebounding and defending, but the athlete complained of discomfort in the
shoulder with prolonged running. To avoid aggravating the upper extremity while maintaining cardiovascular
fitness, the athlete alternated bike and elliptical workouts. Although the scapular winging was still present, the
dyskinesis was beginning to mimic a more normal/functional pattern. The athlete could shoot a basketball since
the injury does not involve his shooting hand, using his guide hand to about 90o of forward flexion before
experiencing pain. By 8 weeks he was able to begin participating in sport specific drills wearing a brace
designed to stabilize the scapula. He completed the rest of the basketball season with minimal limitations,
mostly complaining of muscular fatigue in the shoulder. There is no timeframe for full recovery, but the
orthopedic surgeon discussed performing a surgical decompression if he is not recovered in a year. For now the
athlete would like to continue a conservative approach of modalities and rehabilitation. Uniqueness: Long
thoracic nerve palsy is rare, but when present it is usually the result of a traction force, direct blow, vigorous
overhead activity, or pressure being placed on the nerve from a backpack, all causes which the athlete denied.
The athlete did not present with pain or dysfunction immediately after, or even the day after practice. Rather his
onset was insidious; he awoke unable to raise his arm. The athlete’s quick return to play is not typical and is
likely attributed to the non-dominant side being affected, allowing him to become functional more quickly.
Conclusions: Without an MOI, the exact cause of long thoracic nerve palsy is hard to conclude. Clinicians must
differentially diagnose the injury and subsequent cause of shoulder dysfunction so that proper rehabilitation is
implemented. It is challenging to put a timeframe on complete recovery with some cases taking up to 2 years
and possibly requiring surgical intervention. It is important for the clinician and athlete to understand the goals
of the rehabilitation process, and the longer duration it takes for nerve tissue to heal. Word Count: 596
Right Brachial Plexus Avulsion of a 19 Year Old Male Collegiate Football Player
Selby MW, Ziobro R, Simington J, Janik G: Kings College, Wilkes Barre, PA
Background: A 19-year-old male football player was involved in a football tackling drill during a spring
practice on March 29 2010, when an opposing player’s helmet collided with the athlete’s shoulder. The
patient’s neck was forced into lateral flexion and his right shoulder was depressed. The patient reported
paresthesia and loss of motor function in his right arm during the initial on-field assessment. EMS was activated
and the patient was spine boarded and taken to the local emergency room. He was diagnosed with a right
shoulder tendon rupture and was discharged. Several hours after injury the patient returned to the hospital with
extreme pain, a burning sensation and loss of motor function. The team’s physician was present and determined
the patient needed more advanced care. The patient was transported to the Hospital of the University of
Pennsylvania. Once at the trauma center an evaluation and diagnostic testing, including MRI, were performed
over a week’s time. The patient was diagnosed with a brachial plexus avulsion of nerve roots C5, C6, and C7 on
his right side. Following this diagnosis, surgery was recommended to repair the damaged nerves; the
musculocutaneus nerve and the supraclavicular nerve were too damaged to fuse back together without nerve
grafts. The patient has a previous medical history of brachial plexopathies, the most recent occurring 20 minutes
prior on the same side as the nerve root avulsion. Differential Diagnosis: Brachial plexus avulsion, brachial
plexopathy, disc herniation, nerve root compression, spinal cord injury. Treatment: Two nerve grafts were
used to repair the damaged nerve roots. Nerve roots C5, C6, and C7 were unrepairable. The patient’s sural nerve
was harvested and one portion was used to connect the phrenic nerve to the musculocutaneous nerve. A second
portion was used to connect the accessory nerve to the supraclavicular nerve for reinnervation. The goal of the
surgery was to regain function at the patient’s right arm. The patient was immobilized for 3 weeks, with a
shoulder sling and soft cervical collar. Patient started therapy on May 10, 2010. Patient’s manual muscle tests
were trace to fair plus on the right side, with the majority of the strength in the wrist and fingers. Therapy
included moist heat for pain management; soft tissue massage; strength and range of motion exercises at the
fingers, wrist, and shoulder and passive stretching to prevent adhesive capsulitis at the shoulder. The patient
was instructed to use the affected arm as much as possible with activities of daily living to promote
reinvervation. After four months of therapy, manual muscle tests had improved in all but the biceps and triceps,
which were still 0 or trace. After eight months of rehabilitation the patient’s manual muscle test have improved
to fair plus or good in all but the biceps (0/5), triceps (0/5) and external rotators (2⁺/5). Uniqueness: Full
avulsions of multiple nerve roots at the brachial plexus are extremely rare in athletics. These injuries most often
occur in motor vehicle accidents (1-3). In athletics, avulsions typically take place in a game, but this injury
occurred in a practice. Also this injury was correctly diagnosed and immediately treated with surgery. Previous
reported cases were initially misdiagnosed for weeks and treated conservatively prior to surgery. Conclusions:
Brachial plexus avulsions are extremely rare in athletics and typically result in lifelong functional defects.
Athletic Trainers must be aware of this injury and must know how to prevent, treat, and rehabilitate it quickly.
Even with rapid diagnosis and treatment the outcome is frequently poor and life altering. Word Count: 580
A Distal Fibula and Pilon Fracture with a Dislocated Proximal Fibular Head in a Collegiate Softball
Athlete.
Smith JC, Ribbons KL, Stephenson LJ: Stony Brook University, Stony Brook, New York.
Background: An 18 year old female softball outfielder with a previous history of proximal fibular subluxation
injured her left leg during sliding drills performed at full speed on field turf. While sliding her left, tuck, leg
became lodged in the turf forcing her knee into external rotation and ankle into eversion and plantar flexion.
Athlete experienced substantial pain and had an obvious deformity at the ankle with foot in eversion and
protruding of the lateral malleolus. The proximal fibular deformity was obstructed by her athletic apparel. Onfield evaluation revealed a possible distal fibular fracture with neurovascular status intact. Athlete had a
positive squeeze test with pain proximally and distally. Athlete was extremely tender to palpate around ankle
and fibular head and could not plantar or dorsiflex. The athlete’s cleat was removed with shears and a vacuum
splint was applied. Athlete was immediately referred to emergency department Differential Diagnosis: Grade
III deltoid ligament sprain, tibial plateau fracture, syndesmotic sprain, proximal fibular head dislocation,
fracture of distal tibia, fracture of distal fibula. Treatment: Diagnostic imaging from MRIs and CT scan
revealed a dislocated proximal fibular head, closed distal fibular and pilon ankle fracture, and a grade II PCL
sprain. The fibular head was initially reduced and athlete was placed in a fiberglass cast for approximately two
weeks to allow for swelling to decrease. A surgical ORIF was performed to stabilize the distal tibia and fibula
and bone fragments were excised from the ankle joint. Athlete was placed in a fiberglass cast for three months
and was non-weight bearing (NWB). Upon cast removal athlete was placed in a walking boot and NWB
exercises were initiated. Athlete preformed active ankle range of motion, strengthening for quadriceps and
intrinsic muscles of the foot. After one week of rehabilitation the athlete began progressive resistive ankle
exercises. After two weeks the athlete was able to walk without walking boot for short distances and was placed
in an air cast splint. At six months status post ORIF a jogging protocol was initiated; at which point she
demonstrated hip external rotation during the swing phase and engaged in gait training that includes augmented
feedback during straight-ahead jogging and sport specific motions. Athlete continues to complain of substantial
bone related pain when jogging. Uniqueness: The type of injury sustained most commonly occurs in high
velocity, high force impacts such as a motor vehicle accident, and most typically involves an open fracture.
This athlete sustained her injuries during participation in an athletic event with relatively low forces and
velocities, and all fractures were closed. The nature of this injury has resulted in increased proximal tibiofibular
and ankle mortise joint play, which decreases stability at the ankle joint. Even with ORIF this athlete displays
biomechanical dysfunction that needs to be addressed with functional assessments and neuromuscular
rehabilitation that includes augmented feedback. Conclusion: It is important to recognize that playing surface
can have an effect on the type and severity of injury sustained during athletic practices. When an athlete
sustains a severe injury to the structures of the ankle mortise and knee, any alterations in gait biomechanics
must be recognized and addressed to improve function and allow for return to play. Word Count: 529
Thoracic Pain in a Collegiate Runner
Sweeney C, Rothbard M, Morin G: Southern Connecticut State University, New Haven, CT
Background: A 22 year-old female runner presented with chronic respiratory difficulty, unremitting lateral
right dorsal thorax pain, fingertip pallor, and numbness in the upper extremities. Pain quotient was described as
5/10 at rest, 7/10 with inspiration, and 8/10 during and after activity. Physical examination revealed a right
hump of the thoracic cage in the flexed position, palpable tenderness between ribs 3-6, sensory and motor
deficits of the left lateral upper arm, and a weak radial pulse. ROM testing revealed full trunk flexion, but
limited extension, left and right rotation and side bending. The patient’s medical history was significant for
structural scoliosis and hypermobility that was diagnosed at the age of 13 with a 36° thoracic and 33°lumbar
curve. Later radiographs taken at the age of 20 revealed an increase in the thoracic (40°) and lumbar (43°)
curves. Previous treatment consisted of 3••• years of rehabilitation starting at age 18 focusing on strengthening
and manual therapy including mobilizations and traction to alleviate symptoms. Differential Diagnosis:
Rheumatoid arthritis, asthma, pulmonary embolism, thoracic outlet syndrome, Raynaud’s disease, and
restrictive lung disease. Treatment: After the initial evaluation, the patient was referred to her PCP. The PCP
ordered an MRI that revealed degenerative discs at C2-C3 and C5-C6, and minimal bulging at L2-L3; however,
results were inconclusive to the chief complaint. The patient was referred to an orthopedic spine specialist who
prescribed an NSAID, ordered blood tests that ruled out rheumatoid pathology, and referral to a pulmonologist.
The pulmonologist ordered a chest x-ray and a pulmonary function test. Radiographs were unremarkable;
however, the pulmonary function test revealed consistent reduction in forced vital capacity and total lung
capacity implying restriction. The patient was diagnosed with restricted right lung disease and referred back to
the orthopedist. Status posts two months; plain film radiographs were taken and identified an increase in the
thoracic (51°) with no changes to the lumbar (43°) curve. The orthopedist definitively diagnosed the patient
with restrictive right lung disease, thoracic outlet syndrome, and Raynauds’s disease secondary to her
progressive structural scoliosis and concluded that her condition would continue to deteriorate without surgical
intervention. A posterior T5-L1 interbody vertebral fusion was performed. A post-operative right lung pleural
effusion developed resulting in further dyspnea. An ultrasound-guided thoracentesis removed 1.4 L of fluid.
Three months post-operative pulmonary function test demonstrated an increase of 1 L in total lung capacity.
Five months post-operative the patient continues to progress with full body and respiratory rehabilitation and is
expected to make a full recovery. Uniqueness: This case is unique because the patient’s increasing thoracic
scoliotic curve was the underlying cause of her chronic respiratory difficulty. The progression of scoliosis
characteristically discontinues when growth is completed; however, in this case further increases were due to
inherent spinal instability. As the vertebral bodies involved in the scoliosis rotated, the spinous processes
deviated toward the concave side of the curve, and the ribs followed the rotation of the vertebrae. This rotation
placed a 30% restriction on the right lung and as the thoracic curve gradually increased, the pulmonary
restriction would have as well. Conclusions: Restrictive lung disease is caused by a deformity of the chest wall.
Changes to the thoracic cavity associated with significant scoliosis can dramatically affect respiratory function.
Due to the rarity of this condition, clinicians must be aware of a patient’s medical history and its potential to
affect a patient’s future health. Proper evaluation, management, and intervention of scoliosis have the capacity
to limit the debilitating nature of the condition to facilitate the continuation of a physically active lifestyle.
Word Count: 590
Ankle Dislocation with Maisonneuve Fracture: A Case Report
Tracz A*, Powers ME: Marist College, Poughkeepsie, New York, University of
Maryland, Baltimore County, Baltimore, Maryland*
Background: We present the case of an ankle dislocation complicated by a unique proximal fibula fracture in a
high school football athlete. A healthy sixteen-year-old male running back suffered a direct blow to the lower
extremity while being tackled. The tackler landed on the posterior aspect of the patient’s left ankle and foot,
causing the lower leg to internally rotate while the foot remained in a fixed position on the ground. Upon
examination, a gross ankle deformity was noted as the foot remained in an externally rotated and pronated
position. Distal circulation, sensation, and motor function were present however the patient was experiencing a
significant amount of pain. The team physician diagnosed the injury on the field as a talocrural dislocation and
performed a closed reduction at that time. Distal circulation, sensation, and motor function remained present
after reduction however significant swelling was present. Nothing else was remarkable at that time. The ankle
was then immobilized with a rigid splint and the patient was referred to the emergency department for further
diagnostic testing. Differential Diagnosis: Talus fracture, tibia fracture, Weber or other fibula fracture, Pott's
or Dupuyten’s fracture, lateral collateral ligament sprain, deltoid ligament sprain, syndesmosis sprain.
Treatment: The ankle was reduced on the field and immobilized. At the emergency department, radiographs
confirmed that the patient had suffered an anterior talocrural dislocation and revealed an associated fracture of
the medial malleolus. A fracture at the proximal fibular head was also noted. The distal tibiofibular joint was
stabilized with two screws inserted through the distal fibula extending through the syndesmosis and into the
tibia. The tibial malleolar fracture was fixated with two more screw inserted directly into the medial malleolus
from the distal end. Following surgery, the patient was placed non-weightbearing in a short leg cast for eight
weeks followed by a program of therapeutic exercise to restore range of motion, strength, and neuromuscular
control. Uniqueness: While distal fractures associated with ankle dislocations are common, proximal fractures
are not. Maisonnueve fractures of the proximal fibula are associated with disruption of the tibiofibular
syndesmosis, but are often missed during physical and radiographic exam. While most Maisonneuve fractures
occur distal to the head of the fibula, the present injury occurred at the fibular head itself. Conclusions: Despite
the location of the Maisonneuve fracture, surgical management of the injury was not different than if it had been
it its typical location. The presence of a Maisonneuve fracture implies ligamentous ankle injury with potential
instability not always apparent on static radiographs. It is imperative that clinicians are familiar with this injury
and its clinical and radiographic presentation. If not managed properly, permanent disability and dysfunction
could result. Early surgical intervention is recommended due to the potential instability associated with such an
injury. In the present case, surgery produced satisfactory results, as athlete was able to return to play the
following season. Key Words: Maisonneuve fracture, ankle, dislocation, screw fixation. Word count: 486
Diagnosis of Crohn’s Disease And Ulcerative Colitis in a 22-Year Old Male College Lacrosse Player: A
Case Study
Staney, C E & Vieser K E: Springfield College Athletic Training Education Program, Springfield, MA
Background Information: This case presents a 22 year old male Division I lacrosse player who had started
experiencing unusual gastrointestinal problems during his sophomore year of high school. Symptoms started as
bloody bowel movements, which left standing blood afterwards. These bloody stools were coupled with intense
stomach pains and fatigue that disallowed him from being attentive in class and during practice. The condition
worsened to the point where the pateint lost 12 lbs after spending 12 straight hours in the bathroom, vomiting
and making bowel movements. Afterwards, he told his mother about his persisting problems and they consulted
his pediatrician. The pediatrician referred them a gastroenterologist immediately. Differential Diagnoses:
Dyspepsia, gastritis, peptic ulcer, viral gastroenteritis (“stomach flu”), colorectal cancer, Crohn’s Disease,
ulcerative colitis, and irritable bowel syndrome (IBS). Treatment: After an initial visit to the
gastroenterologist, the patient was referred to have a biopsy of his intestinal tract via a colonoscopy. The
colonoscopy was followed by an upper GI test as well as a Dexascan to check his bone density. Blood was also
drawn to test for other diseases. The tests led to a final diagnosis of Crohn’s Disease and ulcerative colitis, with
some signs of intestinal bowel disease. The patient had a 6 to 8 inch portion of his intestine between his small
and large intestine affected by ulcerative colitis. The patient was prescribed anti-inflammatory Pentasa
(2000mg 2x a day), as well as Omega 3 and folic acid tablets. The patient was instructed to avoid difficult-todigest foods, such as nuts, popcorn and high-fat foods. Though urged to rest, he was never restricted from
sports and continued to compete as tolerated. The patient was able to play lacrosse all four years of college.
Throughout his college career, it was necessary for him to be honest about how he was feeling and
communicate this to the Athletic Training staff. Stressful weeks at school often led to flare ups of his condition
in which he would feel intestinal pains at a more constant rate and higher intensity. In order to decrease the
intestinal pain, he had to work on relaxation techniques to decrease his stress levels. During lacrosse season he
would tell the Athletic Training staff if he was having a bad week and the message would be relayed to the
coach. When experiencing flare-ups he was allowed to rest at his own will and was never asked to push through
it for the better of the team. The Athletic Training staff would also make sure he remained well hydrated.
Uniqueness: Crohn’s disease and ulcerative colitis are often genetically linked conditions, but in this case there
was no pertinent family medical history. There was also no personal medical history indicative of either disease
prior to his diagnosis. Due to the location of the affected area and the type of symptoms he experiences, the
patient is among 2% of Crohn’s patients with Ulcerative Colitis. Approximately 70% of Crohn’s patients and
30% of Ulcerative Colitis patients require surgery as a suggested protocol. Conclusions: Crohn’s disease
affects each individual differently and the severity of the symptoms is dependent on the location of the disease
within the GI tract. This patient was able to compete at a high level for a number of years and manage his
conditions without surgery. This case highlights the importance of patient to athletic trainer communication
when caring for a patient with a potentially debilitating condition. This case also helps to stress the importance
of educating oneself on general medical conditions and associated interventions for patients with similar
pathologies. Word Count: 589
A High School Football Player with a Morel-Lavallee Lesion
Viana S *, Cleaves G†, Rudio C†, Kirste R†: Linden High School, Linden, NJ*; Kean University, Union, NJ†
Background: A 16-year-old male football player suffered a unique injury called a Morel- Lavallee lesion. A
Morel-Lavallee lesion is caused by forces of pressure and sheer stress at the border of subcutaneous tissue and
the muscle fascia or bone. Due to the sheer force this results in the separation of the tissue. Mechanism of
Injury: Direct blow to the medial aspect of the lower leg. Initial examination revealed excessive edema and
ecchymosis along the medial joint line to the proximal third of the tibia. There was an egg shaped contusion
distal to the tibial plateau. No point tenderness or palpable pain was found. Neurological assessment was
normal. Active ROM was normal except for missing last 10 degrees of knee flexion. Valgus, Varus, Anterior
Drawer, Lachman’s, Pivot-Shift, Bouce-Home Test, Godfrey 90-90 were negative. Athlete’s most common
complaint was leg felt tight. Differential Diagnosis: Prepatellar bursitis, Subpatellar bursitis, Tibial Plateau
contusion, tibia fracture, Morel-Lavallee lesion, and MCL sprain. X-rays ruled out any fractures. Athlete was
diagnosed with a Morel-Lavallee Lesion of the knee and lower leg. Treatment: On the first day post injury the
goal of the treatment was to decrease excessive edema and ecchymosis. Biocompression was administered for
30 minutes; electrical stimulation pulsed over the bursitis-like contusion for 20 minutes. This treatment was
done twice that day. The afternoon treatment consisted of Game Ready® for 30 minutes. The athlete was given
a compression sleeve to wear. Two days post injury the athlete report to the orthopedic physician. Physician’s
first impression was subpatellar bursitis. Orthopedic physician ordered aspiration of swollen area. The edema
was not reduced by aspiration. Physician instructed to use heat as a main modality due to the diagnosis of a
Morel-Lavallee Lesion. Athlete returned to orthopedic physician on Friday 10/7 for second aspiration attempt,
with little success; Recommended to continue with treatment. Three weeks post injury, the athlete continues
treatment of heat pack for 20 minutes, then a warm up before practice on the stationary bike on level 5 for 20
minutes keeping the RPM between 70 and 80 RPM. Ice administered post practice. Athlete states he has no
pain or trouble playing football. Athlete no longer feels tightness. Edema has not reduced in size and now
resembles pitting edema. Goals are to decrease the edema, ecchymosis, and to relieve the soft tissue hematoma.
Uniqueness: Morel-Lavallee Lesion is a rare condition that is a closed degloving injury, resulting in a cavity
filled with hematoma and liquefied fat. Skin tears away from fascia or subcutaneous tissue. According to the
few documented diagnosis of this condition, it is has occurred to athletes involved in football, cycling, and
climbers. Pain is usually found in this type of injury. The athlete in this case never reported any pain. His most
severe symptom was lack of ROM and a feeling of tightness. Conclusion: Morel-Lavallee lesion is a rare injury
that has both history and clinical symptoms of a quadriceps contusion and a subpatellar or prepatellar bursitis.
This injury can also be found in the hip and the knee. A French physician first described this injury by the name
of Maurice Morel-Lavallee in 1853. If therapy is insufficient, necrosis can form in large areas of the body. If
this injury is not taken care of properly it can lead to necrosis and edema will remain in that capsule. Word
Count: 590