maria e. reese, md spine & sports rehabilitation center rehabilitation institute of chicago...
TRANSCRIPT
![Page 1: Maria E. Reese, MD Spine & Sports Rehabilitation Center Rehabilitation Institute of Chicago Northwestern University Feinberg School of Medicine Musculoskeletal](https://reader036.vdocuments.us/reader036/viewer/2022062315/5697bf741a28abf838c7fcc2/html5/thumbnails/1.jpg)
Maria E. Reese, MD
Spine & Sports Rehabilitation Center
Rehabilitation Institute of Chicago
Northwestern University Feinberg School of Medicine
Musculoskeletal Ultrasound in a Rehabilitation Population:
Case Presentations
AAPM&R Annual AssemblyOctober 1, 2015
![Page 2: Maria E. Reese, MD Spine & Sports Rehabilitation Center Rehabilitation Institute of Chicago Northwestern University Feinberg School of Medicine Musculoskeletal](https://reader036.vdocuments.us/reader036/viewer/2022062315/5697bf741a28abf838c7fcc2/html5/thumbnails/2.jpg)
• I have no disclosures
![Page 3: Maria E. Reese, MD Spine & Sports Rehabilitation Center Rehabilitation Institute of Chicago Northwestern University Feinberg School of Medicine Musculoskeletal](https://reader036.vdocuments.us/reader036/viewer/2022062315/5697bf741a28abf838c7fcc2/html5/thumbnails/3.jpg)
Inpatient MSK Consults – Hemiplegic Shoulder Pain
-20 -15 -10 -5 0 5 10 15 200
1
2
3
4
5
6
Upper Extremity Dressing FIMsHemiplegic Shoulder Pain - Injection
Days From Injection
![Page 4: Maria E. Reese, MD Spine & Sports Rehabilitation Center Rehabilitation Institute of Chicago Northwestern University Feinberg School of Medicine Musculoskeletal](https://reader036.vdocuments.us/reader036/viewer/2022062315/5697bf741a28abf838c7fcc2/html5/thumbnails/4.jpg)
Case 1: MN
-20 -15 -10 -5 0 5 10 15 200
1
2
3
4
5
6
Upper Extremity Dressing FIMsHemiplegic Shoulder Pain - Injection
Days From Injection
![Page 5: Maria E. Reese, MD Spine & Sports Rehabilitation Center Rehabilitation Institute of Chicago Northwestern University Feinberg School of Medicine Musculoskeletal](https://reader036.vdocuments.us/reader036/viewer/2022062315/5697bf741a28abf838c7fcc2/html5/thumbnails/5.jpg)
Case 1: MN
• 43 yr old left handed male
• Left MCA, ICA stroke after total thyroidectomy with resultant right hemiparesis
• PMH: HTN, GERD, morbid obesity, hypothyroidism with thyroid nodule
• PSH: Thyroidectomy, left hemicraniectomy, cranioplasty
![Page 6: Maria E. Reese, MD Spine & Sports Rehabilitation Center Rehabilitation Institute of Chicago Northwestern University Feinberg School of Medicine Musculoskeletal](https://reader036.vdocuments.us/reader036/viewer/2022062315/5697bf741a28abf838c7fcc2/html5/thumbnails/6.jpg)
Case 1: MN
MSK Consult: Right shoulder pain• Anterior & posterior, 5/10, sore• Worse: Walking, abduction 90 deg• Better: Lying down
Physical Exam (right shoulder):• +Sulcus, TTP anterior shoulder• Pain with abduction 90 deg, ER 70 deg, IR 20 deg
![Page 7: Maria E. Reese, MD Spine & Sports Rehabilitation Center Rehabilitation Institute of Chicago Northwestern University Feinberg School of Medicine Musculoskeletal](https://reader036.vdocuments.us/reader036/viewer/2022062315/5697bf741a28abf838c7fcc2/html5/thumbnails/7.jpg)
Case 1: MN, Right Shoulder X-Ray
• AP • Axillary
![Page 8: Maria E. Reese, MD Spine & Sports Rehabilitation Center Rehabilitation Institute of Chicago Northwestern University Feinberg School of Medicine Musculoskeletal](https://reader036.vdocuments.us/reader036/viewer/2022062315/5697bf741a28abf838c7fcc2/html5/thumbnails/8.jpg)
Case 1: MN, Impression & Plan
• Ultrasound: Intact RTC and biceps tendons, mild AC joint OA• Right shoulder pain due to subluxation• Right GH joint corticosteroid injection under US guidance
R GH JT INJECTION
![Page 9: Maria E. Reese, MD Spine & Sports Rehabilitation Center Rehabilitation Institute of Chicago Northwestern University Feinberg School of Medicine Musculoskeletal](https://reader036.vdocuments.us/reader036/viewer/2022062315/5697bf741a28abf838c7fcc2/html5/thumbnails/9.jpg)
Case 1: MN
Pre-Injection:• Complained of R shoulder pain
in OT daily
Post-Injection:• No report shoulder pain 6 days
following injection• Don shoulder brace with min verbal
cues
-20 -15 -10 -5 0 5 10 15 200
1
2
3
4
5
6
Upper Extremity Dressing FIMsHemiplegic Shoulder Pain - Injection
Days From Injection*
![Page 10: Maria E. Reese, MD Spine & Sports Rehabilitation Center Rehabilitation Institute of Chicago Northwestern University Feinberg School of Medicine Musculoskeletal](https://reader036.vdocuments.us/reader036/viewer/2022062315/5697bf741a28abf838c7fcc2/html5/thumbnails/10.jpg)
Case 2: SG
• 64 yr old female with history of HTN• Cardiac arrest due to complete heart block• Cardioembolic infarcts with resultant right sided hemiparesis
MSK Consult: Right shoulder weakness• Denies pain• Difficulty lifting arm overhead• Regaining distal motor recovery but not proximal• No prior shoulder pain/injury• Fall at time of cardiac arrest – unclear mechanism
![Page 11: Maria E. Reese, MD Spine & Sports Rehabilitation Center Rehabilitation Institute of Chicago Northwestern University Feinberg School of Medicine Musculoskeletal](https://reader036.vdocuments.us/reader036/viewer/2022062315/5697bf741a28abf838c7fcc2/html5/thumbnails/11.jpg)
Case 2: SG
Physical Exam (right shoulder): • No TTP AC joint, biceps tendon• AROM: Shoulder hiking with limited abduction • PROM: Full, pain free abduction, flexion • Negative Hawkins-Kennedy, Negative Neer’s• Weakness with Empty Can testing
![Page 12: Maria E. Reese, MD Spine & Sports Rehabilitation Center Rehabilitation Institute of Chicago Northwestern University Feinberg School of Medicine Musculoskeletal](https://reader036.vdocuments.us/reader036/viewer/2022062315/5697bf741a28abf838c7fcc2/html5/thumbnails/12.jpg)
Case 2: SG, Bilateral Shoulder Ultrasound
• Right supraspinatus
• Left supraspinatus
![Page 13: Maria E. Reese, MD Spine & Sports Rehabilitation Center Rehabilitation Institute of Chicago Northwestern University Feinberg School of Medicine Musculoskeletal](https://reader036.vdocuments.us/reader036/viewer/2022062315/5697bf741a28abf838c7fcc2/html5/thumbnails/13.jpg)
Case 2: SG, Right Shoulder Ultrasound
R SUPRASPIN IMPING VIEW
• High riding humeral head; loss of tendon; cortical irregularity
![Page 14: Maria E. Reese, MD Spine & Sports Rehabilitation Center Rehabilitation Institute of Chicago Northwestern University Feinberg School of Medicine Musculoskeletal](https://reader036.vdocuments.us/reader036/viewer/2022062315/5697bf741a28abf838c7fcc2/html5/thumbnails/14.jpg)
Case 2: SG, Impression & Plan
• Right shoulder weakness with full thickness supraspinatus tear that is no longer painful
• Add periscapular strengthening/stabilization to PT program• No indication for injection as no pain
*
![Page 15: Maria E. Reese, MD Spine & Sports Rehabilitation Center Rehabilitation Institute of Chicago Northwestern University Feinberg School of Medicine Musculoskeletal](https://reader036.vdocuments.us/reader036/viewer/2022062315/5697bf741a28abf838c7fcc2/html5/thumbnails/15.jpg)
Case 3: EM
• 58 yr old female with HTN, hypercholesterolemia • Right basal ganglia, internal capsule stroke 2012 with resultant
left hemiparesis
MSK outpatient consult: Left shoulder pain• Subacute onset during prior inpatient rehabilitation (OSH)• Tried sling, anti-spasticity medications, pain medications with
minimal benefit• Pain 8/10, anterior, lateral, posterior• Worse: Active & passive motion• Strength improving with PT/OT
![Page 16: Maria E. Reese, MD Spine & Sports Rehabilitation Center Rehabilitation Institute of Chicago Northwestern University Feinberg School of Medicine Musculoskeletal](https://reader036.vdocuments.us/reader036/viewer/2022062315/5697bf741a28abf838c7fcc2/html5/thumbnails/16.jpg)
Case 3: EM
Physical Exam (left shoulder):• +Sulcus on inspection• Diffuse TTP• PROM: ER 10 deg, flexion 30 deg, abduction 30 deg; painful• Left upper extremity strength: 1/5 shoulder abduction, 4/5
distally
![Page 17: Maria E. Reese, MD Spine & Sports Rehabilitation Center Rehabilitation Institute of Chicago Northwestern University Feinberg School of Medicine Musculoskeletal](https://reader036.vdocuments.us/reader036/viewer/2022062315/5697bf741a28abf838c7fcc2/html5/thumbnails/17.jpg)
Case 3: EM, Left Shoulder X-Ray
![Page 18: Maria E. Reese, MD Spine & Sports Rehabilitation Center Rehabilitation Institute of Chicago Northwestern University Feinberg School of Medicine Musculoskeletal](https://reader036.vdocuments.us/reader036/viewer/2022062315/5697bf741a28abf838c7fcc2/html5/thumbnails/18.jpg)
Case 3: EM, Left Shoulder Ultrasound
L SUBSCAP LAX L SUBSCAP SAX
![Page 19: Maria E. Reese, MD Spine & Sports Rehabilitation Center Rehabilitation Institute of Chicago Northwestern University Feinberg School of Medicine Musculoskeletal](https://reader036.vdocuments.us/reader036/viewer/2022062315/5697bf741a28abf838c7fcc2/html5/thumbnails/19.jpg)
Case 3: EM, Left Shoulder Ultrasound
L SUPRASPIN LAX
L SUPRASPIN SAX
![Page 20: Maria E. Reese, MD Spine & Sports Rehabilitation Center Rehabilitation Institute of Chicago Northwestern University Feinberg School of Medicine Musculoskeletal](https://reader036.vdocuments.us/reader036/viewer/2022062315/5697bf741a28abf838c7fcc2/html5/thumbnails/20.jpg)
Case 3: EM, Left Shoulder Ultrasound
L SUPRASPIN IMPING VIEW
![Page 21: Maria E. Reese, MD Spine & Sports Rehabilitation Center Rehabilitation Institute of Chicago Northwestern University Feinberg School of Medicine Musculoskeletal](https://reader036.vdocuments.us/reader036/viewer/2022062315/5697bf741a28abf838c7fcc2/html5/thumbnails/21.jpg)
Case 3: EM, Impression & Plan
• Left shoulder adhesive capsulitis & subluxation• Left GH joint corticosteroid injection, US guidance
L GH JT INJECTION
![Page 22: Maria E. Reese, MD Spine & Sports Rehabilitation Center Rehabilitation Institute of Chicago Northwestern University Feinberg School of Medicine Musculoskeletal](https://reader036.vdocuments.us/reader036/viewer/2022062315/5697bf741a28abf838c7fcc2/html5/thumbnails/22.jpg)
Case 3: EM
• Pre: 8/10; abduction/flexion 30 deg• Post: 0/10; abduction/flexion 100 deg
• 2 wk follow-up: 0/10• +Sulcus; No TTP• AROM: Abduction, flexion 70 deg• PROM: Abduction, flexion 150 deg; ER 30 deg
• Dressing, grooming improving• Ambulating independently (no longer focusing on pain)
*
![Page 23: Maria E. Reese, MD Spine & Sports Rehabilitation Center Rehabilitation Institute of Chicago Northwestern University Feinberg School of Medicine Musculoskeletal](https://reader036.vdocuments.us/reader036/viewer/2022062315/5697bf741a28abf838c7fcc2/html5/thumbnails/23.jpg)
Case 4: OP
• 80 yr old female with history of hypothyroidism, osteopenia
• Right parietal intraparenchymal hemorrhage from unwitnessed fall at home
• 7 days later, admitted to acute inpatient rehabilitation
• MSK Consult: Right upper leg pain
![Page 24: Maria E. Reese, MD Spine & Sports Rehabilitation Center Rehabilitation Institute of Chicago Northwestern University Feinberg School of Medicine Musculoskeletal](https://reader036.vdocuments.us/reader036/viewer/2022062315/5697bf741a28abf838c7fcc2/html5/thumbnails/24.jpg)
Case 4: OP, Hip X-ray
![Page 25: Maria E. Reese, MD Spine & Sports Rehabilitation Center Rehabilitation Institute of Chicago Northwestern University Feinberg School of Medicine Musculoskeletal](https://reader036.vdocuments.us/reader036/viewer/2022062315/5697bf741a28abf838c7fcc2/html5/thumbnails/25.jpg)
• Severe right hip osteoarthritis • Right hip intra-articular corticosteroid injection, US guided
Case 4: OP, Impression & Plan
• Pre-injection pain 8/10; Post-injection pain 2/10
R HIP JT INJECTION
![Page 26: Maria E. Reese, MD Spine & Sports Rehabilitation Center Rehabilitation Institute of Chicago Northwestern University Feinberg School of Medicine Musculoskeletal](https://reader036.vdocuments.us/reader036/viewer/2022062315/5697bf741a28abf838c7fcc2/html5/thumbnails/26.jpg)
Case 4: OP, Functional Independence Measure (FIM)
Pre-injection FIM (June 14):• Bed mobility: Max assist• Transfers: Total assist• Ambulation: N/A• Sitting balance: Max assist
Day of injection FIM (June 19):• Bed mobility: Max assist• Transfers: Max assist• Ambulation: N/A• Sitting balance: Max assist
Post-injection FIM (June 22):• Bed mobility: Mod assist• Transfers: Mod assist• Ambulation: Mod assist, 20ft RW• Sitting balance: Mod assist
Day of discharge FIM (June 26):• Bed mobility: Close supervision• Transfers: Mod assist• Ambulation: Mod assist, 34ft RW• Sitting balance: Close supervision
*
![Page 27: Maria E. Reese, MD Spine & Sports Rehabilitation Center Rehabilitation Institute of Chicago Northwestern University Feinberg School of Medicine Musculoskeletal](https://reader036.vdocuments.us/reader036/viewer/2022062315/5697bf741a28abf838c7fcc2/html5/thumbnails/27.jpg)
Case 5: LM
• 19 yr old female with history of GERD• L2 ASIA A SCI due to L3 burst fracture from MVA• Multiple intra-abdominal injuries requiring surgical intervention
• Left humeral surgical neck non-displaced fracture– Discovered 2 wks after initial injury– Initially PWB x 6 wks; WBAT upon rehab admission
• SH: Sophomore collegiate soccer player
![Page 28: Maria E. Reese, MD Spine & Sports Rehabilitation Center Rehabilitation Institute of Chicago Northwestern University Feinberg School of Medicine Musculoskeletal](https://reader036.vdocuments.us/reader036/viewer/2022062315/5697bf741a28abf838c7fcc2/html5/thumbnails/28.jpg)
Case 5: LM
MSK Consult: Left shoulder pain• 6-9/10, anterior superior, aching• Worse since WB status upgraded• Worse: WB, use, lying on left side, end range of
motion• Better: Rest, oxycodone
Physical Exam (left shoulder):• Diffusely TTP anteriorly• Active flexion 170 deg, abduction 160 deg with pain.
Passive flexion/abduction 180 deg with pain. ER/IR not restricted
• +Speed’s, +Neer’s, +Hawkins-Kennedy, Neg Empty Can, Neg resisted IR/ER
![Page 29: Maria E. Reese, MD Spine & Sports Rehabilitation Center Rehabilitation Institute of Chicago Northwestern University Feinberg School of Medicine Musculoskeletal](https://reader036.vdocuments.us/reader036/viewer/2022062315/5697bf741a28abf838c7fcc2/html5/thumbnails/29.jpg)
Case 5: LM, Left Shoulder X-Ray, AP view
• Current x-ray • X-ray 1 month prior
![Page 30: Maria E. Reese, MD Spine & Sports Rehabilitation Center Rehabilitation Institute of Chicago Northwestern University Feinberg School of Medicine Musculoskeletal](https://reader036.vdocuments.us/reader036/viewer/2022062315/5697bf741a28abf838c7fcc2/html5/thumbnails/30.jpg)
Case 5: LM, Left Shoulder X-Ray, axillary view
• Current x-ray • X-ray 1 month prior
![Page 31: Maria E. Reese, MD Spine & Sports Rehabilitation Center Rehabilitation Institute of Chicago Northwestern University Feinberg School of Medicine Musculoskeletal](https://reader036.vdocuments.us/reader036/viewer/2022062315/5697bf741a28abf838c7fcc2/html5/thumbnails/31.jpg)
Case 5: LM, Left Shoulder Ultrasound
• Normal appearing RTC tendons & biceps tendon, no subacromial/subdeltoid bursitis
• Cortical irregularity of humerus correlated to fracture site
L HUM FX
![Page 32: Maria E. Reese, MD Spine & Sports Rehabilitation Center Rehabilitation Institute of Chicago Northwestern University Feinberg School of Medicine Musculoskeletal](https://reader036.vdocuments.us/reader036/viewer/2022062315/5697bf741a28abf838c7fcc2/html5/thumbnails/32.jpg)
Case 5: LM
Female Athlete Triad Screen:• Menarche age 12 yr• Irregular (every 2 mo) and painful cycles since onset• Birth control implant x 1 yr• 3 work-outs per day: Running, weights, soccer games• Denies disordered eating but did not increase kCal intake on training
days• No to minimal calcium rich foods; no calcium supplements• No prior stress fracture• Denies FH osteoporosis
![Page 33: Maria E. Reese, MD Spine & Sports Rehabilitation Center Rehabilitation Institute of Chicago Northwestern University Feinberg School of Medicine Musculoskeletal](https://reader036.vdocuments.us/reader036/viewer/2022062315/5697bf741a28abf838c7fcc2/html5/thumbnails/33.jpg)
Case 5: LM, Impression & Plan
1. Left shoulder pain consistent with slow healing humeral surgical neck fracture2. Female Athlete Triad: Low energy availability, dysmenorrhea, slow healing fracture
• Check Vit D level & supplement• Calcium supplementation • Calcitonin nasal spray to aid with fracture related pain• Nutrition, Sports Med follow-up
femaleathletetriad.org
*
![Page 34: Maria E. Reese, MD Spine & Sports Rehabilitation Center Rehabilitation Institute of Chicago Northwestern University Feinberg School of Medicine Musculoskeletal](https://reader036.vdocuments.us/reader036/viewer/2022062315/5697bf741a28abf838c7fcc2/html5/thumbnails/34.jpg)
Questions?
![Page 35: Maria E. Reese, MD Spine & Sports Rehabilitation Center Rehabilitation Institute of Chicago Northwestern University Feinberg School of Medicine Musculoskeletal](https://reader036.vdocuments.us/reader036/viewer/2022062315/5697bf741a28abf838c7fcc2/html5/thumbnails/35.jpg)
Thank You
![Page 36: Maria E. Reese, MD Spine & Sports Rehabilitation Center Rehabilitation Institute of Chicago Northwestern University Feinberg School of Medicine Musculoskeletal](https://reader036.vdocuments.us/reader036/viewer/2022062315/5697bf741a28abf838c7fcc2/html5/thumbnails/36.jpg)