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

• I have no disclosures

Inpatient MSK Consults – Hemiplegic Shoulder Pain

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Upper Extremity Dressing FIMsHemiplegic Shoulder Pain - Injection

Days From Injection

Case 1: MN

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Upper Extremity Dressing FIMsHemiplegic Shoulder Pain - Injection

Days From Injection

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

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

Case 1: MN, Right Shoulder X-Ray

• AP • Axillary

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

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

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Upper Extremity Dressing FIMsHemiplegic Shoulder Pain - Injection

Days From Injection*

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

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

Case 2: SG, Bilateral Shoulder Ultrasound

• Right supraspinatus

• Left supraspinatus

Case 2: SG, Right Shoulder Ultrasound

R SUPRASPIN IMPING VIEW

• High riding humeral head; loss of tendon; cortical irregularity

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

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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

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

Case 3: EM, Left Shoulder X-Ray

Case 3: EM, Left Shoulder Ultrasound

L SUBSCAP LAX L SUBSCAP SAX

Case 3: EM, Left Shoulder Ultrasound

L SUPRASPIN LAX

L SUPRASPIN SAX

Case 3: EM, Left Shoulder Ultrasound

L SUPRASPIN IMPING VIEW

Case 3: EM, Impression & Plan

• Left shoulder adhesive capsulitis & subluxation• Left GH joint corticosteroid injection, US guidance

L GH JT INJECTION

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)

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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

Case 4: OP, Hip X-ray

• 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

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

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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

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

Case 5: LM, Left Shoulder X-Ray, AP view

• Current x-ray • X-ray 1 month prior

Case 5: LM, Left Shoulder X-Ray, axillary view

• Current x-ray • X-ray 1 month prior

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

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

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

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Questions?

Thank You