Pityriasis Rosea in a Female Runner

CASE HISTORY: The patient was a 40-year-old, physically active, mother and teacher. She had no previous history of autoimmune disease, Shingles, or other skin disorder. She reported having Herpes Zoster (Chicken Pox) at about six years old. In this case, she reported having a bug bite superior to the right iliac crest. After two days of itching the bite appeared normal and the pruritis stopped. After 10 days, the patient reported that the bite was not resolving but was not causing any symptoms. The athlete reported that the area had become scaly. PHYSICAL EXAM: Physical exam revealed a raised, scaled patch that measured approximately 2.5 centimeters wide and 1.5 centimeters tall. There were no other patches or skin abnormalities present. The athletic trainer thought that it could be ringworm so she applied topical Nystatin and covered it with a bandage. This was repeated for three days. The athlete then left on an out-of-town ski trip. Five days after initially reporting the possible bug bite, the athlete reported small red bumps over her entire abdomen and back. She attributed the small bumps to possible dry skin due to cold and altitude on the ski trip. Upon return, the rash over the abdomen and back had spread and the bumps turned into flat patches. The initial suspected bug bite was still the same size and scaly, having not responded to the antifungal cream. The athlete was referred to the general physician. DIFFERENTIAL DIAGNOSES: Shingles, ringworm, impetigo, tinea, Psoriasis. TESTS & RESULTS: The physician did a visual inspection and ordered blood work to rule out any systemic issues. The blood work came back normal. FINAL DIAGNOSIS: The final diagnosis was Pityriasis Rosea. DISCUSSION: Pityriasis Rosea is not well understood by the medical community. However, due to its docile nature and lack of sequela, it is often not pursued in research. The initial presentation of a Herold Patch, sometimes known as the Mother Patch, followed days or weeks later by a rash over the truck and abdomen. None of the ensuing patches are as big as the Herold Patch. Pityriasis Rosea is commonly seen in older children or young adults (ages 10-35). It can be triggered by a viral infection and is thought to possibly be akin to the Herpes Zoster virus. Some research notes that Pityriasis Rosea could be triggered by stress, which may explain why this patient experienced it, also notably at a later age than what is commonly seen in the research. OUTCOME OF THE CASE: The patient was told that Pityriasis Rosea was not contagious, and it would resolve itself in three to 10 weeks. She was offered but declined prescription strength hydrocortisone cream for pruritis. No activity restrictions were placed on the patient. RETURN TO ACTIVITY AND FURTHER FOLLOW-UP: The patient did not miss any day of training due to Pityriasis Rosea. She only reported mild discomfort for the first couple days. There is no need for follow-up as cause and sequela of Pityriasis Rosea is unknown

Kinetic Chain Rehabilitation in a Juvenile Idiopathic Arthritis Patient

CASE HISTORY: The patient’s chief complaint was decreasing ROM and pain noticed after conservative orthopedic treatment in the dominant (left) elbow. After extensive evaluation, the patient was diagnosed with juvenile idiopathic arthritis (JIA) at 9 years old. PHYSICAL EXAM: Upon physical therapist examination, it was determined that she had deficits throughout the entire left upper extremity and quadrant. Findings include signs and symptoms of Upper Cross Syndrome including pectoralis muscle group tightness, weakness of deep neck flexors with overuse of sternocleidomastoid and scalenes group, weakness of posterior shoulder and upper back including lower trap, middle trap, and all scapular stabilizing musculature including significant overuse of the upper trapezius and levator scapula complex. This presented as poor scapulothoracic rhythm and scapular dyskinesis with significant scapular winging, forward head and rounded shoulders causing inefficient mechanical function during functional movement patterns. Other specific objective findings included pectoralis minor length difference of right to left of one inch, MMT grade of teres minor and latissimus 3+/5, serratus anterior 3+/5, other rotator cuff reveals 4/5, with subscapularis 4/5. The initial AROM of the elbow revealed a 40° extension lag, excessive supination of 105° with limited pronation of 70°. DIFFERENTIAL DIAGNOSES: Medial epicondylitis, avulsion fracture, rheumatoid arthritis, ankylosing spondylitis. TESTS & RESULTS: X-rays and MRIs were obtained in order to make the JIA diagnosis. Imaging obtained by the patient’s rheumatologist nine months ago showed a slowing of the disease processes, confirmation of the cessation was confirmed on MRI obtained 3 months ago. After failing occupational therapy for ROM and joint sparing techniques, she was referred to physical therapy (PT) to address kinetic chain dysfunction to avoid other joint involvement. FINAL DIAGNOSIS: The final diagnosis was JIA with multiple joint involvement. For the purpose of this case study, Upper Cross Syndrome with associated scapular dyskinesis was addressed in rehabilitation. DISCUSSION: Treatment of JIA is often targeted at the involved joints. It is important for the medical professional to evaluate and address joints that are not currently involved in the disease process. In this case, the patient’s parents advocated for physical therapy. Many cases will go untreated which could affect the long-term functioning of the kinetic chain. Additionally, early intervention can improve functioning of other joints and increase strength of muscles that, when functioning at full capacity, could affect the involved joint. OUTCOME OF THE CASE: After 2 months of PT, objective findings revealed great improvements in pectoralis minor flexibility as demonstrated through measurement of just ½ inch which is symmetrical to the right side; increased postural awareness of downward scapular retraction; appropriate chin tuck posture due to increased deep neck flexor strength; decreased compensation of scalenes and upper trap and levator complex; improved rotator cuff strength and AROM pronation 82°. Most important, she is demonstrating improved awareness of correct downward retracted scapular position with little winging and good head alignment utilizing a chin tuck position. All AROM of the elbow remained the same. RETURN TO ACTIVITY AND FURTHER FOLLOW-UP: The patient is navigating all activities of daily living for her age group with a lack in ROM of her elbow. She competes on a shotgun team and plays sports at recess. She will continue with PT once per week for the next 3 months. After revaluation, she may be released with a maintenance program

Athletes\u27 Perception on How Psychological Effects of Anterior Cruciate Ligament Reconstruction Influences Their Decision to Return to Sport

Anterior Cruciate Ligament (ACL) injuries remain a common injury amongst student athletes. While some athletes return to play (RTP) and some do not, many athletes make the decision to not RTP. PURPOSE: This research study aimed to determine reasons why athletes choose to RTP or choose not to RTP. METHODS: Athletes from multiple universities were emailed a survey about their experience with Anterior Cruciate Ligament Reconstruction (ACLR) and subsequent rehabilitation. RESULTS: Thirteen student-athletes participated in the voluntary survey. Seven athletes reported having ACL Reconstruction; all of responses with ACLR reported were female. Athletes varied in sport participation: soccer (42.9%), basketball (28.6%), softball (14.3%), tennis (14.3%). Out of the seven athletes with reported ACLR, 71.4% of athletes indicated they did RTP, while 28.6% did not RTP. When asked about fear of returning, on a scale of 1-5 (1 being, ‘not scared at all’, 5 being ‘terrified’), 60% answered they were at a level four upon returning to competition, while the remaining 40% indicated they were at a level two. Of the 7 athletes that did RTP, 60% said they felt back to pre-injury levels in biomechanics and sport-specific movements. Results indicated that some athletes feel they could have had more support from their rehabilitation team. The survey confirmed the theory that student-athletes suffer from mental stresses associated with their ACL injury and while their physical body heals, their mental stresses are not always addressed. While some most student-athletes regain function and athletic performance, there remains apprehension to continue training and competition. CONCLUSION: Athletes should be given the opportunity to discuss the psychological challenges that come with ACLR. If athletes can openly address and seek help with the mental stresses associated with ACL injury, more student-athletes can feel better supported to RTP

Bilateral Acromioclavicular Sprains

CASE HISTORY: The patient is a 20-year-old linebacker who sustained two AC sprains in the span of nine days. The patient sustained his right AC sprain by tackling with a lowered shoulder. After he was cleared to play from his first injury, he sustained his second AC sprain nine days after. Interestingly, the second shoulder injury occurred by tackling the same opponent with a lowered shoulder. PHYSICAL EXAM: The athletic training staff assessed the right shoulder immediately after injury and tested his shoulder strength. After examination the athletic training staff came to the conclusion that it was an AC sprain, so they removed him from practice. Nine days after the first injury, the patient sustained another AC sprain to the other shoulder the same way he sustained his first AC sprain. The athletic training staff assessed him right away and discovered it was another grade 2 AC sprain. DIFFERENTIAL DIAGNOSES: Shoulder dislocation, Shoulder Impingement Syndrome, Rotator cuff injury. TESTS & RESULTS: The patient did not receive a MRI or XRay. Special tests included (+) piano keys, (-) Jobe’s test, (-) Hawkins-Kennedy. FINAL DIAGNOSIS: The final diagnosis was a grade 2 AC sprain for both of the shoulders. DISCUSSION: This is abnormal to sustain two AC sprains in the same season, let alone within two weeks of each other. It is thought that due to pain from his first injury, he was posturing abnormally while playing and overcompensating with his left shoulder when tackling. This study shows the importance of posture and compensation when it comes to re-injury. Understanding the proper tackling form for specific football positions can prevent injury. Additionally, staying current on best practices for return to play after AC joint injuries is important. OUTCOME OF THE CASE: The athlete was in the Athletic Training Clinic everyday working on his rehabilitation program and received treatment. He was very disciplined and returned to play the next week. RETURN TO ACTIVITY AND FURTHER FOLLOW-UP: After the first AC sprain to the right shoulder, the athlete returned to practice the next day. Nine days later after his first injury, he sustained his second AC sprain, this time to his left shoulder. Since his second injury was worse, he practiced with padding for 3 days before returning as a non-contact player for 2 days. The next day he did not practice. After a day of no practice, he returned to full participation. He still deals with occasional pain, most likely due to an increase in tackling after changing his position to running back

Thoracic Spine Staples in a Collegiate Volleyball Player

CASE HISTORY: The participant in this research study was diagnosed with idiopathic scoliosis at the age of 8. PHYSICAL EXAM: Upon physical examination it was determined that she had a lateral curvature of the spine. DIFFERENTIAL DIAGNOSES: Herniated disk, erector spinae muscle strain, thoracic back pain, quadratus lumborum strain, or scoliosis. TESTS & RESULTS: She underwent many different x-rays and MRIs to get the best possible imaging of her spine. These images determined she had idiopathic scoliosis. She underwent seven total surgeries to repair the scoliosis present. The first of these surgeries was to place one Harrington Rod to correct the scoliosis present. Another surgery was performed to place 5 spinal staples into her thoracic spine. Three years after the first surgery a final surgery was performed to remove the Harrington Rod. FINAL DIAGNOSIS: The final diagnosis was idiopathic scoliosis. DISCUSSION: During the years between the surgery processes she was confined to a back brace which prevented her from participating in athletics. Approximately 6-9 months after her final surgery she began participating in volleyball. Research shows there is no measurable effect on upper extremity functionality for subjects who have undergone surgery to repair idiopathic scoliosis. Spinal fusion patients often learn how to perform sport movements effectively even though they are less mobile in the thoracic spine area. This is because patients have less range of motion in the spine but learn how to move their trunk and extremities to be effective in sports activities. If the thoracic spine is no longer able to move adequately, the cervical and lumbar spine will compensate, or the movement does not occur. Therefore, they are able to play sports that most people would believe they would not be able to do. Many of these individuals may also have a reduced equilibrium compared to others who have not undergone spinal fusion surgery to repair idiopathic scoliosis. Therefore, the person may not have a good understanding of their body positioning because of the lack of mobility in the thoracic spine. This could possibly be a negative effect on sport performance because of not being fully aware of the position of the body at all times. Lack of equilibrium could possibly be dangerous to the athlete if they are not able to detect their body angles when jumping or diving. Patients who have undergone corrective surgery may also show a decrease in physical activity compared to preoperative levels due to decreased flexibility and pain that could be present. OUTCOME OF THE CASE: The participant returned to activities of daily living and athletic competition post-surgery. RETURN TO ACTIVITY AND FURTHER FOLLOW-UP: The participant returned to athletic competition and currently competes in NCAA Division I athletics as a volleyball player. She has had no further complication with scoliosis since the procedures were performed

Patient Perceptions of Pain Before and After Cupping

Cupping is an ancient modality that has many benefits. Benefits include improving blood flow, decreasing pain, and increasing function to the applied (Cage et. al., 2020). Research has shown that cupping and its effectiveness can be manipulated by perceptiveness and perceived thoughts about the modality itself, by the clinician and patient (Cage et. al., 2020, Silva et. al. 2019). PURPOSE: The purpose of this study was to collect data that will assist in making clinical decisions regarding cupping as a therapy. The research question that this study aims to answer is: Does cupping therapy decrease patient-reported pain due to injury? The ensuing research examines different aspects of perceived pain before and after cupping, type of injury, type of cupping treatment, time and type of pain. METHODS: The method used included a researcher-designed survey. The survey was taken twice, once before and once after treatment. The pre-treatment survey asked for demographic information including: participants’ age, race and ethnicity, injury site, duration of injury, type of pain, and sport participation. The survey included Likert scales that were rated from 0-5. The pre-treatment Likert question asked about current pain levels. During the second survey, the participants were only asked about pain during treatment, helpfulness of the treatment, and pain scale after the treatment, with no demographic questions. RESULTS: The survey resulted in 44 responses, for a total participation of 22 participants. Cupping was used for many different injuries across different sports. Cupping was predominantly used for tightness (81.8%). Moreover, it was also used for tendonitis and strains (9%) and other unlisted injuries (9%). Injury site was also observed with back (54.5%) and shoulder (18%) observed the most. Time with the injury was shown that most injuries had been bothering the athlete for four or more weeks (36%). Track and football utilized cupping the most, at 36% each. Two-tailed paired samples t-test showed that there was an increase in pain after cupping was used. The result of the two-tailed paired samples t-test was significant based on an alpha value of .05, t(21) = -4.12, p \u3c .001. This finding suggests the difference in the mean of pre-treatment pain levels and the mean of post-treatment pain levels were significantly different from zero. The mean of the pre-treatment pain level datum was significantly lower than the mean of the post-treatment pain level datum. There was not a significant difference in pain during treatment between fire and suction cupping. Time duration of injury did not have a significant impact on pain levels before or after treatment. Type of pain also had no significant correlation to pain levels. CONCLUSION: Cupping is a treatment that is used best when in combination with a proper rehabilitation program. While both fire and suction cupping were observed, suction cupping was used the most (72.3%). Patient-reported pain levels were significantly higher post-treatment. This is interesting as it was thought that cupping would help alleviate pain. Further research needs to be done to examine if pain levels decrease hours or days after treatment instead of directly after treatment

Myocardial Infarction in a 23-year-old Post-Collegiate Athlete

CASE HISTORY: The patient is a 23-year-old post-collegiate football player who was playing a recreational basketball game when his chest started hurting. The patient reported he was in a great amount of pain, and he felt it was not with his breathing but rather with his heartbeat. The patient had EMS contacted and awaited their arrival where they originally evaluated him. The patient’s health at the time of arrival was good according to the emergency personnel, so the patient opted to return home. The patient went home and was still in discomfort making him unable to sleep. He then decided to go the emergency room where he was taken in for further examination. PHYSICAL EXAM: Upon the arrival of the EMS, the patient’s blood pressure and heart rhythm were checked and seemed normal to the paramedics. When the patient went to the emergency room, they took blood samples and found that his troponin levels were high and admitted him into the hospital for further evaluation. DIFFERENTIAL DIAGNOSES: Severe indigestion, rib contusion, pericarditis, aortic stenosis, myocarditis. TESTS & RESULTS: Upon examination the patient had an electrocardiogram done which came back normal. However, the patient had elevated troponin levels which required the patient to receive an angiogram. The angiogram showed a 75% blockage of a left ventricle. DIAGNOSIS: Acute anterior NSTEMI (non-ST-elevation myocardial infarction) type 1. DISCUSSION: Acute Anterior NSTEMI type 1 is a myocardial infarction that is on the lower spectrum of diagnosis. Type 2 or 3 would have been more severe and have the potential to leave life-long lasting effects. Myocardial infarctions are more common in patients who are of older age and are rarely seen in patients who are collegiate athletes or just out of college athletics. Factors that could contribute to a myocardial infarction are genetic predisposition, dietary lifestyle, and activity level. OUTCOME OF THE CASE: The patient completed his angiogram and was admitted into the catheter lab to insert a stent into the ventricle with that was blocked. Once the procedure was complete, another angiogram was completed to ensure proper blood flow. The patient was held in the hospital until the following day and was released with pain medication subscriptions. RETURN TO ACTIVITY AND FURTHER FOLLOW-UP: The patient was scheduled a one-month follow up and was able to return to work the following week. He did not experience any worsening of pain or discomfort after the surgery and is now living a normal lifestyle

Return to Play Variations Due to Rehabilitation Compliance in Division 1 Athletes with Midfoot Sprains

CASE HISTORY: Patient A was a 20-year-old collegiate running back with a history of a left midfoot sprain in the previous spring season. Patient A presented with right foot pain after the second game of the season. He reported pain and a feeling of a ‘fallen arch’ when weight bearing. Patient A reported symptoms one day after the injury and was evaluated and treated immediately. Patient B was an 18-year-old collegiate cornerback with no significant history. Patient B reported midfoot pain after being tackled during a practice. Patient B was assessed in the athletic training clinical after practice. Patient B reported moderate pain with ambulation and a fallen arch with ambulation. PHYSICAL EXAM: Patient A had a positive tuning fork test and was referred for an X-ray because of a suspected fracture. Patient B had mild swelling in his midfoot, was tender to palpation over the dorsal 1st tarsometatarsal joint and had pain with 1st tarsometatarsal joint mobilization. Patient B was referred for an X-ray to rule out a fracture. DIFFERENTIAL DIAGNOSES: Midfoot bony contusion, Midfoot fracture, and Midfoot dislocation. TESTS & RESULTS: Patient A had an X-ray of his right foot which was negative for an acute fracture of the midfoot. Patient B had and X-ray of the left foot which was also negative for any acute fractures. FINAL DIAGNOSIS: Grade 1 Midfoot Sprain in both patients. DISCUSSION: Patient A’s history of a more severe midfoot sprain aided the patient in being compliant with rehabilitation exercises and the athletic training staff’s recommendations. Patient B was a freshman with no history of serious injuries. Patient B was non-compliant with rehabilitation exercises and the athletic training staff’s recommendations. Patient A never missed a rehabilitation session while patient B frequently missed 2-3 rehabilitation sessions a week. Rehabilitation compliance is a key factor in the return to participation timeline. OUTCOME OF THE CASE: Patient A returned to full participation after 3 weeks while patient B return to full participation after 6 weeks. RETURN TO ACTIVITY AND FURTHER FOLLOW-UP: Both patients returned to participation performing at the same level prior to injury

Partial Rupture of the Distal Biceps Tendon in a Collegiate Football Player

CASE HISTORY: The patient is a 20-year-old collegiate football player who presented to the athletic training staff with pain in his left arm near his elbow. He states that he was attempting to make a tackle and that his arm was pushed into hyperextension by another player. He reported discomfort, pain, and numbness in his arm. He attempted to continue to play after completing arm flexion and extension in between plays. His pain levels increased as his range of motion activity continued. The patient could no longer continue during practice and was taken to the medical tent for further evaluation PHYSICAL EXAM: He had point tenderness around the distal end of his biceps brachii muscle and had limited range of motion. The patient presented with a deformity the cubital region of his left arm when compared bilaterally. The patient was referred to the team physician for further evaluation and diagnostic imaging. DIFFERENTIAL DIAGNOSES: Strained biceps muscle, strained brachioradialis muscle, strained triceps muscle, ruptured biceps tendon. TESTS & RESULTS: The patient underwent magnetic resonance imaging (MRI) which revealed a partial rupture of the biceps tendon. FINAL DIAGNOSIS: Partial rupture of the distal biceps tendon. DISCUSSION: Ruptures of the distal biceps tendon are commonly seen in men over the age of 40, usually the result of overuse. The mechanism of injury in this case was an eccentric load placed on the arm as the arm moved from flexion into extension. The patient is young, collegiate football player, and the injury is not commonly seen in collegiate level athletes. OUTCOME OF THE CASE: After consulting with the patient’s family and the sports medicine staff, it was decided that surgery was the best option for the patient. He underwent a successful surgery to repair his partially ruptured tendon. The operating physician utilized a dual incision technique to reattach the ruptured tendon. The patient was placed in an immobilizing brace for two weeks, and then began his rehabilitation. RETURN TO ACTIVITY AND FURTHER FOLLOW-UP: The rehabilitation plan currently consists of active, passive, and resisted range of motion. He is able to lift a dumbbell for arm flexion and extension, and he is working on grip strength and forearm supination as well. He continues to work with the athletic training staff, and will follow up with the team physician if necessary

Student-Athlete Perceptions of Sources of Stress and Coping

The purpose of this study was to explore stress in student-athletes. Stress, especially distress, can lead to mental health issues. This topic has traditionally not been discussed in coaching but is becoming more necessary. Student-athletes are more in tune with their mental health than even before, and coaches are not always sure how to handle situations that arise on this topic. PURPOSE: The intent of this study was to help strength and conditioning coaches become more aware of their student-athletes’ stress and coping mechanisms. METHODS: This study was conducted through an emailed survey to student-athletes. No identifying information was collected in the survey. The survey asked the student-athletes questions about stress, where the stress was derived from, what influenced the stress, did stress hinder their performance, and what they did to relieve from stress. RESULTS: Of the 43 student-athletes that answered the survey, it was found that 100% experienced stress. Of the respondents, 86% reported to be most stressed in-season, and 44.2% felt they never had time for themselves when they were stressed. Over half of student-athletes (60.5%) said stress hindered their athletic performance. Approximately 63% of participants reported that they talked to someone when they were stressed. Of the 63% that talked to someone, 86% said they talked to their parents, 83.7% said they talked to their friends, and 72.1% said they talked to a fellow teammate. When trying to identify where the stress came from, 96.4% of the student-athletes said that ‘classroom expectations and goals’ were what caused most stress; closely behind was ‘athletic performance’ at 78.6%. When asked if school overwhelms the student-athlete, 81% said yes. When diving deeper into the overwhelmingness of school, 34.3% said the workload was the main source of stress, 38.6% said tests were most overwhelming, and 25.7% said finding time to study stressed them out. When asking the student-athletes about what stressed them out about school, 86% of student-athletes said grades stress them out the most, 72.1% said tests were a source of stress, and 60.5% said finding time to study. CONCLUSION: This study found that student-athletes’ stress level is great, and the sources of stress vary. It is clear that academic stress is greater than athletic stress. Distress can be a source of mental health issues and that is something that needs to be investigated more. Both student-athletes and coaches would benefit from learning more about the sources of stress and how to help relieve stress during the season. Future research should focus on collecting demographic data to sort stress levels and sources by year of the athlete, which sports’ athletes feel more stressed, and to investigate why student-athletes talk to their parents and friends more than a coach or athletic trainer