Shoulder Trauma and Humeral Avulsion of the Glenohumeral Ligament (HAGL)

CASE HISTORY: A 17-year-old right-hand dominant female presents with left shoulder pain. Pain has continued to worsen over time with continued participation in competitive cheerleading activities. Swelling occurred over the entire shoulder with pain having a burning sensation and a decrease in range of motion. Subject was given medication, however pain continued. Subject had no other shoulder injury and/or medical diagnoses. PHYSICAL EXAM: With all glenohumeral movement, pain persisted. Palpation also elicited painful results. DIFFERENTIAL DIAGNOSES: Rotator cuff tears are characterized by pain and weakness when lifting, lowering, and rotating the arm. SLAP (Superior Labrum Anterior and Posterior) tears however result in decreased motion, popping or locking sensations, as well as pain with movement. Alternatively, shoulder dislocations produce weakness, numbness, or tingling near the injury site. TESTS & RESULTS: Range of motion assessment validated declined movement while magnetic resonance imaging (MRI) provided evidence of a dislocated shoulder, broken acromion, and longitudinal tear on the bicep tendon. FINAL DIAGNOSIS: Based on how the injury occurred and MRI results, shoulder trauma and HAGL were diagnosed. DISCUSSION: Physicians treat shoulder trauma and HAGL in many ways. Arthroscopic surgery can be performed to repair causes of instability on the anterior-inferior aspect of the labrum only. Previous literature has shown this method to have long-term failure due to only repairing the anterior and inferior aspects of the shoulder. Another method of shoulder trauma and HAGL treatment repairs three aspects of the shoulder - anteriorly, inferiorly, and superiorly. Treatment of this kind has had much success due to repairing all causes of instability. This method also allows the patient to have all sources of injury repaired in one session, thus limiting the need for more surgery. Lastly, non-surgical options are utilized for shoulder injuries that do no damage ligaments and other soft tissue. Typically, ice and immobilization along with medications to reduce swelling are used. Specialists then work to improve strength of the muscles and range of motion as normal activities are slowly reintroduced. Success of this method is dependent upon injury severity and rehabilitation compliance with recovery usually occurring within weeks or months. OUTCOME OF THE CASE: The patient underwent arthroscopic surgery for rotator cuff reconstruction. Following surgery, she was prescribed an 8-week rehabilitation program along with codeine for pain. Her first follow-up occurred one day post-surgery to see how she was feeling. At 3-weeks post–surgery, she began a home exercise program, performing abduction and forward flexion exercises until fatigue 2-3 times per day. At 4-weeks post, she was able to elevate and laterally raise the arm when assessed by the physician that performed her surgery. Finally, at week seven, the patient returned to have her stitches removed and the home exercise program was discontinued due to patient’s noncompliance. RETURN TO ACTIVITY AND FURTHER FOLLOW-UP: Following rehab, the patient gradually began to partake in athletic activity by cautiously doing overhead movements. Six months post-surgery, she was back to normal motions achieved prior to injury. Since surgery, she has not experienced any pain or limitations in regards to her left shoulder. Currently, the subject is 19-years-old and she continues to participate in cheerleading activities, both as an athlete and as a coach

Left Distal Biceps Tendon Avulsion

CASE HISTORY: Patient is a 31-year-old male who presented himself with a left distal biceps tendon rupture. Patient incurred the injury while performing a deadlifting exercise. PHYSICAL EXAM: Focused examination demonstrated intact skin, the absence of distal biceps, and a noticeable bulge in the upper part of the arm – “Popeye” sign. Swelling was apparent with a gap in the anterior portion of the elbow due to the absence of the tendon. Clinical screening revealed a positive hook test, and limited range of motion (ROM) (i.e., elbow flexion, and pronation and supination of the forearm). DIFFERENTIAL DIAGNOSES: Impingement syndrome; Rotator cuff disease; Shoulder dislocation/instability; Humeral/radial head fracture. TESTS & RESULTS: Patient had an MRI of the left elbow performed that revealed a full distal biceps tendon rupture.FINAL DIAGNOSIS: Complete left distal biceps tendon avulsion. DISCUSSION: Full distal biceps tendon ruptures can be preceded by tendon degeneration and later, tendinopathy. It is not uncommon for a patient to experience biceps tendinitis as well. These pathologies can lead to insufficient blood supply which further potentiates tendon avulsion. With that said, placing a sudden eccentric load on the flexed and supinated forearm will cause a tendon to rupture fully. There are several factors such as age, overuse, and smoking that can also attribute to a tendon rupture. Although surgery is not necessary, it is recommended to regain full function and aesthetic to the arm (i.e., muscle not retracted into the shoulder).OUTCOME OF THE CASE: Patient underwent full tendon repair surgery using the anatomic approach. In this case, the surgical method involved the double incision technique. Using a transverse incision in the antecubital fossa the retracted tendon was resected, and two locking sutures were passed through the distal part of the tendon. Exposing the tuberosity with a muscle splitting technique the biceps tendon was pulled into the bicipital tuberosity, and the sutures were pulled tight then tied. Following surgery, the patient was subjected to wearing a sling for a few weeks. Ibuprofen, Oxycodone, and Meloxicam were prescribed for inflammation, pain, and prevention of heterotopic ossification, respectively. Physical therapy (PT) was prescribed one-month following surgery. PT included the following modalities, Russian estim for muscle re-education, ultrasound to improve tissue healing, intermittent icing to control swelling, voodoo floss banding to improve active ROM, isometric holds with a light load for strengthening of the tendon, occlusion training to rebuild strength, and Kinesio tape for muscle contraction improvement. RETURN TO ACTIVITY AND FURTHER FOLLOW-UP: Three months post-surgery the patient was able to return to activity at his discretion while maintaining a conservative approach. Six months post-surgery the patient was back to his normal activities, despite still having some weakness and slight discomfort in the injured area

Femoral Neck Stress Fracture: Early Identification and Treatment

CLINICAL PRESENTATION & EXAM: Femoral neck stress fractures have devastating consequences if not detected and treated early, since as much as 60% of athletes diagnosed fail to return to pre-injury performance levels. Patients’ histories identify dull aching pains aggravated by high-impact or weight-bearing activity, and is alleviated with rest. Patients often recall an uncharacteristic increase in exercise intensity; e.g. marathon training. The pain is poorly localized to the lateral thigh, hip, or groin. An antalgic gait and non-capsular pattern of limitation of hip motion is observed. Pain and a marked decrease in mobility is noted at the end range of motion for hip abduction, flexion, and external rotation. Physical examination reveals extreme muscle tenderness in the anterior superior iliac spine, and deep palpitation elicits pain. Passive straight leg raise, thigh log roll, single leg hop, rectus femoris stretch (Ely’s test), and Thomas tests confirm localization and pain. ANATOMY & PATHOLOGY: The femoral neck connects the femoral head and shaft and serves as a muscular junction for major hip motion muscles. The femoral circumflex arteries supply blood through the femoral neck to the femoral head and upper hip bone. Damage to the femoral neck hinders blood flow, potentially leading to avascular necrosis (AVN) of the hip and other issues. The femoral neck absorbs 3-5 times the body weight when running. Continual loading of the femoral neck through rhythmic activity without rest initiates microscopic fractures, and without time for proper healing mechanisms, a stress fracture propagates. Weight-bearing loads create compressive forces on the inferior-medial aspect and tensile forces on the superior-lateral aspect of the femoral neck. There are 3 classifications of femoral neck stress fractures. Compression fractures are less severe and can be managed conservatively for full recovery while tension fractures are more severe and have greater risk of displacement. Displacement fractures result from unchecked progression of compression or tension fractures. DIAGNOSTIC TESTING & CONSIDERATIONS: Plain X-ray films usually yield negative results until 3 weeks after fracture onset. MRIs locate and differentiate between fractures types and determine severity. Bone scintigraphy further confirms the fracture. CT scans provide 3-D imaging if surgery is considered. Laboratory blood tests for metabolic abnormalities in calcium or phosphate levels indicate whether low bone density is a cause of fracture. Holistic assessment of diet, training regimen, gait biomechanics, baseline fitness, and medication should be performed. TREATMENT & RETURN TO ACTIVITY: Treatment options vary based on femoral neck stress fracture type and severity. Incomplete compression fractures, or50%, surgical fixation with dynamic hip screws is necessary. Tension or displacement fractures require immediate surgical fixation. Regardless of fracture type, non-weight bearing status should be maintained until relatively pain-free activity in the hip region. Physical therapy and cross-training can be introduced to regain flexibility and strength. Increase weight bearing activity, with no more than a 10% increase in strenuous volume per week, until full-weight bearing capability. Additional radiography during recovery ensures no fracture redevelopment or complications like AVN

Patellofemoral Pain Syndrome

CLINICAL PRESENTATION & EXAM: Patellofemoral Pain Syndrome (PFPS) can be a result of both malalignment and muscular dysfunction that results in up to 25%of injuries to runners, twice as common in women. Examination of knee begins with taking patient history. Dull, aching pain is usually reported in the anterior of the knee, specifically around or behind the patella. Pain is expressed as increasing during exercise involving knee movement such as: running, jumping, and/or squatting. Less common symptoms may include crepitus and movement restriction. Examination involves palpation of the region, inspection of biomechanics, and measurement of range of motion. ANATOMY & PATHOLOGY: The patellofemoral joint is comprised of the patella stabilized directly by the quadriceps tendon and the patellar ligament. The lateral and medial retinaculums, relative to the patellar ligament, connect fibers from the vastus medialis and vastus lateralis to the tibia. They also serve to preserve the position of the patella relative to the femur. The iliotibial band is lateral to the patella and, along with the femoral trochlea, provides static stabilization to the patellofemoral joint. PFPS is a cause for anterior knee pain that stems from imbalance in the forces controlling the patella during movement of the joint. PFPS is usually characterized by the dynamic valgus as a result of weak hip muscles or abnormal rear-foot eversion with pes pronatus valgus leading to patellar maltracking. The childhood development of Sinding-Larsen-Johansson Syndrome or the closely related Osgood-Schlatter disease is linked to PFPS. DIAGNOSTIC TESTING & CONSIDERATIONS: When testing for PFPS, multiple examinations are implemented such as the patellar tilt test, patellar mobility test, and lateral patellar tracking to eliminate knee conditions that present in a similar manner. Factors that lead to PFPS include: increased Q angle, poor flexibility of hamstrings, hips, and quadriceps, muscle dysfunction, and femoral rotation. Such factors should be considered in combination with the age of the patient. PFPS is usually diagnosed after various other conditions have been ruled out such as: saphenous neuritis, intra-articular pathologies, patellar tendinopathy, peripatellar bursitis, and patellar stress fracture. Functional performance tests can be performed such as anteromedial lunge, single-leg press, and a balance and reach in order assess mechanics of the lower extremities, but also to set a base line for rehabilitation. Additionally, X-rays, CT scans, and MRIs are usually utilized to provide a final diagnosis. TREATMENT & RETURN TO ACTIVITY: Treatment can be as simple as resting for an extended period of time and treating with ice. Other simple treatments options include: knee braces and sleeves, patellar taping to assist with the malalignment, foot orthotics to help correct rear-foot eversion, and pes pronatus while nonsteroidal anti-inflammatory drugs can help with the pain. Usually though, PFPS requires some form of physical therapy that improves tightness of surrounding muscles and ligaments. Exercises that focus on hip muscles, the iliotibial tract, quadriceps, hamstrings, and trunk stability can help with pain reduction and improved mechanics. When physical therapy has been attempted for at least a year with no improvement and pain management is inadequate, surgical intervention is considered. Such options can include the release or realignment of the lateral retinaculum, but is generally considered a last resort especially amongst younger patients

Acute Partial Sleep Deprivation and High-Intensity Exercise Effects on Cardiovascular Autonomic Regulation and Lipemia Network

Autonomic nervous system imbalance demonstrated by decreased heart rate variability (HRV) is linked to acute partial sleep deprivation (ASPD) and cardiovascular disease (CVD). Cardiometabolic lipemia has been linked to changes in HRV. Habitually active individuals exercising in the morning hours under APSD and consuming afterwards a high-fat breakfast, may disrupt the network coordination of both the cardiovascular autonomic regulation and cardiometabolic lipemic systems jeopardizing their health. The human organism is comprised by an integrated network of interconnected organ systems and functions, therefore, a disruption/failure of one system can trigger a cascade of failures manifested as disease state. PURPOSE: To investigate the postprandial network interactions of autonomic regulation assessed by heart rate variability (HRV) and cardiometabolic lipemia assessed by low-density lipoprotein (LDL) cholesterol under APSD and after a high-intensity interval exercise (HIIE). METHODS: Fifteen healthy males (age 31 ± 5 years) participated in: (a) reference sleep (RS) (~ 9.5 h) and HIIE (RSX) and (b) APSD and HIIE (SSX). HIIE was performed in 3:2 min intervals at 90% and 40% of VO2reserve. HRV selected time and frequency domain indices were recorded the night before (D1), the morning of the next day (D2), 1 hr post-HIEE (1hrPE), 2 hr (2hrPE)-, 4hr (4hrPE), and 6-hr post-HIIE (6hrPE). Postprandial LDL was assessed at D1, D2, 1hrPE and 4hrPE. Pearson correlation coefficients and correlation matrices were used to investigate the physiologic network during RSX and SSX. Interactions within each network were computed by the number of links (i.e. number of significant Pearson correlations) and presented as positive and negative links. RESULTS: The total number of links increased by 90% under SSX compared to RSX due to: (i) manifestation of weak and intermediate negative links between the HRV and the LDL sub-networks and (ii) a 100% increase of positive links within the LDL sub-network. CONCLUSION: This study shows a complex network of interactions between autonomic regulation and cardiometabolic lipemia. Our results uncover how this physiological network reorganizes in response to APSD confirming the inverse relationship between HRV and LDL. HRV can be used as an alternative non-invasive marker of CVD

Measuring Mental Toughness in Firefighters: Preliminary Results on the Concurrent Validity of Two Inventories

Mental toughness (MT) research is predominantly cross-sectional and based on self-assessment. MT has been consistently positively associated with performance metrics when investigated in stressful and demanding environments, such as sports and tactical. The Sports Mental Toughness Questionnaire (SMTQ) has been used extensively in sports, while the Military Training Mental Toughness Inventory (MTMTI) in the military. In firefighting, MT research is scarce. There is no firefighting-specific MT instrument. Firefighters are considered tactical athletes. PURPOSE: To examine the concurrent validity of SMTQ and MTMTI in firefighters via a repeated-measure design. METHODS: Male firefighters from two departments (n = 14; Age: 29.0 ± 7.0; BMI: 26.3 ± 2.7) participated in the data collection process that took place over two days (two administrations; once per day). The firefighter’s MT level was assessed via both inventories. SMTQ (14 items; 4-point Likert scale) was administered to participants (self-assessment), while the MTMTI (6 items; 7-point Likert scale) to two of their officers (peer-rating). We computed the mean SMTQ and MTMTI scores over the two days (for the MTMTI scores we first calculated the mean score per day per assessor and then, combined both assessors) and for statistical analysis, we converted them to z-scores. Concurrent validity was assessed with Pearson (r) correlation, Concordance correlation coefficient (CCC), and two-way random Intraclass correlation coefficient (ICC2k) agreement on z-scores using R statistical packages in Jamovi version 2.3 (p \u3c .05). RESULTS: Inventories were significantly negative correlated (r = -.68, p = .008, 95%CI [-.89, -.23]) and had poor strength of agreement (CCC = -.68, 95%CI [-.88, -.25]) and reliability-agreement (ICC2k \u3c .001, 95%CI [-1.58, .61]). CONCLUSION: Our results do not indicate agreement between the two inventories. Therefore, the inferences of the MT scores of these two different inventories are not in agreement, either. This could suggest the need for a firefighting-specific MT instrument. Regardless, practitioners should be cautious when interpreting the scores of the current MT instruments on this specific tactical population

Open Reduction and Internal Fixation of Three Displaced Malleoli

CASE HISTORY: A 20-year-old, white/Hispanic, female visited Emergency Room with severe inflammation, lateral ecchymosis, tenderness, and displacement of the left ankle due to a fall. Patient was unable to move foot, remained non-weight bearing, and had 10/10 pain levels with palpation to ankle and foot. PHYSICAL EXAM: Upon orthopedics’ physical examination, pain on palpation was noted on the left hallux. Her pedal pulses were readily palpable. There was moderate nonpitting edema to the left lower extremity. DIFFERENTIAL DIAGNOSES: Grade 3 lateral ankle sprain. TESTS & RESULTS: General radiology (GR) on ankle, tibia, fibula, and a computerized tomography (CT) on left ankle were ordered. GR found acute displaced angulated trimalleolar fracture with soft tissue swelling and ankle joint malalignment. CT indicated displacement of distal medial malleolar fragment, minimal posterior displacement of both the distal lateral and posterior malleolar fragment. No damage was found to the tendons and ligaments. FINAL DIAGNOSIS: Three displaced malleoli. DISCUSSION: Open reduction and internal fixation of lateral malleolus with 1/3 tubular internal fixation systems (IFS) plate and six locking and nonlocking screws across the plate. Medial malleolar displacement was reduced with a 1.25 K-wire then internally fixated with one 4.0 partially threaded cancellous IFS screw measuring 45mm in length. Fluoroscopy was used to confirm medial and lateral malleolar alignment and proper screw length. Reduction of the lateral and medial malleoli caused accidental reduction to posterior malleolar displacement and no internal fixation was needed. Patient was placed in a controlled ankle movement (CAM) walker and transferred from operating room to post-anesthesia care unit. Vital signs were stable and neurovascular status was intact in left lower extremity. She was readmitted to the floor for postoperative management and discharged two days postop. Patient was instructed to be strict non-weight bearing to her left lower extremity. She was instructed to keep the CAM walker on with ankle at 90º dorsiflexion and she ambulated with crutches. X-rays were taken during follow up with podiatrist to rule out hallux fracture, in which case there was no fracture. Patient was to be non-weight bearing with left lower extremity elevated for 3 months postop. Physical therapists were asked to evaluate and gait train the patient. OUTCOME OF THE CASE: Patient received 1-3 hour physical therapy sessions, tri-weekly, for three months in an outpatient facility. Therapist provided scar massages to remove scar tissue and help gain range of motion (ROM). Patient was weaned into applying full body weight to left lower extremity with CAM walker. Once patient was full weight-bearing she was permitted to cease need for CAM walker. RETURN TO ACTIVITY AND FURTHER FOLLOW-UP: Patient’s goal was to gain the strength to run and the flexibility to wear heels again. Therapist focused on building muscle, gaining balance and stability, increasing ROM, and decreasing pain. After three months, patient was able to run and wear heels without issues. Patient fully recovered from injury and now lives comfortably with the IFS plate and screws

What experiences are needed to become a Division 1 Baseball, Football, or Track Athlete? A Retrospective Study of the Quantity of Deliberate Play

The acquisition of expert performance in various sports is generally attributed to the extended engagement in deliberate practice activities. Sport-specialization in high-school or earlier derives from the intent of developing sport expertise as well as the economic benefit of obtaining collegiate scholarships. Alternatively, sport-sampling allows for deliberate play. Deliberate play activities provide youths an opportunity to explore a variety of movements and tactics while encouraging innovation, improvisation, and the development of strategies. The influence of the family in the development of talent in sport is already established. Limited research exists that examines how deliberate practice activities in varied extracurricular activities throughout one’s youth contribute to performance in a particular sport. PURPOSE: Investigate the quantity of deliberate play that is required to become a collegiate division 1 athlete in the sports of baseball, football and track and field. METHODS: We used a structured online interview as proposed by Côté, Ericcson and Law (2005) to collect retrospective information. Fifty-one Division 1 collegiate athletes rated the daily activities they were involved when they were young as well as during their current period of development and assessed different factors that may have contributed to their current achievement level. RESULTS: Concerning early activities, 96% of the participants were involved in sports, 65% in musical, 17% in artistic, 72% in organized games with rules, and 48% in other sport-related activities (e.g. watching sports on television). In regards to physical factors that may have contributed to their exceptional athletic achievement, all participants’ height was average or above average when compared to peers and 78% sustained injuries that had adverse effect on their activity involvement. During their current stage of development, the participants tend to spend 26 hours per week sleeping, 10 hours eating, 10 hours socializing, 8 hours for school/career activities, and 8 hours studying. Lastly, although 75% of the athletes’ parents were not top athletes, 75% of them played a role and 86% were very involved when the participants first started in sport, and all parents were supportive/excited when their children decided to specialize in sports. CONCLUSION: The findings provide useful insights to all stakeholders (e.g., parents, coaches, inspiring collegiate athletes, athletic trainers, managers) in regards to developmental issues of D1 collegiate student-athletes, such as early sport and non-sport activity involvement, current daily activities, and the role of family. The developmental path of D1 student-athletes support Simon’s and Chase’s 10-year rule and Côté’s impact of family. Comparing the pattern of results in the developmental history between collegiate and professional and high-school and professional athletes should be included in the goals of future efforts

Strength Versus Deficit Educational-based Mental Toughness Interventions on Mental Health of Female Student-athletes

Educational-based psychological skills training (PST) is effective in terms of Mental Health (MH) outcomes. Mental toughness (MT), a Positive Psychology construct, is positively associated with MH. Sports training emphasizes working on the weaknesses of the athlete. Positive Psychology is rooted in strength-based interventions. In Applied Sports Positive Psychology, where females are underrepresented, the two approaches appear contradictory. PURPOSE: To examine the effects of deficit- versus strength-based MT interventions on MH levels of female collegiate athletes. METHODS: Out of the 161 female athletes of a SUNYAC institution, 95 participated. MH scores were collected via the Mental Health Continuum Short Form (MHC-SF) while MT scores were via the eight-item, Mental Toughness Index (MTI). Each MTI question (score range: 1-7) represents one key MT dimension (e.g., Q7: Buoyancy). We had previously created and successfully pilot-tested eight educational PST videos (one per key dimension). MT scores 1-3 were considered low (deficits) and 6-8 high (strengths). Participants were clustered into two groups. Power analysis yielded a sample size of 34. Group 1 (n=18) received intervention in the form of 1-3 videos based on their deficits, whereas Group 2 (n=18) on their strengths. Descriptive statistics, a two-sided t-test, and an analysis of variance (ANOVA) on the gain scores were produced on SPSS 28. RESULTS: Deficit Group MH scores: MPRE=43.2, SD=10.3; MPOST=51.9, SD=12.5. Strength Group MH scores: MPRE=52.2, SD=7.1; MPOST=52.9, SD=9.4. Gain scores: ΔDEFICIT=8.7, SD=11.7; ΔSTRENGTH=0.7, SD=7.2. T-test of deficit group: t(17)=-3.2, p=.01, d=0.84. T-test of strength group: t(17)=-.4, p=.68, d=0.09. ANOVA: F(1,34)=6.1, p=.19, =.151. CONCLUSION: Both interventions were effective. Only the deficit-based intervention was significant and of large magnitude. The difference between the groups in the effect of the interventions was also significant and of large magnitude. This is the first study to examine the effectiveness of a telehealth education-based PST strength­ versus deficit-based MT intervention on MH

10-Yr Follow-up for Adolescent with Low Back Pain & Symptomatic Lumbo Sacral Transitional Vertebra/Bertolotti’s Syndrome: A case study

CASE HISTORY: A 16-yr old female presented a lower back pain (LBP) with significant axial pain extending bilaterally to buttocks and anterolateral thighs. Past health history revealed laminectomy for removal of a benign tumor on L4/L5 at 8-yr old and structural scoliosis (e.g., C-curve). Computed tomographic (CT) scans of the lumbosacral spine conducted 10 years prior revealed: an abnormal articulation between the L5 transverse processes and the sacrum ala bilaterally with 5 regular lumbar vertebrae and a transitional vertebra (L6); there was no evidence of disc degeneration or spinal nor foraminal stenosis. Initial diagnosis revealed lumbosacral transitional vertebra (LSTV), however classification wasn’t proposed due to patient of adolescent age. LBP was stated to be potentially due to a complicated case of Bertolotti’s syndrome (BS). Conservative therapy was recommended and a follow-up post-pubertal changes to see if articulating surfaces fused with time and determine if disc above the LSTV incurred degeneration. PHYSICAL EXAM: Recent physical exam revealed no lack of strength bilaterally in lower extremities. The LBP intensity on a numeric rating scale was 7/10 and Oswestry score of 33 (moderate disability). LBP affected by prolonged sitting or standing and presenting tenderness. Provocative factors included forward flexion-based movement and restricted mobility in back extension- based movement. DIFFERENTIAL DIAGNOSES: Disc degeneration or herniation; facet joint arthrosis; spinal canal or foraminal stenosis. TESTS & RESULTS: CT scan for comparison with initial diagnosis were ordered; complete lumbarization/sacralization with complete fusion with the neighboring sacral basis with no disc herniation or degeneration. FINAL DIAGNOSIS: CT scan revealed LSTV classification type III. DISCUSSION: LSTV are congenital spinal anomalies with variation of L5 in which enlarged/elongated transverse processes form a joint or fusion with sacrum or ilium. BS is stated to be the association of LSTV with LBP with change in biomechanical properties of the lumbar spine, however, the etiology of pain is unclear. The contact between bones at the pseudo-articulation has been debated as a source of pain which can be manifested as sacroiliac, hip, groin or imitating an L5 radicular pain. Infiltration with local steroids and anesthetics, along with positive imaging are useful diagnostic tool to study BS and pain generator—more specifically which patients have pain generator exclusively at the pseudo-articulation (complete relief of pain after the injection) and which patients have pain due to the irritation of L4 or L5 nerve root. In rare cases, patients with negative response to injections are candidates to more complex procedures such as resection of L5 transverse process and decompression with varied results. OUTCOME OF THE CASE: Patient received an interlaminar and a transforaminal epidural steroid injection with negative response. RETURN TO ACTIVITY AND FURTHER FOLLOW-UP: Despite the steroid injections, muscle relaxants and an aggressive physical therapy rehab regimen (core strengthening, stretching/flexibility, hydrotherapy, massage therapy) has been unsuccessful in pain mitigation. Resection of the abnormality has been proposed. Further research is warranted, given the pathophysiology of BS remains obscure and there being no consensus about the most appropriate therapy/management of disorder in each patient especially for younger populations