Mike Lawler M.A., ATC, LATSenior Associate Athletic Trainer

The University of Iowa

Introduction

Case presentation

Discussion

Conclusions

Rowing at IowaBeginning 16th year as an intercollegiate sport60-70 rowers on teamVarsity and NovicePractice for 2½ hours on water and 1 hour

with strength & conditioning coach

Case Presentation20 YO female rower for the University of Iowa. No

previous experience as a rower prior to enrolling at Iowa in 2005.

Onset: April 12, 2007 during spring season - 3 weeks left in her season

CC: Swelling and pain at left anterior rib cage Painful left upper back; Pain while rowing in practice Numbness at left mid back below scapula Occasional dyspnea

Previous hx: None; gradual onset with no acute episodeContinued to participate in practices until symptoms

worsened and performance became affectedSymptoms initially only with rowing but now during

ADL’s

Examined by certified athletic trainer in athletic training roomAssessment: Possible costochondritis; posterior rib

stress reaction; paraspinal strain treated with therapeutic modalities

Cold/ice bagallowed to continue rowing, as tolleratedAfter one week her symptoms failed to improveShe was referred to UISMC and orthopaedic

physician on April 18, 2007

Musculoskeletal Injuries 1994 - 2006Low Back 104 27.7%Knee 49 13.1%Chest/Rib 40 10.7%Upper Back 26 6.9%Ankle 25 6.7%Wrist 23 6.1%Shoulder17 4.5%Patella 17 4.5%Hip 16 4.3%Foot 16 4.3%Tibia 13 3.5%Neck 8 2.1%Elbow 7 1.9%Forearm 6 1.6%Fibula/Calf 3 0.8%Finger 2 0.5%Other 3 0.8% TOTAL 375 100%

Physical Examination by Orthopaedic Team Physician – 4/18/07

Examination findings:Slight prominence of the costochondral joint from

anterior left side of chestPalpable tenderness in left paraspinal musclesNumbness noted in the left thoracic paraspinal

area Posterior thoracic pain is aggravated with motion

in all directionsUpper extremity function was normalNeurologic exam: normalRadiograph studies:

X-rays

L-Spine Standing AP & Standing Lateral Flexion/Extension views

Findings/Impression: There is no evidence of a fracture or dislocation.

The osseous structures are in gross anatomic alignment. There is no soft tissue abnormality

Negative exam

ImpressionCostochondritis left anterior rib cage

Referred pain posteriorly

Thoracic radiculopathy

PlanProvided prescription for naproxen – 500 mg BID

MRI imaging was offered to rule out thoracic disk herniation if sx.’s fail to improve or worsen

Progress to be followed by staff athletic trainer

She was able to finish out spring season but not without resolution of symptoms; treated symptomatically.

Status as of August 22, 2007 prior to start of 2007-2008 season

2-3 months of no rowing during summerUnproductive chiropractic treatments during summerResolution of left anterior chest swellingSame amount of continuous pain, described as a

“pinching” just below scapula on left sideWhen active, pain increased but was less severe than

when she would rowPatch of numbness was still present just below left

scapulaNumbness had slightly migrated to right side of back

and up right side of her back to just above right scapula

She had not noticed any UE weakness

Return Visit to OrthopaedicTeam Physician – 8/22/07

Examination findings:Palpable tenderness about T10 just to left of

thoracic spine. No other tendernessNumbness noted inferior to left scapulaNo palpable tenderness of anterior chest wallIncrease of pain with lateral bending and

twisting. No pain with flexion & extensionChest X-rays - normal

Plan

MRI imaging was scheduled to rule out thoracic disc herniationReasoning?

Persistent painPatch of numbnessPain with movementTo look deeper for a cause

Thoracic & Cervical MRI FindingsA small syrinx within the midthoracic spinal cord

from the T6 through portion of T8 levels, measuring 1.8 mm max. diameter

Above and below syrinx, thin central high T2 signal appeared most consistent with normal spinal CSF central canal

No abnormal focus on enhancementNo underlying lesion was identifiedSpinal cord signal was otherwise unremarkableNo central stenosisCervical & thoracic spine exhibited no

degenerative changesNormal configuration of the intra cranial

posterior fossa structures, without evidence for Chiari malformation

SyrinxA syrinx is a fluid-filled cavity within the

spinal cord (syringomyelia) or brain stem (syringobulbia).

Taber’s Cyclopedic Medical Dictionary

Symptoms include flaccid weakness of the hands and arms and deficits in pain and temperature sensation in a capelike distribution over the back and neck

Sx.’s not reported by this patient

Referral to Spine Team Physician - 8/27/07

Exam FindingsLE neurovascular exam – normalTenderness to palpation over posterior rib at

T8 level on leftChest x-ray showed a possible lytic lesion on

left 8th rib posteriorlyNo indication of myelopathic findings – syrinx

is not likely cause of her symptomsPlan: Obtain CT scan of 7th – 9th posterior ribs

CT Scan of RibsAxial CT scanning of the mid and lower thoracic

spine and medial aspect of of the ribs was performed without intravenous contrast

FINDINGS: No lytic or sclerotic lesions were identified in the

medial aspects of posterior ribs. No abnormal soft tissue masses were identified.There were no degenerative changes of the

visualized thoracic spineIMPRESSION: No abnormality in the medial

aspects of the mid and lower thoracic ribs.

Where do we stand at this point?1. Ongoing symptoms of back pain in middle aspect of

spine, left side2. “Numbness” in her back on left side3. Mid thoracic spine and left paraspinal tenderness4. MRI showed syrinx that was determined to not be cause

of symptoms5. CT scan showed no abnormal findings6. Chest x-ray read as normal7. Treatment with therapeutic modalities: heat, e-stim, ice8. Prior pain in left anterior aspect of ribs has resolved9. Still experiencing pain while rowing – participation is

limited

Plan

Continue local therapeutic modalitiesNeurosurgery consult for possible facet or

nerve root injectionMedrol dose pack for competitionsFollow-up with team orthopaedic physician

and/or Spine Team orthopaedic physician prn

Allowed to participate, as tollerated

Referral to UIHC Pain Clinic – Neurosurgery Consult

Received costovertebral/costotransverse injection on 11/02/07

Allowed to return to rowing activity Patient reported that “the injection helped

for a little while but then wore off.”

Additional Referral and Treatment

Medication changed from Naproxen to Piroxicam

Second series of 2 injections at T9 and T11 on 11/28/07

Prescribed Lidoderm patches by Pain Clinic physician

Treatment with iontophoresis in athletic training room

Treatment with T.E.N.S.

Spring 2008 Rowing Season2008 Winter Training Trip

Stationary bicycle – no erging, only drill work on waterFebruary – May 2008

Continued to row until pain forced her to restRepeated this pattern throughout spring 2008

Reported previous injections had somewhat helped because pain was not as intense

Persistent symptoms of skin sensitivity and “numbness”

Attended follow-up care with UIHC Pain ClinicAllowed to finish out season, as tolerated

Fall 2008 Rowing SeasonResumed practicing with recurrent symptoms

of pain, tenderness over posterior ribs, just to left of thoracic spine, and mid-back and left side numbness

Symptoms presented during rowing and strength training activities, diminished with rest

Continued to participate in most practices and competed in all fall races

End of fall season follow-up with Spine team orthopaedic physician

Follow-up Examination with Spine Team Orthopaedic Physician – 12/15/08

Review of 8/22/07 MRI findingsBenign other than incidental thoracic syrinx

not felt to be contributing to her symptomsNeurovascular exam was normalPlan:Repeat thoracic spine MRI with contrast to

evaluate any progression of syrinxRenew prescription for Lidocaine patches

Repeat Thoracic Spine MRI with Contrast

IMPRESSION:Stable mid thoracic small syrinxNo lesion visualized

PLAN:Refer back to team orthopaedic physician and

Pain Clinic for continuation of care

Spring 2009 Rowing SeasonParticipated, as tollerated, in Winter Training TripContinued to experience pain and numbness sx.’sTreatment with:

Lidoderm patchesT.E.N.S.IontophosesisNSAID - Piroxicam

Participated in spring practices and races“good days and bad days”

Finished out rowing career on May 17, 2009Graduated from the University of Iowa

DiscussionHx. of chest/rib pain in rowersDiscovery of benign syrinx by MRIMultidisciplinary team approach to care

of patientMultiple treatments used with varied

resultsEven with best efforts, there was a failure

to achieve complete relief of symptomsConclusive diagnosis?

Conclusions1. MRI showed a midthoracic small spinal cord

syrinx that was concluded to not be cause of her symptoms

2. Persistent mid-thoracic back pain and numbness

3. “It’s not about what it is, but what it isn’t” No rib stress fracture No herniated thoracic disc No abnormal soft tissue masses No degenerative changes of thoracic spine

Thank you