Just Keep Swimming...Just Keep Swimming

History: We present a 15-year-old right hand dominant high school swimmer with no significant past medical history, who complains of right elbow pain along the distal biceps' tendon for a 2 months. Pain was insidious in onset, sharp, intermittent, and described as a 0 to 6 out of 10. The patient has been swimming more frequently over the last few months to prepare for competition and noticed progressive pain with swimming. He went on vacation and then was diagnosed with a COVID-19 infection and took an additional 2 weeks off due to fatigue. He returned to sport without re-integration and increased his swimming intensity to 1 to 2 hours daily, which worsened his pain. Performing the butterfly and breaststroke provoke symptoms and cessation of activity reduces the pain. Denies pain at rest. He took Advil which did not reduce his pain. Denies acute trauma, prior injuries, or paresthesias. Physical Exam: Inspection of right elbow: no swelling or signs of discoloration. Palpation: Tenderness at the distal biceps tendon but can hook the tendon without pain. No shoulder or wrist tenderness. Active Range of Motion: Elbow extension 0 degrees, elbow flexion 130 degrees, supination and pronation normal. Normal shoulder and wrist ROM. Muscle strength: 5/5 grip, wrist extension, and wrist flexion. Pain elicited with resisted elbow flexion at the distal humerus. Maneuvers: pain with distal humerus squeeze. Negative Maudsley and negative Cozen test. Differential Diagnosis: 36. Distal Biceps Tendonitis/Tear 37. Stress Reaction of the Distal Humerus 38. Medial Epicondyle Apophysitis 39. Capitellar Osteochondritis Dissecans 40. Radiocapitellar Plica Syndrome Test Results: x-ray right elbow: AP and Lateral views indicate no abnormalities to the bones, alignment, or soft tissue structures. MRI right elbow No IVCON: Biceps tendon intact. There is periosteal edema and endosteal aspect marrow edema along the medial aspect of the distal diaphysis and metaphysis of the humerus. Several small foci of increased cortical signal. No fractures, joint effusion, or chondral defects. Findings comparable to Fredrickson grade 4a distal humerus diametaphysis stress injury. Final Diagnosis: Right Elbow Supracondylar Grade 4a Stress Reaction. Discussion(s): Actives that involve repetitive motion are susceptible to overuse injuries. Cases of upper extremity stress reactions in swimmers have been documented along the inferior angle of the scapula, upper ribs, and olecranon. Stress reactions along the distal humerus in swimmers is not well documented. This pathology has been seen in baseball players, cricket bowlers, and tennis players. In swimming, the butterfly technique requires significant endurance and athletic strength. During a sprint, fast synchronized upper extremity revolutions occurring up to 60 cycles perminute counterforcewater surface area friction leading to excessive loading forces even at 50 meter distances. Outcome(s): The patient was withheld from upper body work outs and swimming for 6 weeks. VitaminDand Calcium levels were drawn revealing a normal calcium level (10.2), but a vitamin D level of 28.1. Patient was started on 600 IU of Vitamin D and 1300 mg of Calcium daily. The patient started a return to swim program and returned to full competition at 7 months post presentation. Follow-Up: At 6 weeks, started an upper extremity low impact non-aquatic physical therapy program. Then a slow progressive return to swimming was initiated at 50% effort for 4 weeks. At 10 weeks, a return to sport plan including 200 m all strokes except butterfly, progressed to 250 m at week 2, 300 m at week 3, and 350 m at week 4. Finally, initiated speed work in =0 to 100 m increments and elbow loading workouts.

An 81-Year-old Woman With Proximal Weakness

An 81-year-old woman developed progressive proximal weakness and myalgias several months following a COVID-19 infection. She was admitted to her local hospital for progressive weakness, peripheral edema, and exertional dyspnea. Neurology evaluation noted proximal arm and leg weakness. She had creatine kinase 740 U/L, white blood cells 21,000/mL (with abnormal differential), and abnormal antibody serologies. Additional diagnostic testing obtained included a thigh MRI and muscle biopsy. During her COVID-19 admission, a mediastinal mass had been detected, which was increased in size on this current admission. Notably, she had a remote history of an incidentally discovered mediastinal mass, which had been incompletely resected 18 years prior. At neuromuscular follow-up one month later, she reported improvement in peripheral edema and dyspnea but ongoing weakness. Strength exam noted symmetric Medical Research Council grade 4 weakness in neck flexion/extension, shoulder abduction, elbow flexion/extension, wrist extension, hip flexion/abduction/extension, and knee flexion. She had no fatiguability and no facial or bulbar weakness. Remainder of her neuromuscular examination was unremarkable. Her white blood cell count differential remained abnormal but had improved from her initial presentation. Her recent muscle biopsy slides were reviewed again. Bone marrow biopsy and mediastinal mass biopsy were obtained. A unifying diagnosis was made, and she was started on therapy with resolution of her weakness, myalgias, and abnormal cell counts.