D
deleted162650
I have a unique case for you guys too:
28yo otherwise healthy avid runner with sudden onset of R-posterior leg pain. He is a full paleo barefoot runner.
On exam, he has severe R-posterior leg pain with some swelling and mild bulge just inferior to the gluts. Ultrasound exam shows normal neurovascular structures and no osseous abnormalities. Instead, it finds he had a spontaneously ruptured R-hamstring muscle with a free-fluid collection in the capsule of the muscle.
On my evaluation, he is utterly dismayed and appears defeated. He relays "I am scheduled to run my first marathon tomorrow. I was told that sitting this one out is my only option here, so I guess that's the way it's gotta be."
He really wanted to experience the visceral pain of running the marathon, but the somatic pain from the ruptured muscle was just unbearable.
So what did we do? (what would you do)
He had stable vitals. He clearly had nothing wrong internally and his symptoms strongly pointed to MSK source in our discussion with the Ortho team (chiropractic consulted Ortho for the workup of the leg pain).
We decided to place a R-sided subgluteal sciatic catheter. Placement was challenging because the lean runner's legs stretched the planes so tightly it was hard to identify and place a needle into it. Nevertheless we were successful after some struggling. We bolused it 25 mL 0.2% ropivacaine and his posterior pain entirely resolved. The catheter was not hooked to an infusion because it would be too difficult to run while carrying an On-Q pump. He hobbled down the course for 48 hours and the catheter allowed us to repeat boluses which we did every 4 hours by intercepting him in a chase car.
We considered whether or not anesthetizing the nerve would exacerbate the ruptured muscle. In all reality it was likely therapeutic by preventing that muscle from contracting on itself when it's injured. I discussed with him that there's a slightly possibility his stride could be weaker with the sciatic catheter in place and he may unable to run with the foot drop, but we really didn't know HOW or even IF it would affect his ability to complete the race.
After hobbling for 48 hours (again, unclear if that was a consequence of the sciatic catheter) the pain and exhaustion grew excruciating and he was progressing slowly. He then requested a wheelchair on his own and shortly thereafter was deemed unable to complete the race. We took him to the finish line in the chase car and left the catheter in place so we could use it post-race if he needed it.
Post-race course, interestingly, was benign. After he stopped trying to run, the tension on the muscle was relieved and his pain went from severe to tolerable.
He and his wife told us later that the turning point of their experience was the placement of the sciatic catheter because they felt like they were heard, respected, and empowered. He decided on his own for the ride to the finish line and was happy that we tried to find an alternative strategy before jumping right to it. He didn't use shoes
28yo otherwise healthy avid runner with sudden onset of R-posterior leg pain. He is a full paleo barefoot runner.
On exam, he has severe R-posterior leg pain with some swelling and mild bulge just inferior to the gluts. Ultrasound exam shows normal neurovascular structures and no osseous abnormalities. Instead, it finds he had a spontaneously ruptured R-hamstring muscle with a free-fluid collection in the capsule of the muscle.
On my evaluation, he is utterly dismayed and appears defeated. He relays "I am scheduled to run my first marathon tomorrow. I was told that sitting this one out is my only option here, so I guess that's the way it's gotta be."
He really wanted to experience the visceral pain of running the marathon, but the somatic pain from the ruptured muscle was just unbearable.
So what did we do? (what would you do)
He had stable vitals. He clearly had nothing wrong internally and his symptoms strongly pointed to MSK source in our discussion with the Ortho team (chiropractic consulted Ortho for the workup of the leg pain).
We decided to place a R-sided subgluteal sciatic catheter. Placement was challenging because the lean runner's legs stretched the planes so tightly it was hard to identify and place a needle into it. Nevertheless we were successful after some struggling. We bolused it 25 mL 0.2% ropivacaine and his posterior pain entirely resolved. The catheter was not hooked to an infusion because it would be too difficult to run while carrying an On-Q pump. He hobbled down the course for 48 hours and the catheter allowed us to repeat boluses which we did every 4 hours by intercepting him in a chase car.
We considered whether or not anesthetizing the nerve would exacerbate the ruptured muscle. In all reality it was likely therapeutic by preventing that muscle from contracting on itself when it's injured. I discussed with him that there's a slightly possibility his stride could be weaker with the sciatic catheter in place and he may unable to run with the foot drop, but we really didn't know HOW or even IF it would affect his ability to complete the race.
After hobbling for 48 hours (again, unclear if that was a consequence of the sciatic catheter) the pain and exhaustion grew excruciating and he was progressing slowly. He then requested a wheelchair on his own and shortly thereafter was deemed unable to complete the race. We took him to the finish line in the chase car and left the catheter in place so we could use it post-race if he needed it.
Post-race course, interestingly, was benign. After he stopped trying to run, the tension on the muscle was relieved and his pain went from severe to tolerable.
He and his wife told us later that the turning point of their experience was the placement of the sciatic catheter because they felt like they were heard, respected, and empowered. He decided on his own for the ride to the finish line and was happy that we tried to find an alternative strategy before jumping right to it. He didn't use shoes
