Case Study: Speed Skater with a Sports Injury

A speed skater suffering from sports injury who returns to the ice with the help of MR Neurography and Interventional MR Guidance procedures.

The patient reports that he has had a right groin and stabbing sharp pain for three and half years. He notes that he was doing some dead-man weightlifting exercises when he felt a pull to his right inner thigh. After that he began having difficulties, especially with squatting and abducting his legs. He has no change or increase in pain level since the onset. When he has a significant flare-up he will note some numbness. He notes that his pain is at 6 out of 10 and continuous.

Based on this history, exam, data and findings, the patient was diagnosed with an obturator internus syndrome. There is some possibility of involvement of the obturator externus muscle; however, the exam and physical exam findings including the positive response to the resisted adduction of the flexed internally rotated thigh are consistent with the presence of an obturator internus syndrome. This is also consistent with the image finding of venous dilatation on the medial aspect of the obturator internus muscle. Based on these findings we proceed with an MRI-guided injection for the targeted chemomyolytic treatment of the obturator internus muscle in order to learn whether relaxation of this individual muscle immediately relieves the symptom. We may also upon reexamination find there is persistent sensitivity and proceed to inject the obturator externus as well. Based on this we should be able to have a definitive diagnosis of the problem. We will then look at the duration of response to injection. If he has a prolonged response no further treatments will be required. If his response is just over some weeks with subsequent recurrence we may consider re-injecting. We will also do a hyaluronidase injection along the course of the nerve to the obturator internus in order to try to release any adhesions, which may be precipitating this; although this is part of the procedure we will re-inject the obturator internus muscle.

We proceed with the open MRI image-guided injection, which allows us to selectively target this individual muscle, as well as the nerve approaching it. After the interventional MR Guided injections for obteratur internus, we find that there is an immediate relief of pain to this nerve area that had previously been consistent at 6 out of 10 for three and half years. The accuracy of the IMR injection highlights the failed accuracy of ultrasound, CT, and Fluroscopy guided injections. The precision of IMR injection shows a clear plan for surgery involving a relatively straight forward procedure involving nerve release for the nerve to the obturator internus in which the patient should be able to recover over two to four weeks. Surgery itself has quite rapid recovery, but assuring that he would be fully capable for his sports activity it is more likely in four weeks with reassessment at that point.

The patient is approximately two weeks post right transgluteal approach for neuroplasty of the obturator internus nerve. The patient reports that in the past couple of weeks he has noted a reduction in his pain level when adducting his right thigh. The patient reports only noting a “pinch” which is notably reduced from his pre-op levels. We had an extensive discussion regarding various types of exercising and the importance of slowly increasing his activity level as tolerated and avoiding exercises that aggravate his symptoms.

The patient is about two-and-half months out from his surgery, which involved a neuroplasty of the nerve to the obturator internus. At first he had significant improvement, but when he commenced skating again in preparation for his season he had some recurrence. Now he is enthusiastic to report that as the weeks went by and he limited his skating activity that he has been pain free for almost one month. Since returning to competition, he has experienced improvement in that he is able to do more of the skating with less of the symptoms, so at this point it is fairly minimal with the patient reporting an activity pain level of 2 out of 10.