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Abstract

Background: A 21-year-old male collegiate baseball pitcher reported to the athletic training staff complaining of thoracic back pain when throwing during the non-traditional season. The patient did not recall a specific mechanism of injury, and noted that his pain had gradually increased over time. The patient reported no previous history of thoracic or lumbar spine injury. Further evaluation revealed multiple myofascial adhesions that did not resolve with conservative treatments. After the failure of conservative treatment, the patient was referred to the team physician for further evaluation.. Differential Diagnosis: Myofascial adhesions, Rib subluxation, Thoracic Disc Herniation Treatment: Upon referral, the team physician obtained x-rays and an MRI of the patient’s thoracic and lumbar spine. X-rays were negative for abnormalities, and the MRI only revealed a mild degenerative disc disease at the L4-L5 level. After confirming that the degenerative disc disease was not related to the thoracic back pain, the physician began a course of lidocaine trigger point injections under fluoroscopy. This course of treatment was effective, and the patient was able to return to sport-related activities. During the winter break, the patient contacted his athletic trainer and stated that his back pain had returned. When the patient returned for the spring semester, he was referred to the team physician for another round of trigger point injections. During this examination and treatment, the team physician noted that the patient’s myofascial adhesions had improved, and his muscular tenderness had largely resolved. While performing the exam, the physician noted a seven cm by three cm patch overlying the right side of the lumbosacral region with pink base and numerous one mm papules. When asked, the patient did not report any itching or pain over lesion, but did state that he had noticed a paresthesia in the area over the past few days. The patient reported having not noticed the rash previously, and had never had a similar lesion. The physician diagnosed the patient with herpes zoster, and prescribed a seven day course of valACYclovir. At one week follow up, the lesion had begun to resolve and paresthesia had completely resolved. Following this round of trigger point injections and valACYclovir, the patient was able to participate in their competitive season without further complication. Uniqueness: While the lifetime risk of contracting herpes zoster has been reported as 30-50%, the majority of cases occur in patients over the age of 50. Additionally, herpes zoster patients often report pain and itching at the site of the lesion. Had this patient not already been undergoing treatment near the area the lesion occurred, it is likely it would have gone undiagnosed for some time. Conclusions: When performing physical exams, it is important to take note of any unusual lesions. Should an incidental finding be observed, it is still crucial to patient care to ensure that the finding is addressed. While some conditions may be uncommon in the patient population a clinician is treating, it is still important to be aware of the possibility of occurrence.

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