MANUSCRIPT TYPE ABSTRACT PRESENTATION 8 Copyright © by Indiana State University Clinical Practice in Athletic Training All rights reserved. ISSN Online 2577-8188 Volume 5 – Issue 3s – November 2022 Southwest Athletic Trainers’ Association Free Communications Abstract Presentations The following abstracts were accepted and presented at the 68th Southwest Athletic Trainers’ Association (SWATA) Symposium, 2022. CRITICALLY APPRAISED TOPIC Suspension Training as an Effective Intervention to Improve Core Stability: A Critically Appraised Topic Stiltner S, Boham M, Melrose D: Texas A&M University-Corpus Christi, Corpus Christi, Texas Clinical Scenario: The core is a functional unit connecting the upper and lower extremities consisting of abdominal, back, and hip musculature. Core stability is a determining factor in patient motor performance and provides optimal force production and precision of movement. A highly functional core is essential in injury prevention and rehabilitation. Traditional means of core stability training are performed on a stable surface. Emerging research suggests patients may benefit from core stability training on unstable mediums such as is used with suspension training. Clinical Question: Does suspension training improve core activity in an active population? Search Strategy: Key words used to guide the search were core strength OR core stability AND suspension training, unstable surface AND strength. Inclusion criteria included articles published in or after 2017, manuscripts that explored suspension training AND core stability, strength, endurance, and were completed using an active adult population. Manuscripts were excluded if they were published prior to 2017, did not assess pre and post measurements, and were completed on a sedentary or injured population. Data bases searched included EBSCO Host, SportDiscus, and PubMed. Search Results: Overall 11 articles were collected and appraised to determine relevance to answering the clinical question. Evidence was appraised by three researchers using the Oxford Centre for Evidence-Based Medicine Level of evidence criteria and the PEDro scale to determine validity of evidence. Evidence at a level 1B or higher and a PEDro score of 5 or higher were included. Best Evidence: In total, two relevant studies emerged to meet inclusion criteria. These studies utilized suspension training or TRX to facilitate activation of the core musculature. All three studies met level 1B criteria of the CEBM. Clinical Bottom Line: Evidence suggests improvement to core strength, endurance, and stability can be achieved with the inclusion of suspension training. Suspension exercises of push-up, inverted row, bridge, and planks show greatest activation of core musculature. A 6 month program of incorporating suspension training in addition to a routine program shows most beneficial. This evidence combined suggests suspension training is an effective tool in improving core activity. Further, evidence to identify the lasting benefits of suspension training to train core activity is inconclusive and should be continued. Strength of Recommendation: Grade B evidence exists that suspension training is an effective intervention to improve core activity in an active population. ABSTRACT PRESENTATION 9 Copyright © by Indiana State University Clinical Practice in Athletic Training All rights reserved. ISSN Online 2577-8188 Volume 5 – Issue 3s – November 2022 ORIGINAL RESEARCH A Perfect Storm?: The Association of Vitamin D with Injury Prevalence among Acrobatics & Tumbling Athletes Lee K, Gallucci A, Funderburk L, Cherpe de Souza L, Irvin L, Boyer E: Baylor University Waco, TX Context: Acrobatics and Tumbling (A&T) was recently placed on the NCAA’s emerging sports list. Due to the novelty of the sport, limited research related to injury prevalence and correlates are available. Anecdotal evidence suggests that the sport presents with high injury rates and associated costs. Information related to causes and prevalence of injury would help ATs working in the collegiate setting. Increased understanding of injury and its correlates in this population may allow ATs to provide better care. Objective: To examine descriptive injury data of acrobatics and tumbling athletes and evaluate the relationship between serum vitamin D, injury and time loss. Design: Cohort Study Setting: NCAA Division I University Sponsored Athletic Department Patients or Other Participants: Forty-two participants on the active A&T roster consented to participate in the study. Average age in the sample was 19.69 ± 1.199 years. Positional composition: 19 tops, 23 bases. Interventions: Serum vitamin D was analyzed at two timepoints 8 weeks apart. Main Outcome Measures: Serum vitamin D (ng/ml), Injury history (i.e., prevalence, mechanism, outcomes), Time loss (i.e., no time loss, time loss). Descriptive statistics were utilized in addition to t tests and ANOVAs to determine if significant differences existed in injuries and time loss based on serum vitamin D levels, or athletic position (i.e., top, base). Results: Twenty-eight injuries were sustained during the 8-week period. 11 participants sustained a time loss injury. Between week 1 and week 8, participants serum vitamin D decreased an average of 6.093 ± 10.973. There was no significant difference in serum vitamin D or change in vitamin D based on injury status (i.e., injured, non-injured) or time lost. There was a significant decrease in the serum vitamin D levels of participants between week 1 and week 8. Conclusions: No significant differences were found in injuries or time loss related to differences in serum vitamin D. However, identifiable patterns were found in injuries sustained by participating A&T athletes. Injuries identified included a high prevalence of lower extremity and soft tissue injuries. In a sport with multiple components, the majority of injuries were sustained during tumbling activities. Fifty percent of injured participants missed time due to their injuries. Serum vitamin D levels at the beginning and end of the study period showed a significant decrease as volume and intensity increased. A direct relationship between serum vitamin D and injury prevalence was not identified. However, significant decreases in serum vitamin D and high injury prevalence was found amongst participants over the eight-week period. This indicates a need for further monitoring of biomarkers such as vitamin D in these athletes, and further research to determine additional injury prevention strategies. ABSTRACT PRESENTATION 10 Copyright © by Indiana State University Clinical Practice in Athletic Training All rights reserved. ISSN Online 2577-8188 Volume 5 – Issue 3s – November 2022 ORIGINAL RESEARCH Hiring Practices Among NCAA Division II Head Athletic Trainers Warner BJ*†, Winkelmann ZK‡, Cage SA†§, Gallegos DM§?, Trail LE§?: *Grand Canyon University, †The University of North Carolina, Greensboro, ‡University of South Carolina, §University of Texas at Tyler, ?UT Health East Texas Context: To the authors’ knowledge, there are few studies on how athletic trainers (ATs) are hired by NCAA institutions. Current legislation protects many demographics from discrimination during hiring, but these laws may not be enforced by institutions. Therefore, the purpose of this study was to describe factors that might influence the hiring practices of NCAA Division II Head Athletic Trainers. Methods: We used a web-based survey (Qualtrics) that was distributed to by email to 278 NCAA Division II Head Athletic Trainers. A total of 96 ATs completed the survey (response and completion rate=34.5%). The survey included a prompt for hiring an athletic trainer for an NCAA Division II athletics program, questions on demographic data, impact of candidate demographic factors, and impact of candidate skills and education on hiring practices. After the collection window had closed, we calculated central tendencies for all responses. Results: Most ATs reported they would be most likely to hire a candidate with three to five years of experience (3-5 Years Experience=96.9%, 1-2 Years Experience=87.6%, 6-10 Years Experience=86.4%). Most ATs also reported that they would be most likely to hire a candidate with primarily collegiate athletics experience (College Experience=89.6% , High School Experience=61.5%, Clinic Experience=40.7%). Regarding education, most ATs were most likely to hire a candidate with a master’s degree in athletic training (Master’s in Athletic Training=92.8%, Masters not in Athletic Training=78.2%, Clinical Doctorate=64.5%). For demographic factors, most ATs responded in the mid- range of agreement about the impact these factors had on hiring practices. More athletic trainers stated a willingness to hire a candidate of a different race, different religion, different sex, and different sexual orientation. When asked about the credentials most likely to improve chances of being hired for candidates, ATs ranked Corrective Exercise Specialist, Graston Technique Certified, and Certified Strength and Conditioning Specialist highest. Conclusions: Most head athletic trainers agreed that three to five years of professional experience, previous experience with collegiate athletics, and a master’s degree in athletic training were the most attractive characteristics a candidate could possess. However, many participants answered in the mid-range of agreement when asked about the effect of demographic factors on hiring practices. These responses may suggest an unwillingness to respond favorably or unfavorably on the topic. Future research should focus on examining hiring practices in a way that requires participants to respond favorably or unfavorably. Athletic trainers and administrators must work to ensure that they are hiring the best candidate regardless of demographic factors that have no bearing on performing the tasks related to the position being filled. ABSTRACT PRESENTATION 11 Copyright © by Indiana State University Clinical Practice in Athletic Training All rights reserved. ISSN Online 2577-8188 Volume 5 – Issue 3s – November 2022 ORIGINAL RESEARCH Hiring Practices Among NCAA Division III Head Athletic Trainers Goza JP*, Cage SA†‡, Winkelmann ZK§, Warner BJ†?, McKenney M?: *Collin College, †University of Texas at Tyler, ‡The University of North Carolina, Greensboro, §University of South Carolina, ?Grand Canyon University Context: Limited empirical evidence exists on how athletic trainers (ATs) are hired by NCAA institutions. Current legislation protects many demographics from discrimination during hiring, but these laws may not be enforced by institutions. Thus, the purpose of this study was to describe potential factors that might influence the hiring practices of NCAA Division III Head Athletic Trainers. Methods: We used a web-based survey (Qualtrics) that was distributed by email to 329 NCAA Division III Head Athletic Trainers. A total of 114 ATs completed the survey (response and completion rate=34.7%). The survey included a prompt for hiring an assistant athletic trainer for an NCAA Division I athletics program, questions on demographic data, impact of candidate demographic factors on hiring practices, and impact of candidate skills and education on hiring practices. After the collection window had closed, we calculated central tendencies for participant responses. Results: Most ATs reported they would be most likely to hire a candidate with three to five years of experience (3-5 Years Experience=90.3%, 6-10 Years Experience=82.4%, 1-2 Years Experience=82.4%). Most ATs also reported that they would be most likely to hire a candidate with primarily collegiate athletics experience (College Experience=91.2% , High School Experience=41.2%, Clinic Experience=30.7%). Regarding education, most ATs were most likely to hire a candidate with a master’s degree in athletic training (Master’s in Athletic Training=95.6%, Masters not in Athletic Training=86.8%, Clinical Doctorate=64%). For demographic factors, most ATs responded in the mid-range of agreement about the impact these factors had on hiring practices. More athletic trainers stated a willingness to hire a candidate of a different race (50%), different religion (45.6%) and different sex (48.2%). Responses regarding sexual orientation were near the mid-range for both same and different sexual orientation. When asked about the most attractive credentials for candidates, ATs ranked Corrective Exercise Specialist, Graston Technique Certified, and Performance Enhancement Specialist highest. Conclusions: Most head athletic trainers agreed that three to five years of professional experience, previous experience with collegiate athletics, and a master’s degree in athletic training were the attributes most likely to influence a candidate being hired. However, many ATs responded toward the mid-range of agreement when asked about demographic factors when considering candidates. This may indicate an unwillingness to respond favorably or unfavorably on the topic. Future research should focus on assessing hiring practices in a manner that requires a favorable or unfavorable response. Athletic trainers involved in the hiring practice at their institutions must work to ensure that they are hiring the best candidate irrespective of demographic factors that have no bearing on technical standards of the position. ABSTRACT PRESENTATION 12 Copyright © by Indiana State University Clinical Practice in Athletic Training All rights reserved. ISSN Online 2577-8188 Volume 5 – Issue 3s – November 2022 ORIGINAL RESEARCH Effect of Dry Needling on Sinus Congestion in Otherwise Healthy Adults Gallegos DM*†, Warner BJ‡§, Peebles R†?, Cage SA*§: *University of Texas at Tyler, †UT Health East Texas, ‡Grand Canyon University, §The University of North Carolina, Greensboro, ?University of Texas Health Science Center Context: Dry needling refers to the practice of inserting monofilament needles into the skin without injecting any liquids. Many of the principles of needle insertion are similar to those used in acupuncture. Previous literature has suggested that acupuncture may be a potential adjunct treatment for nasal congestion. However, there are not any studies examining the efficacy of dry needling to alleviate nasal congestion. Therefore, the purpose of this case series was to present the cases of four patients suffering from nasal congestion who experienced immediate relief following treatment with dry needling. Methods: Four male patients (23.25 ± 2.36 years, 182.25 cm ± 8.39, 92.99 kg ± 15.61) were recruited and consented to participate in this study. All patients were afebrile and without other symptoms of illness, except for nasal congestion. None of the patients reported using any medications besides over-the-counter pseudoephedrine. Prior to treatment, all patients completed the Congestion Quantifier 7 (CQ7). The treatment site was then cleaned using an isopropyl alcohol prep pad, and the patients were instructed to use hand signals to answer questions once needles were inserted. The dry needling treatment consisted of inserting 1.27 cm needles bilaterally above the orbital rim, along the zygomatic arch, and into the nasal fold for 10-minutes. Within 2-minutes of completion of the treatment all patients were asked to complete the CQ7 a second time. Data analysis was performed using a paired samples t-test to determine statistical significance of differences in CQ7 scores before and after treatment. Results: Following one dry needling treatment, the patients experienced a significant decrease in congestion symptom severity (3.00 ± 1.19 to 1.61 ± 0.09, p < 0.01). Patient’s average a 46.3% decrease in symptoms. None of the participants reported any adverse effects as a result of the dry needling treatment. Conclusions: These findings demonstrated that in otherwise healthy patients, dry needling significantly decreased symptoms of nasal congestion. While dry needling does not treat the root cause of nasal congestion, it may warrant consideration as a non-medicinal treatment for congestion. Clinicians must use discretion when choosing a treatment option if a patient will be performing physical activity afterwards. ABSTRACT PRESENTATION 13 Copyright © by Indiana State University Clinical Practice in Athletic Training All rights reserved. ISSN Online 2577-8188 Volume 5 – Issue 3s – November 2022 ORIGINAL RESEARCH Characteristics of Sickle Cell Trait Policies and Procedures at NCAA Division I Institutions Parker H*†, Warner BJ‡§, Gallegos DM*†, Cage SA*: *University of Texas at Tyler, †UT Health East Texas, ‡The University of North Carolina, Greensboro, ‡The University of Texas at Tyler, §Grand Canyon University Context: In 2010, the National Collegiate Athletic Association (NCAA) introduced a proposal addressing sickle cell trait screening. This proposal later became a policy that required student-athletes in their first year of eligibility to provide their institution with accurate information regarding their sickle cell trait status. There does not appear to be a recent study published that has examined the sickle cell trait policies and procedures currently being used by NCAA Division I institutions. The purpose of this study was to describe the characteristics of sickle cell trait policies and procedures at NCAA Division I institutions. Methods: We used a web-based survey (Qualtrics, Qualtrics Inc., Provo, UT) that was distributed to the 329 NCAA Division I Head Athletic Trainers . A total of 67 athletic trainers accessed and completed the survey (response and completion rate=20.4%). The survey tool included questions to assess the availability of sickle cell trait testing, availability of sickle cell trait waivers, and policy and procedure revision processes. After the collection window had closed, we calculated frequencies of participant responses using a commercially-available statistics package (SPSS Version 26, IBM, Armonk, NY). Results: The majority of head athletic trainers reported their institutions requiring sickle cell trait testing for their student-athletes (74.6%, n=50). All responding institutions offered sickle cell trait testing to their student-athletes either at the institution’s or the student-athlete’s expense. However, the majority of these institutions did not provide their student-athlete population with yearly education on sickle cell trait (64.2%, n=43). On average, institutions (82.1%) and team physicians (80.6%) reviewed their sickle cell trait policies and procedures on a yearly basis. 16.7% (n=11) of institutions had not reviewed their sickle cell trait policies within the past two years, and 17.9% (n=12) of institutions did not have sickle cell trait policies and procedures that had been reviewed by their team physician in the past two years. Conclusions: While the majority of responding NCAA Division I institutions appear to be compliant with NCAA requirements, athletic training staff and institutions should conduct annual reviews of their sickle cell trait screening policies and procedures with athletic training staff, the team physician, institutional legal counsel and institutional risk management departments. Athletic trainers should ensure that they have current knowledge of the pathology, recognition and management of patients with sickle cell trait. Lastly, institutions should require annual sickle cell trait education for student-athletes, regardless of SCT status. ABSTRACT PRESENTATION 14 Copyright © by Indiana State University Clinical Practice in Athletic Training All rights reserved. ISSN Online 2577-8188 Volume 5 – Issue 3s – November 2022 ORIGINAL RESEARCH Characteristics of Sickle Cell Trait Policies and Procedures at NCAA Division III Institutions Eilers MA*, Warner BJ*†, Gallegos DM‡§, Clark JA‡§, Cage SA‡: *Grand Canyon University, †The University of North Carolina, Greensboro, ‡The University of Texas at Tyler, §UT Health East Texas Context: In 2010, the National Collegiate Athletic Association (NCAA) introduced a proposal addressing sickle cell trait screening. This proposal later became a policy that required student-athletes in their first year of eligibility to provide their institution with accurate information regarding their sickle cell trait status. There does not appear to be a recent study published that has examined the sickle cell trait screening policy and procedures currently being used by NCAA Division III Institutions. Thus, the purpose of this study was to describe the characteristics of sickle cell trait policies and procedures at NCAA Division III institutions. Methods: We used a web-based survey (Qualtrics, Qualtrics Inc., Provo, UT) that was distributed to the 442 NCAA Division III Head Athletic Trainers . A total of 158 athletic trainers accessed and completed the survey (response and completion rate=35.7%). The survey tool included questions to assess the availability of sickle cell trait testing, availability of sickle cell trait waivers, and policy and procedure revision processes. After the collection window had closed, we calculated frequencies of participant responses using a commercially-available statistics package (SPSS Version 26, IBM, Armonk, NY). Results: The majority of head athletic trainers reported that their institutions did not require sickle cell trait testing (70.25%, n=111). The majority of head athletic trainers also stated that their institutions offered sickle cell trait testing to their student-athletes in some form (institution’s expense=119, individual’s expense=13). Additionally, a slight majority of institutions required all student-athletes to undergo yearly sickle cell trait education (56.33%, n=89). On average, institutions (79%) and team physicians (56.7%) reviewed sickle cell trait policies and procedures on a yearly basis. However, 18.9% (n=30) of institutions did not have sickle cell trait policies and procedures that had been reviewed by their team physicians at any point. When asked whether sickle cell trait and sickle cell disease were different conditions, 8 head athletic trainers (5%) stated they were not. Conclusions: While the majority of responding NCAA Division III institutions appear to be at least compliant with NCAA regulations, athletic training staff and institutions should be encouraged to conduct annual reviews of their sickle cell trait screening policies and procedures with athletic training staff, the team physician, institutional legal counsel and institutional risk management. Athletic trainers should ensure that they are well versed in the pathology, recognition and management of patients with sickle cell trait. Also, institutions should require annual sickle cell trait education for student- athletes, regardless of SCT status. ABSTRACT PRESENTATION 15 Copyright © by Indiana State University Clinical Practice in Athletic Training All rights reserved. ISSN Online 2577-8188 Volume 5 – Issue 3s – November 2022 ORIGINAL RESEARCH Impact of a Virtual Education Presentation on Perceived and Actual Knowledge of Cupping Therapy Among Athletic Trainers Cage SA*†, Gill DL*, Brown PK*, Schmitz R*, Warner BJ*‡: *The University of North Carolina Greensboro-Kinesiology, †The University of Texas at Tyler, ‡Grand Canyon University Context: Within the athletic training profession, there are continuing education requirements in order to maintain national certification. Although the profession mandates completion of continuing education, little research has assessed the effectiveness of continuing education interventions. Furthermore, there has been even less research conducted on the effectiveness of virtual continuing education interventions. The purpose of this study was to determine the effect of a virtual continuing education presentation on perceived and actual knowledge of cupping therapy among certified athletic trainers. Methods: 31 certified athletic trainers began this study (age = 38 ± 11, years of credentialed experience = 15 ± 11). A web-based survey assessed education, usage, and perceived and actual knowledge of cupping therapy. Upon completing the initial survey, participants were asked to watch a recorded continuing education presentation on cupping therapy and take a second survey with 19 completing the survey. One month after completion of the second survey, participants were sent a follow up survey to assess retention of knowledge. For all rating questions means with standard deviations and frequencies were recorded. Paired t-tests were performed to determine if there were any differences in perceived and actual knowledge before and after the intervention and one month after the completion of post-presentation survey. Significance was set with a p value of p < 0.05. Statistical procedures were performed using SPSS V26 (IBM, Armonk, NY). Results: Prior to the presentation participants had a mean perceived knowledge score of 29.1 ± 19.4 out of 60 indicating that on average, they had at least some confidence in their knowledge of cupping therapy. Following the presentation, the mean perceived knowledge score was 20.2 ± 6.1 out of 60 with lower scores indicating more confidence. This represented a significant improvement in perceived knowledge, t(16) = 4.31, p < .01. At the one-month follow the mean perceived knowledge score was 17.3 ± 6.2 with no significant change over the month, t(7) = -.07, p = .943. Initially, participants had a mean sum of correct actual knowledge items (n=22) of 19.5 ± 1, which was equivalent to 88.5% had this been a written exam. Following the presentation, the mean sum of actual knowledge items was 19.9 ± 1.62, with no significant increase in actual knowledge (p = .382). Conclusion: These findings suggest that a virtual presentation directed toward athletic trainers may be effective in improving perceived knowledge. Although there was no significant improvement in actual knowledge, this may be due to the high initial scores on actual knowledge items. Further research should be conducted to determine the effectiveness of virtual continuing education on topics with which individuals are less knowledgeable. ABSTRACT PRESENTATION 16 Copyright © by Indiana State University Clinical Practice in Athletic Training All rights reserved. ISSN Online 2577-8188 Volume 5 – Issue 3s – November 2022 CASE REPORT Anisocoria as the Sole Initial Symptom of Concussion in a Collegiate Volleyball Player: A Case Report Hopper I*, Warner BJ†‡, McKenney M†, Galbraith RM§?, Cox C*, Cage SA*: *The University of Texas at Tyler, †Grand Canyon University, ‡The University of North Carolina Greensboro-Kinesiology Department, §UT Health East Texas, ?University of Texas Health Science Center Background: A 21-year-old female collegiate volleyball player reported to the athletic training staff after a competition upon noticing that her pupils were unequal. The patient stated that she was not experiencing any other signs or symptoms that would indicate a concussion, but did recall striking her head on the court during pre-competition warmups. The patient reported no previous history of concussion or eye injury. Further evaluation did not reveal any issues with the patient’s reflexes, balance, or memory. At this time, the decision was made to preemptively withhold the patient from participating in athletic activities so she could be monitored for the development of further signs and symptoms. Differential Diagnosis: Concussion, Oculomotor Nerve Palsy, Acute Eye Trauma Treatment: Approximately six hours after the patient was removed from competition, the patient began experiencing a headache and pressure in her head. The onset of new symptoms furthered the athletic training staff’s belief that the patient had sustained a concussion when she struck her head. The coaching staff was then informed that the patient would be admitted into the institutional concussion protocol, and not allowed to participate in physical activity until receiving clearance from the athletic training staff. Two days after the patient began experiencing symptoms she was evaluated by the team physician who confirmed the diagnosis of a concussion. With the confirmed diagnosis, the patient continued to be withheld from team activities and was instructed to abstain from all other activities that increased severity of symptoms. Within four days of experiencing symptoms, the patient’s pupils were symmetrical once again. The patient’s headache and sensation of pressure had resolved within five days. On day six, the patient began the institutional return to participation protocol. Twelve days from the onset of symptoms, the patient was cleared to return to full participation in team activities. For the remainder of the season, the patient did not experience anisocoria or any of the previously experienced symptoms. Uniqueness: To the authors’ knowledge, no previous case studies or original research have described anisocoria as the only initial symptom that a patient experienced following a concussion. Given that anisocoria is not one of the more common signs or symptoms of concussion, it is possible that the concussion would not have been recognized had the patient not self reported her asymmetrical pupils. Conclusions: When caring for patients, it is paramount that the clinician take into account all patient reported signs and symptoms. In the event that a patient reports an unusual sign or symptom, the clinician must exhaust all possible options to explain the sequelae. Furthermore, thorough preparticipation concussion education is critical to helping patients understand the importance of reporting symptoms after potentially concussive trauma. ABSTRACT PRESENTATION 17 Copyright © by Indiana State University Clinical Practice in Athletic Training All rights reserved. ISSN Online 2577-8188 Volume 5 – Issue 3s – November 2022 CASE REPORT Herpes Zoster as an Incidental Finding During Treatment for Thoracic Back Pain in a Collegiate Baseball Player Trail LE*†, Warner BJ‡§, Peebles RL†?, Galbraith RM†?, Cox C*, Cage SA*: *The University of Texas at Tyler, †UT Health East Texas, ‡Grand Canyon University, §The University of North Carolina Greensboro-Kinesiology Department, §UT Health East Texas, ?University of Texas Health Science Center at Tyler 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.