Working Diagnosis:
Multiple sclerosis, possibly precipitated or uncovered by her sports concussion

Treatment:
The patient's neurologist recommended starting treatment for multiple sclerosis immediately to delay progression of the demyelinating process. She was started on glatiramer acetate at ten months post-injury. At fourteen months follow-up post-injury, she had symptomaticaly resolved with treatment, and at eighteen month follow-up she had received no further treatment.

Outcome:
The patient was treated for multiple sclerosis for several months during the course of her unique illness. Her clinical symptoms did improve, and follow-up MRI's demonstrated stable, non-progressive, white matter lesions. Since discontinuation of treatment, she has remained clinically stable, with only lingering symptoms being occasional headache, insomnia, and short-term memory impairment. The patient had previously accepted the fact that she may never be able to participate in athletics again, but as of her last follow-up, she has been cleared to begin light training activities in hopes of returning to the collegiate soccer field in the fall.

Author's Comments:
The theory that trauma may play a role in the pathogenesis of MS has been considered since the earliest descriptions of the disease (1,2). Several authors have supported the hypothesis that trauma to the central nervous system can result in precipitation and exacerbation of the disease (3-11). Others have suggested that there is no true link between physical trauma and MS, asserting that any supposed correlation is due to coincidence (12-17). There have been studies involving hundreds of thousands of patients looking at the possibility of head injury being a risk factor for MS. However, there has never been any research concerning sports concussions in young athletes and the development of the disaese. There is no possible way to establish causation in our case; nonetheless, it is a concerning preposition that this patient's concussion could be related in some way to the onset of her MS. More research in the area of sports concussions and onset of MS needs to be conducted before a relationship can be truly examined.

References:
1. Charcot JM. Lectures on diseases of the nervous system. London: New Sydenham Society, 1879: 157-222.
2. Mendel K. Tabes und multiple Sklerose in ihren Beziehungen zum Trauma. Neurol Ctrbl 1897; 16: 140-141.
3. McAlpine D, Compston N. Some aspects of the natural history of disseminated sclerosis. Q J Med 1952; 21: 135-167.
4. Miller H. Trauma and multiple sclerosis. Lancet 1964; 1: 848-850.
5. Millar J. Multiple sclerosis: a disease acquired in childhood. Springfield, Illinois: Charles C Thomas, 1971: 65.
6. Bamford CR, et al. Trauma as an aggravating factor in multiple sclerosis. Neurology 1981; 31: 1229-1234.
7. Poser C. Pathogenesis of multiple sclerosis. Acta Neuropathol 1986; 71: 1-10.
8. Poser CM. Trauma and multiple sclerosis: an hypothesis. J Neurol 1987; 234: 155-159.
9. Poser CM. The role of trauma in the pathogenesis of multiple sclerosis: a review. Clin Neurol Neurosurg 1994; 96: 103-110.
10. Poser CM. Trauma to the central nervous system may result in formation or enlargement of multiple sclerosis plaques. Arch Neurol 2000; 57: 1074-1077.
11. Chaudhuri A, Behan PO. Acute cervical hyperextension-hyperflexion injury may precipitate and/or exacerbate symptomatuic multiple sclerosis. Eur J Neurol 2001; 8: 659-664.
12. Sibley WA, et al. A prospective study of physical trauma and multiple sclerosis. J Neurol Neurosurg Psychiatry 1991; 54: 584-589.
13. Siva A, et al. Trauma and multiple sclerosis: a population-based cohort study from Olmstead County, Minnesota. Neurology 1993; 43: 1878-1882.
14. Kurland LT. Trauma and multiple sclerosis. Ann Neurol 1994; 36: S33-S37.
15. Cook SD. Trauma does not precipitate multiple sclerosis. Arch Neurol 2000; 57: 1077-78.
16. Goldacre MJ, et al. Risk of multiple sclerosis after head injury: record linkage study. J Neurol Neurosurg Psychiatry 2006; 77: 351-353.
17. Pfleger CC, et al. Head injury is not a risk factor for multiple sclerosis: a prospective cohort study. Mult Scler 2009; 15: 294-298.

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