1. Rand Sports Questions

What is the role of calcium in muscle contraction? A. calcium binds troponin, moving tropomysin and allowing crossbridge linkages and contraction B. calcium binds troponin allowing for release of ATP and therefore initiating contraction C. calcium binds tropomysin, moving troponin and allowing crossbridge linkages and contraction D. calcium binds tropomysin allowing for release of ATP and therefore initiating contraction

A. calcium binds troponin, moving tropomysin and allowing crossbridge linkages and contraction

The "stinger" injury is (pick one): A. traction or compression of the brachial plexus B. results in bilateral arm weakness and paresthesias C. generally resolves in 6-8 hours D. precludes return to participation in the same contest

A. traction or compression of the brachial plexus

You and your friends were out fishing in the gulf and had a great day catching mackerel and grouper. You decide to have the fish for dinner and even experiment with some sushi that used the fish. By the next day, everyone in your group is experiencing nausea and vomiting and odd neurological symptoms. The cold beer you are drinking feels incredibly hot and the hot coffee feels strangely cold as you hold the cups. What is wrong and what is the treatment?

Ciguatera fish poisoning (or ciguatera) is an illness caused by eating fish that contain toxins produced by a marine microalgae called Gambierdiscus toxicus. People who have ciguatera may experience nausea, vomiting, and neurologic symptoms such as tingling fingers or toes. They also may find that cold things feel hot and hot things feel cold. Ciguatera has no cure. Symptoms usually go away in days or weeks but can last for years. People who have ciguatera can be treated for their symptoms.

Which of the following tests is recommended during a typical high school preparticipation physical? A. Echocardiogram B. Electrocardiogram C. Pulmonary Function testing D. Urine Drug Screen E. Auscultation of the heart in standing and lying position

E. Auscultation of the heart in standing and lying position

Define the four criteria of the Ottawa Ankle Rules in determining when to obtain imaging of ankle injuries.

Ottawa Ankle Rules for ankle or foot X-ray include: a. Inability to bear weight for four steps. b. Age over 55 ( I add in age under 16 to include possibility of physeal injury -- "Braunreiter's fifth criterion") c. Tenderness at the base of the 5th metatarsal. d. Tenderness along posterior edge of either malleolus. e. Tenderness over navicular.

What is the difference between type 1 and type 2 Decompression sickness?

Type 1 DCS shows pain in the joints, marbling of skin and lymph nodes Type 2 DCS will also show neurologic, inner ear and cardiopulmonary symptoms

What motor deficiency would be seen with a L4-5 disc herniation?

Weakness in dorsiflexion of the great toe and inability to heel walk.

In response to intense exercise, catecholamine release will occur. These hormones can lead to several effects in the athlete. Which of the following is due to alpha receptor effect? A. Vasoconstriction B. Cardiac acceleration C. Lipolysis D. Bronchodilatation E. Increased myocardial contractility

Correct: A Vasoconstriction Cardiac acceleration, increased myocardial contractility, and lipolysis are beta1 receptor effects (B,C,E). Bronchodilatation is a beta2 effect (D).

Name 3 juvenile osteochondropathies of the lower extremity (with eponyms) in skeletally immature athletes.

Base of the 5th metatarsal - Iselin's disease Calcaneal apophysis - Sever's disease Tibial tubercle apophysis - Osgood Schlatter's disease Inferior pole of the patella - Sindig-Larson-Johanson disease

A tall thin wide receiver is tackled hard on the field. He comes off the field complaining of shortness of breath and some right sided upper chest pain. His chest wall is non tender to palpation. You choose to observe him and then are distracted by another injury on the field. On your return, you find him markedly short of breath. He is mildly cyanotic, has distended neck veins and you note the trachea deviated to the left. What diagnosis are you most concerned about and what is the indicated emergency procedure?

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Give 3 physical exam cardiac auscultation maneuvers that can help distinguish hypertrophic cardiomyopathy murmurs from benign flow murmurs.

1. Valsalva increases HCM murmur, Decreases flow murmur 2. Standing increases HCM murmur, Decreases flow murmur 3. Squatting Decreases HCM murmur, Increases Flow murmur

A collegiate swimmer develops medial winging of the scapula. If the EMG and nerve conduction studies are abnormal, the most likely nerve roots to be involved are? 1. C7, C8, T1 2. C6, C7, C8 3. C5, C6, C7 4. C4, C5, C6 5. C3, C4, C5

3. C5, C6, C7 Classic medial winging of the scapula is due to paralysis of the serratus anterior muscle which is supplied by the long thoracic nerve which holds the scapula to the chest wall and prevents the inferior angle of the scapula from migrating medially. It is innervated by the long thoracic nerve (C5, 6, 7). Surgical treatment often is reserved for those that don't recover by 9 months of physical therapy or up to two years afterwards, and may require muscle transfer to compensate for the loss of serratus function. Lateral winging may be caused by spinal accessory nerve palsy (CN XI, also ventral ramus C2,3,4). The nerve may be injured during neck surgery. This causes trapezius weakness, allowing the inferior pole of the scapula to migrate laterally.

A 45-year-old male presents with altered sensation on the sole of his foot and has weakness in the ability to plantarflex his ankle. Which nerve is involved in his symptoms? A. Sural B. Superficial peroneal C. Deep peroneal D. Femoral E. Tibial

ANSWER: E. Tibial EXPLANATIONS: E. TRUE: The tibial nerve provides cutaneous sensation to the sole of the foot and innervates the muscles involved in plantar flexion of the foot at the ankle (the gastrocnemius and soleus). In the foot, the tibial nerve divides into medial and lateral plantar branches. A. FALSE: The sural nerve is a sensory nerve in the leg made up of collateral branches from the tibial nerve and common fibular nerve. It has no motor function. B and C. FALSE: The superficial and deep peroneal nerves are the two divisions of the common peroneal nerve. The superficial peroneal nerve innervates the peroneus longus and peroneus brevis muscles, as well as most the skin over the greater part of the dorsum of the foot. The deep peroneal nerve supplies muscular branches to the tibialis anterior and the extensors of the digits (which mediate dorsiflexion of the ankle and extension of the foot respectively). It provides sensory innervation to the ankle joint as well as to the webbing between the first and second digits. Damage to the deep fibular nerve, as occurs with traumatic injury to the lateral knee, results in foot drop. D. FALSE: The femoral nerve is located more proximally. It provides motor innervation to the anterior and some of the medial compartments of the thigh. It provides cutaneous sensation to the anterior and lateral thigh via the anterior and lateral femoral cutaneous nerves, respectively.

Patient presents with midfoot pain after playing soccer. States his foot was planted and plantar flexed when stepped on from behind. Ankle exam does not reveal laxity, but he has a positive pronation-abduction stress test. What is the likely diagnosis and how should you manage this injury?

Answer is.....Lisfranc injury I can't. Just look at Orthobullets. A condition characterized by disruption between the articulation of the medial cuneiform and base of the second metatarsal * unifying factor is disruption of the TMT joint complex * injuries can range from mild sprains to severe dislocations * may take form of purely ligamentous injuries or fracture-dislocations * ligamentous vs. bony injury pattern has treatment implications Epidemiology * incidence -* account for 0.2% of all fractures * demographics* - more common in the third decade -* more common in males Mechanism & Pathoanatomy* causes include MVAs, falls from height, and athletic injuries* mechanism is usually caused by indirect rotational forces and axial load through hyperplantar flexed forefoot* hyperflexion/compression/abduction moment exerted on forefoot and transmitted to the TMT articulation* metatarsals displaced in dorsal/lateral direction* Associated conditions* proximal metatarsal fractures or tarsal fractures* Lisfranc equivalent injuries can present in the form of continguous proximal metatarsal fractures or tarsal fractures* Prognosis* missed injuries can result in progressive foot deformity, chronic pain and dysfunction* tarsometatarsal fracture-dislocations are easily missed and diagnosis is criticalAnatomy* Osteology* Lisfranc joint complex consists of three articulations including* tarsometatarsal articulation* intermetatarsal articulation* intertarsal articulations* Ligaments* Lisfranc ligament* critical to stabilizing the second metatarsal and maintenance of the midfoot arch* An interosseous ligament that goes from medial cuneiform to base of 2nd metatarsal on plantar surface* Lisfranc ligament tightens with pronation and abduction of forefoot* plantar tarsometatarsal ligaments* injury of the plantar ligament between the medial cuneiform and the second and third metatarsals along with the Lisfranc ligament is necessary to give transverse instability.* dorsal tarsometatarsal ligaments* dorsal ligaments are weaker and therefore bony displacement with injury is often dorsal* intermetatarsal ligaments* between second-fifth metatarsal bases* no direct ligamentous attachment between first and second metatarsal* Biomechanics* Lisfranc joint complex is inherently stable with little motion due to* stable osseous architecture* second metatarsal fits in mortise created by medial cuneiform and recessed middle cuneiform, "keystone configuration"* in coronal plane, second metatarsal base serves as the cornerstone in a "Roman arch" configuration* ligamentous restraints* see individual ligaments above* Columns of the midfoot* medial column* includes first tarsometatarsal joint* middle column* includes second and third tarsometatarsal joints* lateral column* includes fourth and fifth tarsometatarsal joints (most mobile)Classification* Multiple classification schemes described* none proven useful for determining treatment and prognosisPhysical Exam* Symptoms* severe pain* inability to bear weight* Physical exam* inspection & palpation* medial plantar bruising* swelling throughout midfoot* tenderness over tarsometatarsal joint* motion & stability* instability test* grasp metatarsal heads and apply dorsal force to forefoot while other hand palpates the TMT joints* dorsal subluxation suggests instability* if first and second metatarsals can be displaced medially and laterally, global instability is present and surgery is required* when plantar ligaments are intact, dorsal subluxation does not occur with stress exam and injury may be treated nonoperatively* provocative tests* may reproduce pain with pronation and abduction of forefoot* compartment syndrome* always check for compartment syndrome and take compartment pressures if high suspicionImaging* Radiographs* recommended views* AP, lateral, obliques* stress radiograph* may be helpful to show instability when non-weight bearing radiographs are normal and there is high suspicion* weight-bearing radiographs with comparison view* may be necessary to confirm diagnosis* findings* five critical radiographic signs that indicate presence of midfoot instability* disruption of the continuity of a line drawn from the medial base of the second metatarsal to the medial side of the middle cuneiform* widening of the interval between the first and second ray* medial side of the base of the fourth metatarsal does not line up with medial side of cuboid on oblique view* metatarsal base dorsal subluxation on lateral view* disruption of the medial column line (line tangential to the medial aspect of the navicular and the medial cuneiform)* lateral* non weight-bearing radiographs may show dorsal displacement of the proximal base of the first or second metatarsal* AP* malalignment of medial margin of the second metatarsal base and the medial edge of the middle cuneiform diagnostic of Lisfranc injury* may see bony fragment (fleck sign) in first intermetatarsal space* represents avulsion of Lisfranc ligament from base of 2nd metatarsal* diagnostic of Lisfranc injury* oblique* malalignment of fourth metatarsal and cuboid* CT scan* useful for diagnosis and preoperative planning* MRI* can be used to confirm presence of purely ligamentous injuryTreatment* Stable injuries: cast immobilization for 8 weeks** indications* no displacement on weight-bearing and stress radiographs and no evidence of bony injury on CT (usually dorsal sprains)* certain nonoperative candidates* nonambulatory patients* presence of serious vascular disease* severe peripheral neuropathy* instability in only the transverse plane* Operative* open reduction and rigid internal fixation* indications* any evidence of instability (> 2mm shift)* favored in bony fracture dislocations as opposed to purely ligamentous injuries* outcomes* anatomic reduction required for a good result* primary arthrodesis of the first, second and third tarsometatarsal joints* indications* purely ligamentous arch injuries* outcomes* level 1 evidence demonstrates equivalent functional outcomes and decreased rate of hardware removal or revision surgery compared to primary ORIF* primary arthodesis is an alternative to ORIF in patients with any evidence of instability with possible benefits* medial column tarsometatarsal fusion shown to be superior to combined medial and lateral column tarsometatarsal arthrodesis* midfoot arthrodesis* indications* destabilization of the midfoot's architecture with progressive arch collapse and forefoot abduction* chronic Lisfranc injuries that have led to advanced midfoot arthrosis and have failed conservative therapy

The instability pattern associated with tears of the lunotriquetral ligament is: A. volar intercalated segment instabilty (VISI) B. dorsal intercalated segment instability (DISI) C. ulnar translocation (UT, NOT the university) D. distal radioulnar joint instability E. pisohamate instability

Answer: A volar intercalated segment instabilty (VISI) Injuries to the lunotriquetral ligaments may range from sprain to partial tear to complete tear with or without carpal malalignment. The carpal instability associated with this injury is a volar intercalated segment instability deformity.

While completing the PPE paperwork on a Down syndrome athlete, you review the report of the lateral c-spine x-rays to screen for atlanto-axial instability. You recall that a normal atlantodens interval (ADI) is A. 0 mm B. <2.5 mm C. >4.5 mm D. >6.0 mm

Answer: B. <2.5 mm AAI is screened with lateral c-spine films in flexion, extension, and neutral. The ADI, the distance between the odontoid process of the axis and the anterior arch of the atlas, is normally less than 2.5 mm. Greater than 4.5 mm is abnormal. If greater than 6.0 mm, the athlete should be restricted from all strenuous activities and evaluated for surgical intervention.

A 35 year old male playing basketball falls and sustains an elbow injury. Clinical exam and radiographs reveal a completely nondisplaced fracture involving 65% of his coronoid process. He has no associated injuries or instability. The recommended treatment is which of the following? A. immob in 90 deg flexion and neutral rotation B. immob in 120 deg flexion and neutral rotation C. immob in 120 deg flexion and supination D. immob in 120 deg flexion and pronation E. ORIF

Answer: E ORIF Fractures of the coronoid are caused by humeral hyperextension and are associated with dislocation of the elbow 10-33% of the time. Treatment of the coronoid fracture depends on fracture stability pattern, which is defined by amount of coronoid involvement. Greater than 50% involvement requires ORIF, even for nondisplaced fractures; less than 50% may be treated with cast immobilization if stable.

Why would an athlete supplement with Human Chorionic Gonadotropin?

Answer: There are multiple reasons, including the stimulation of endogenous testosterone production, and to prevent testicular atrophy during prolonged use of anabolic steroids. In addition, the administration of HCG with testosterone leads to normalization of the testosterone: epistestosterone ratio that is used to detect the presence of exogenous AAS, ( anabolic androgenic steroid)

Please give 2 individual risk factors for decompression sickness. Think of situations or characteristics of the dive for the enviromment and medical or personal issues or behaviors for the individual.

Atrial septal defect (PFO) showing left-to-right shunt. A right-to-left shunt may allow bubbles to pass into the arterial circulation. The following individual factors have been identified as possibly contributing to increased risk of DCS: · dehydration - Studies by Walder concluded that decompression sickness could be reduced in aviators when the serum surface tension was raised by drinking isotonic saline, and the high surface tension of water is generally regarded as helpful in controlling bubble size. Maintaining proper hydration is recommended. · patent foramen ovale - a hole between the atrial chambers of the heart in the fetus is normally closed by a flap with the first breaths at birth. In about 20% of adults the flap does not completely seal, however, allowing blood through the hole when coughing or during activities that raise chest pressure. In diving, this can allow venous blood with microbubbles of inert gas to bypass the lungs, where the bubbles would otherwise be filtered out by the lung capillary system, and return directly to the arterial system (including arteries to the brain, spinal cord and heart). In the arterial system, bubbles (arterial gas embolism) are far more dangerous because they block circulation and cause infarction (tissue death, due to local loss of blood flow). In the brain, infarction results in stroke, and in the spinal cord it may result in paralysis. · a person's age - there are some reports indicating a higher risk of altitude DCS with increasing age. · previous injury - there is some indication that recent joint or limb injuries may predispose individuals to developing decompression-related bubbles. · ambient temperature - there is some evidence suggesting that individual exposure to very cold ambient temperatures may increase the risk of altitude DCS. Decompression sickness risk can be reduced by increased ambient temperature during decompression following dives in cold water. · body type - typically, a person who has a high body fat content is at greater risk of DCS. This is due to nitrogen's five times greater solubility in fat than in water, leading to greater amounts of total body dissolved nitrogen during time at pressure. Fat represents about 15-25 percent of a healthy adult's body, but stores about half of the total amount of nitrogen (about 1 litre) at normal pressures. · alcohol consumption - although alcohol consumption increases dehydration and therefore may increase susceptibility to DCS,[31] a 2005 study found no evidence that alcohol consumption increases the incidence of DCS.

A day after being struck with a pitched ball on the ulnar aspect of the left wrist and hand, a professional baseball player develops "pins and needles" in the small and ulnar half of his ring fingers. He finds it extremely difficult to grab the bat to participate in batting practice. After x-rays demonstrate no acute abnormalities of the left wrist and hand, he is diagnosed with Guyon's canal syndrome. What two bones form Guyon's canal? A. Pisiform and Triquetrum B. Pisiform and Hamate C. Hamate and Lunate D. Triquetrum and Lunate

B. Pisiform and Hamate Guyon's canal syndrome is entrapment of the ulnar nerve as it passes through a tunnel in the wrist called Guyon's canal. The canal is formed by the most lateral bones of the proximal and distal carpal rows, the pisiform and hamate respectively, and the ligament that connects them. The ulnar nerve is accompanied by the ulnar artery as it passes through this canal. Symptoms can include a sensation of pins and needles in the small and ulnar half of the ring fingers, decreased sensation in the same distribution as well as weakness of the small muscles of the palm and the muscle that pulls the thumb towards the palm.

What is the boutonniere deformity of the finger and how is it different from the pseudoboutonniere deformity?

Boutonniere deformity is the rupture of the central slip of the extensor digitorum commons muscle as it crosses over the PIP joint. It is an acquired lesion of the extensor mechanism, in which the PIP joint develops a flexion deformity and the DIP joint develops an extension deformity. In time, these deformities become fixed, as the surrounding ligaments and volar plate become contracted. The patient is able to flex the distal joint, which is not the case in a pseudoboutonniere deformity, which is a flexion contracture of PIP joint without hyperextension of DIP joint.

Which of these is true of normal tendon structure? A. Vascular and lymphatic supply is contained in the loose connective tissue sheath of the endotenon B. Collagen type III makes up about 80% dry weight of the tendon C. Water accounts for about 70% of tendon mass D. The osseotendinous junction is the weakest part of the muscle/tendon unit E. The majority of the blood flow to the tendon midportion arises from vessels originating at the myotendinous junction

C. Water accounts for about 70% of tendon mass Vascular supply is mostly in the paratenon/synovial sheath. Collagen type I makes up 80% dry weight of the tendon Myotendinous junction is the weakest region of the muscle-tendon unit

What is the national organization that exists to help you manage divers with decompression sickness? How do you contact them?

Call the DAN Emergency Hotline Call +1-919-684-9111 to talk to an expert in diving medicine. You may call collect. DAN medical staff is on call 24 hours a day to handle diving emergencies. When You Call the DAN Emergency Hotline: 1. Tell the operator you have a diving emergency. The operator will either connect you directly with DAN or have someone call you back at the earliest possible moment. 2. The DAN staff member may make an immediate recommendation or call you back after making arrangements with a local physician or the DAN Regional Coordinator. DAN Regional Coordinators are familiar with chamber facilities in their area, and because they're qualified in diving medicine, they make recommendations about treatment. 3. The DAN staff member or Regional Coordinator may ask you to wait by the phone while he / she makes arrangements. These plans may take 30 minutes or longer, as several phone calls may be required. This delay should not place the diver in any greater danger. However, if the situation is life-threatening, arrange to transport the diver immediately to the nearest local medical facility for immediate stabilization and assessment of his or her condition. Call the DAN Emergency Hotline (+1-919-684-9111) if you need evacuation assistance through DAN TravelAssist.

Which macronutrient subtype can act as a substrate for anaerobic metabolism for ATP production?

Carbohydrates are the only one that the body can use to generate ATP anaerobically.

A Segond fracture is pathogonomic for which ligamentous injury A. Medial collateral ligament B. Lateral collateral ligament C. Anterior cruciate ligament D. Posterior cruciate ligament

Correct: C Anterior cruciate ligament A Segond fracture is a vertical avulsion fracture of the lateral tibial condyle where the lateral capsular ligament attaches. It occurs with anterior cruciate ligament injuries.

A 22 year old male American football player suffers a hyperpronation injury of the right forearm and this results in a first-time dorsal-ulnar dislocation of the distal radioulnar joint (DRUJ). Fracture is ruled out by radiographs and adequate closed reduction is achieved. How should this injury be managed? A. Thumb spica splint for 2 weeks B. Short arm cast for 4 weeks C. Long arm cast for 6 weeks D. Orthopedic referral for arthrodesis

Correct: C Long arm cast for 6 weeks The long arm cast for 6 weeks is the correct management for a distal radioulnar joint dislocation without fracture. Both the thumb spica a) and short arm b), would not provide the correct immobilization of supination and pronation of the forearm that is necessary. Orthopedic referral d), is also incorrect as the question indicates this is not a recurrent injury and adequate reduction is achieved without fracture

A 38-year-old competitive slalom skier is making a turn to the left around a pole. The right ski sticks in the snow, causing external rotation of the right ski and boot. Which of the following ankle ligaments is most likely to be the initial structure injured? 1. Calcaneofibular ligament 2. Anterior inferior tibiofibular ligament 3. Deep deltoid ligament 4. Superficial deltoid ligament 5. Anterior talofibular ligament

Correct answer is 2. Anterior inferior tibiofibular ligament High ankle sprains are external rotation injuries of the ankle and syndesmosis. They often occur in competitive slalom skiers, and the anterior inferior tibifibular ligament is the initial ligament injured. External rotation of the foot on the leg causes the talus to press against the lateral malleolus. This rotational movement first affects the anterior inferior tibiofibular ligament of the syndesmosis. If external rotation continues, the interosseous membrane and then the posterior tibiofibular ligament will be injured. The review article by Clanton indicates the anterior inferior tibiofibular ligament is the most commonly injured ligament in ankle sprains where the mechanism is of injury is external rotation. This occurs regardless of the position of the foot at the time of injury. Pure dorsiflexion causes the interosseus ligaments to tighten and abduction on a neutral ankle can cause interosseus injury when preceded by deltoid injury or medial malleolus fracture.

All of the following are physiologic adaptations to aerobic conditioning except: A. Increased ventricular wall thickness and decreased internal diameter B. Larger stroke volume C. Lower-end systolic volume D. Lower resting heart rate

Correct answer is A. Increased ventricular wall thickness and decreased internal diameter Cardiac adaptations include increased ventricular wall thickness and INCREASED internal diameter, leading to increased stroke volume, reduced end diastolic volume and a reduced heart rate at rest.

Red flag signs and symptoms of a concussion injury during on field assessment include all of the following except: a. Dizziness b. Progressive headache c. Vomiting d. Observed loss of consciousness

Correct answer is a) dizziness. The signs and symptoms of concussion injury raising concerns for immediate emergency evaluation and possible imaging include items b-d, diplopia, severe neck tenderness, burning in the extremities, seizure, deterioration of mental/physical condition, or inappropriate, restless, agitated behavior. In cases where any of these symptoms present themselves, it is prudent to refer for emergency assessment.

Which of the following statements is correct in predicting recovery from concussion injury? a. Learning disability or ADHD pre-injury increases length of recovery time b. There is no effect on recovery time with pre-existing anxiety or depression c. The severity and number of acute post injury symptoms is directly correlated to recovery time d. Females have been definitely proven to have longer recovery times

Correct answer is c) the higher the severity and number of symptoms, the longer the injury requires on average to recover. There is no currently known connection between the length of recovery from injury if pre-existing LD or ADHD is present, although at one time it was postulated. There may be a longer recovery however, if there is underlying mental health disorders such as depression and anxiety. There has been suggestion that female gender increases recovery time, but there is no definitive data proving that to be true.

A 14-year-old female presents for a pre-sports physical. She complains of back discomfort when she "sits at school for a long time." Her exam reveals scoliosis with a left-sided curve. An MRI of the spine is indicated to rule out which of the following conditions? A. Intraspinal syrinx B. Narrowing of disk space C. Schmorl nodes D. Irregularities in vertebral endplates E. Loss of anterior vertebral height

Correct answer: (A) Intraspinal syrinx. Explanation: About 80% of scoliosis cases appear as a right thoracic curve. A left-sided pattern is associated with risk for intraspinal syrinx or tumor, which can be detected on MRI. The remainder of findings are associated with Schneurmann kyphosis, the 2nd-most common cause of spinal deformities in pediatrics. A scoliotic curve must measure greater than or equal to 10 degrees on a spinal radiograph via the Cobb method (a special tool that measures the angle on radiograph) to meet the criteria for diagnosing scoliosis, but most patients do not exhibit clinically significant respiratory symptoms until the curves measure 60 to 100 degrees. The USPSTF states that treating idiopathic scoliosis during adolescence leads to health benefits in only a small fraction of patients. Most of the cases detected through screening do not become clinically significant, and scoliosis that requires aggressive treatment/operative treatment is likely to be detected without screening because these patients are eventually symptomatic.

You are seeing a 6 year old for a limp. It was initially intermittent but has been becoming more consistent. He does not complain of pain. There was no known injury and he does not play organized sports. He has no fever, no preceding illness, and is otherwise well. The most likely diagnosis is: A. Slipped capital femoral epiphysis B. Legg Calve Perthes disease C. Neoplasm D. Juvenile Idiopathic Arthritis E. Toxic synovitis

Correct answer: (B) Legg Calve Perthes disease. Explanation: Legg Calve Perthes disease is an avascular necrosis of the femoral head which occurs in children ages 2-12 (more commonly ages 4-8). It is more common in boys and classically presents as a painless limp. Hip radiographs (AP and frog leg lateral) are helpful in making the diagnosis. Treatment includes limiting weight bearing, bracing, and surgery. (A) Slipped capital femoral epiphysis classically presents as hip or knee pain and limp in an overweight teenager. It is diagnosed by getting AP and frog leg lateral radiographs and the treatment is usually surgical. (C) Neoplasm: in this age, leukemia could present with a limp secondary to bone pain, although usually fever is present. Primary bone neoplasms (osteosarcoma and Ewing's sarcoma) usually occur in older children/ teenagers. (D) Juvenile Idiopathic Arthritis can present with a limp. Often the symptoms are worse in the morning and improve with activity. When the hip is involved, it is often held in a position of flexion, abduction, and external rotation and there is often pain on range of motion. The child is also more likely to have signs of systemic illness. (E) Toxic synovitis usually occurs in a younger child and presents as hip or knee pain and a limp. There is often a history of a preceding viral illness. The child will resist rotation of the hip. Treatment is supportive and the condition self resolves.

Which of the following is true of weight loss and metabolism during exercise? A. Maximal fat oxidation occurs at high intensity exercise. B At maximal exercise intensity, blood flow increases to adipose tissues. C. Excess post exercise oxygen consumption is highest after long duration of low intensity exercise D. Training adaptations lead to decreased use of fat at the same exercise intensity. E. Fat utilization is decreased during high intensity exercise.

Correct answer: (E) Fat utilization is decreased during high intensity exercise. Explanation: There is a counterintuitive drop in utilization of fat during high intensity exercise that is caused by several factors, including the shunting of blood flow away from adipose tissue during maximal exercise intensity. This causes trapping of fatty acids in the adipose capillary beds, preventing fatty acids from being carried to muscle to be used. (A) Fat oxidation is maximal at low to moderate levels of exercise intensity. (B) Blood is shunted from adipose tissues during exercise at maximum intensity. (C) Excess post exercise oxygen consumption refers to an elevated metabolic rate after exercise that results from energy utilized for muscle cell recovery and glycogen replacement. It is greatest when exercise intensity is high and greater after high intensity interval training compared to exercise for a longer duration at lower intensity. (D) Training adaptations lead to increased use of fat at the same exercise intensity.

Which of the following is correct? A. Congenital sensorineural deafness is associated with long QT syndrome B. Albuterol should be encouraged in patients with suspected congenital prolonged QT interval C. Taking Ciprofloxacin prolongs the QT interval D. Athletes with known prolonged QT can be cleared to run the 110 meter hurdles, but not to run the 1500 meters in track and field

Correct: A Congenital sensorineural deafness is associated with long QT syndrome Sudden cardiac death in young athletes is rare. Long QT syndrome is not the most common cause of sudden cardiac death, but there are important clinical issues related to long QT. Most deaf children and adults do not have long QT syndrome. There is an association with deafness, however. This is an inherited genetic association. Many common medications, including some stimulants, prolong the QT interval. This is particularly important for patients with a borderline QT interval or those currently using other medications where an altered QT interval is a potential side-effect. Drug-drug interactions can affect the QT enough to lead to disaster. Albuterol has been shown to prolong the QT interval in addition to causing hypokalemia. Cardiac clearance for sprinters and hurdlers is essentially the same as cardiac clearance for middle distance runners. Sprinters may run many miles during a work-out, and distance runners will sprint during their training and races. Ciprofloxacin has been linked to injury to soft tissues, including tendon rupture, but not to long QT syndrome.

Where is the purest area for sensory testing of the radial nerve on the hand located? A. Dorsal web between the thumb and the index finger B. Radial side of the hand C. Dorsum of the wrist D. The thenar eminence

Correct: A Dorsal web between the thumb and the index finger The radial nerve provides sensation to the radial side of the hand. Thus, secondary to significant overlap the purest area for testing the radial nerve is the web space between the thumb and index finger. B is incorrect due to overlap. C is incorrect because the posterior interosseous nerve supplies this area. D. is incorrect because innervation to this area is supplied by the palmer cutaneous branch of the median nerve.

A 23 year old professional snowboarder falls while making a jump. He lays on the snow and does not get up. When ski patrol reaches him, he is conscious and complaining of back pain. He is boarded and collared and transported to the nearest hospital. He is neurologically intact. A plain film radiograph shows a compression fracture of T12. What is the appropriate course of treatment? A. Obtain a CT scan to further assess the fracture. B. Place the patient in a TLSO brace and perform follow-up x-rays in 2 weeks. C. Consult the neurosurgeon for surgical correction of the fracture. D. Consult interventional radiology for kyphoplasty of the fracture.

Correct: A Obtain a CT scan to further assess the fracture. Burst fractures can be misdiagnosed as mere compression fractures with plain film radiographs. A CT scan can give more diagnostic information than plain radiographs. Lamina and articular process fractures are typically missed on plain films. If the fracture is established to be stable, the patient can be placed in a TLSO brace and followed with x-rays. Answer b did not assess whether the fracture was stable or not before placing the patient in a TLSO brace. If the fracture is established to be unstable or the patient has neurologic deficits, the neurosurgeon should be consulted for surgical stabilization with or without decompression as needed. Answer c did not assess the stability of the fracture. In answer d, the patient was not assessed further to diagnose the burst fracture and was treated as a compression fracture.

A 20 year old male soccer player presents with 4 months of right groin pain. Its described as a deep ache just to the side of his pubic bone and radiates down the medial thigh when he plays soccer. He also reports some paresthesias along the medial thigh after exercise and difficulty with jumping. On exam he is weak on hip adduction and tender with stretching his adductors. You decide to order an EMG which shows a denervation pattern of the adductor longus and brevis consistent with entrapment of which nerve? A. Obturator Nerve B. Ilioinguinal Nerve C. Superior Gluteal Nerve D. Inferior Gluteal Nerve

Correct: A Obturator Nerve This is a classic presentation of obturator nerve entrapment. It has been found most commonly in males who play soccer or Australian rules football. EMG is the test of choice for diagnosis. Its believed that a chronic adductor tendonopathy leads to fibrosis and fascial adhesions which eventually entrap the nerve. Conservative measures have not been found to be effective and surgery remains the preferred treatment.

A 15 year old High School football player was hit on his blind side as he was running with the football. He landed on the side carrying the football, and the tackler landed on top of him. After needing assistance to the sideline, he became tachycardic, hypotensive and there was a clear change in his mental status. He was transported to the nearest hospital where he was re-evaluated. The patient is initially stabilized with IV hydration. However, the patient's pain is persistent. From the list below, which testing type is LEAST appropriate? A. CT Abdomen and pelvis B. Peritoneal lavage C. MR abdomen D. Plain films of abdomen and chest E. Abdominal ultrasound

Correct: C MR abdomen In the acute setting, any testing needs to be quick, efficient, and provide information about the severity of injury. MR of the abdomen is not quick, and the other tests listed will help the clinician identify a possible need for surgery.

A mother brings her 15 year old son in for evaluation of curvature of the back noted by the Athletic Trainer at his school. He has no complaints about back pain and a normal neurological exam. After your evaluation, to include a scoliosis radiographic evaluation, you identify that he has dextroscoliosis with a Cobb angle of 15 deg. His Risser classification is Risser 3. On further exam his leg lengths are equal. Appropriate recommendations for follow-up evaluation include: A. Follow up evaluation in 6 months B. Refer for Physical Therapy C. Refer to a Pediatric Spine Surgeon D. Order a lumbar MRI E. Only follow up as needed if symptomatic

Correct: A Only follow up as needed if symptomatic Scoliosis is a common adolescent diagnosis. Many of these adolescents are identified in school, during pre-participation physical exam or incidentally during evaluation of back or related complaints. Although most scoliosis does not progress or require anything more that observation the adolescent growth spurt is a period that these curvatures can progress. Peak growth velocities typically occur during Tanner 2-3 in girls and Tanner 3-4 in boys. Generally the peak growth velocity period is ages 12-14 in girls and 13-15 in boys. A more objective measure of growth is the Risser classification observing the closure of the iliac apophysis. The Iliac apophysis develops early in adolescence and can be observed as a radiolucent line over the iliac crest on a pelvic AP view. This apophysis fuses from lateral to medial such that Risser 0 is no observed fusion, Risser 1 is fusion of the lateral 25%, Risser 2 up to 50%, Risser 3 up to 75%, Risser 4 up to 100% and Risser 5 complete fusion. When peak growth velocity has passed and curvature is equal or less that 30 deg the likelihood of progression is very low. Magnetic resonance imaging should be obtained in patients with an onset of scoliosis before eight years of age, rapid curve progression of more than 1 degree per month, an unusual curve pattern such as left thoracic curve, neurologic deficit, or pain

An avid 25 year old male cyclist cycling 120 miles/week complains of left testicular pain and some perineal numbness for the past two months. He has never experienced this before and reports no recent change in his equipment, training intensity or duration in the recent month. He reports his pain as 6-8 out of 10 and is relieved by standing or walking. He has discussed this with his cycling teammates and they have advised he consider changing his seat set-up and brand to a split seat to relieve his symptoms. The likely cause of his symptoms is: A. Pudendal Nerve Compression B. Adductor Tendinopathy C. Ischial Periositis D. Scrotal Ischemia E. Testicular Torsion

Correct: A Pudendal Nerve Compression Perineal symptoms including numbness of the genitalia were reported in 50%-91% of all cyclists and erectile dysfunction was reported in 13%-24% of all cyclists. Causes are related to compression of blood flow, soft tissue or nerve compression. The interaction between the bicycle seat (saddle) and the perineum is the culprit in all cases of perineal symptoms in cyclists. The interaction is dependent on the vertical (downward) and shear (backward) force of the perineum on the saddle, the weight of the rider, the height and angle between the saddle and the handlebars, the saddle tilt angle, and the shape of the saddle. The narrow saddle is associated with more reduction of perineal blood flow ant therefore more symptoms. In extreme cases of perineal pain, Pudendal Nerve entrapment can be a source of this pain. Some cyclists with induced pudendal nerve pressure neuropathy gained relief from improvements in saddle position and riding techniques or fluoroscopic guided injections.

Which of the following statements is true regarding scapular fractures? A. Reduction of an isolated displaced glenoid neck fracture is usually not necessary to achieve a good clinical outcome B. Non-surgical treatment is an option for glenoid fractures that involve 50% or less of the articular surface C. Non-operative treatment of glenoid fractures consists of immobilization with a sling and swathe for at least 2 weeks D. Non-operative treatment of glenoid fractures consists of immobilization with a sling for at least 2 weeks E. Sports-related injury is responsible for almost half of the cases of scapular fractures

Correct: A Reduction of an isolated displaced glenoid neck fracture is usually not necessary to achieve a good clinical outcome The best answer is A. Because of the large range-of-motion of the glenohumeral joint reduction of an isolated displaced glenoid neck fracture is usually not necessary to achieve a good clinical outcome. Association of a glenoid neck fracture with a displaced clavicle fracture or coracoclavicular ligament tear usually results in an unstable injury and therefore will require operative management. Surgical treatment should be strongly considered for involvement of more than 25% of the articular surface. Non-operative treatment of glenoid fractures involves use of a sling for comfort and early mobilization. Motor vehicle accidents are the most common cause of scapular fractures; they are relatively rare in sports since they require a high level of force to occur.

A 26 year old African American female presents to the medical treatment tent you are staffing at a large cross country ski race in upper Wisconsin. She is complaining of painful edematous purple lesions on her face. She is in excellent health, an avid cross country runner from southern Illinois. She denies pregnancy or any medical problems. She does not seem to be in any acute distress. She and her friends have been taking "nips" out of a pocket flask containing Blackberry brandy. Which of the following is true? A. She has classic Pernio or chilblain B. She should immediately stop the race and be transported to the main medical tent 10 kilometers away via ambulance C. She can go back out after applying protective UV cold barrier ointment on her face D. She should quickly rewarm her face by sitting next to the propane gas warmer in the tent E. It is best to warm her face slowly using cool water then to slowly apply heated water to prevent further tissue damage

Correct: A She has classic Pernio or chilblain The patient has classic Pernio, or chilblain, which is characterized by localized inflammatory lesions that result from acute or repetitive exposure to cold. The lesions are edematous, often purple, and are most common in young women. It is one of the milder forms of a cold injury. First degree frostbite is characterized by a central area of pallor and anesthesia of the skin surrounded by edema. A second degree frostbite is recognized by blisters containing a clear milky fluid surrounded by edema and erythema. Third degree frostbite differs from second degree frostbite as the injury is deeper and blisters are hemorrhagic. Alcohol use predisposes cold injury. Risk factors include smoking, previous cold injury and exposure of hands and arms to vibration. African-American women may be at increased risk of cold injury. This patient does not have any other physical signs that would require immediate transportation to the main medical tent. The best medical advice would be to simply stop the race at this point, and get her to a warm environment. In some areas protective ointments applied to the face have been advocated, this may actually increase the risk of a cold injury. The area should be warmed as soon as possible and it is best to get the patient into a warm environment and remove wet clothing. Stoves or open fires used to rewarm frostbitten tissue is not recommended as the tissue is insensitive and thermal injury can occur. If necessary, it is best to rewarm the area in a water bath 40°C to 42°C which feels warm, but not hot, to the patient.

A patient presents to your office unable to dorsiflex his great toe. Which of the following is true? A. The extensor hallucis longus which inserts on base of the distal phalanx of the great toe is the muscle responsible for extending the great toe B. The motor function for this is from L4 and L5 C. The muscles that allow this action are all contained in the lateral compartment of the lower leg D. The muscles that allow this action are inervated by the tibialis anterior nerve

Correct: A The extensor hallucis longus which inserts on base of the distal phalanx of the great toe is the muscle responsible for extending the great toe The extensor hallus longus originates on the medial fibula in the interosseous membrane and it inserts onto the base of the distal phalanx of the great toe. It is inervated by the deep peroneal nerve, not the tibialis anterior nerve and it is inervated by L5, not L4. The muscles that act as extensors of the foot and toe are the anterior compartment of the lower extremity. The lateral compartment contains the proneous longus, proneous brevis and the peroneal nerve.

Which of the following statements is true regarding pronator syndrome? A. The most common cause is mechanical compression by the pronator teres B. Athletes with pes planus are at increased risk for pronator syndrome C. Athletes with pronator syndrome are at increased risk for ankle sprains D. An MRI is often helpful in making the diagnosis E. Pronator syndrome is caused by compression of the radial nerve

Correct: A The most common cause is mechanical compression by the pronator teres Pronator syndrome (a.k.a. median nerve compression syndrome) is an entrapment neuropathy of the median nerve (Answer E is incorrect). Sites of compression include: 1) supracondylar process/ligament of Struthers; 2) lacertus fibrosus; 3) pronator teres; and/or 4) flexor digitorum superficialis arcade. Pronator syndrome is often triggered by repetitive elbow motions such as sculling. Patients present with anterior proximal forearm pain and numbness in the volar forearm and radial 3 and 1/2 digits. Electromyogram (EMG) and nerve conduction studies of the median nerve around the elbow can be technically difficult, and are often normal. They can be made more sensitive by testing after a session of the inciting activity. MRI is usually not helpful in making the diagnosis except in the rare case of a mass compressing the nerve (Answer D is incorrect). Answers B and C are incorrect because they refer to the lower extremity.

Which of the following structures is the primary static stabilizer for preventing lateral subluxation of the patella? A. medial patellofemoral ligament B. vastus medialis obliquus (VMO) C. medial patellotibial ligament D. superficial oblique retinaculum

Correct: A medial patellofemoral ligament Investigations to determine the soft tissue restraints to lateral subluxation of the patella identified the patello-femoral ligament as the primary stabilizer. At 20 degrees of flexion, the PFL contributed 60% of the total restraining force, while the patello-meniscal ligament and lateral retinaculum contributed 13% and 10%, respectively. The medial patellotibial ligament and superficial fibers of the medial retinaculum were not found to be functionally important in preventing lateral subluxation.

A 27 year old female presents to your clinic today complaining of bilateral lower extremity pain that began about 1 month ago. She would like to run a marathon and has been training for the past 3 months. Initially, she felt a dull ache during the first mile of her run that she was able to run through. Gradually, the pain has increased and she now feels it during and at the end of her run. She did try taking a week off and the pain completely subsided but once she started running again, the pain returned. Her physical exam findings are remarkable for diffuse tenderness along the posterior medial aspect of the middle and distal tibia on both lower extremities. Her neurovascular exam is normal. You do not find focal or point tenderness and there are no abnormalities found on x-ray. You make the diagnosis of medial tibial stress syndrome (shin splints) and recommend which of the following treatments: A. Relative rest to allow the patient to be pain free followed by a gradual increase in exercise intensity and duration on soft, level surfaces as long as she remains aymptomatic B. Weight training avoiding cardiorespiratory fitness C. Cam-walker style boot for 4-6 weeks with the application of a bone-stimulator unit at night D. A cool down routine should be initiated emphasizing stretching before and after exercise

Correct: A relative rest to allow the patient to be pain free. The pathogenesis of this syndrome has not been clearly defined; however, excessive stress at the fascial insertion of the medial soleus or flexor digitorum longus muscles appears to be a likely source. Characteristic physical exam findings allow this syndrome to be diagnosed clinically. Stress fractures can be distinguished from MTSS (Medial Tibial Stress Syndrome) because they typically present with focal point tenderness and can be seen on x-ray. A bone scan could also be used to differentiate these two conditions. Exertional compartment syndrome would also be considered in this differential diagnosis, however, this condition is usually asymptomatic on exam. Answer A is correct: The onset of MTSS usually occurs after the initiation of a new running program with a rapid progression in intensity and duration. A reduction in both intensity and duration should alleviate the pain. It is generally recommended that these parameters may be increased approximately 10% per week so that the original training duration or distance is achieved in 3-6 wk. Training may be increased more rapidly as long as the patient remains pain free; however, this increases the chance of reoccurrence. Answer B is incorrect, there is no evidence supporting weight training in the treatment of MTSS, although maintaining cardiorespiratory fitness will be important to the athlete and can often be achieved asymptomatically in other activities such as swimming or cycling. Answer C is incorrect. Immobilization is usually not required, unless briefly to allow pain free activity but certainly not for 4-6 weeks. Answer D is incorrect. Heel cord stretching has been suggested to help prevent this injury therefore a warm-up routine including stretching may be recommended. A review of the literature failed to demonstrate a significant benefit. Ice massage can be helpful at reducing the patient's pain.

A 21 year old type 1 diabetic athlete begins training for a 50 mile bike ride with a partner. She uses an insulin pump and is experienced with running cross country in high school. During her first 30 mile ride she experiences symptoms of hypoglycemia at 25 miles and almost falls before stopping. She is confused and her BS is 40. What is the most appropriate immediate action? A. Eat a banana or sports bar B. Administration of glucagon by her partner C. Drink a carbohydrate sports drink then quickly resume riding to reach a safe destination D. Drink 8 ounces of water to improve volume status

Correct: B Administration of glucagon by her partner Glucagon has most rapid onset of action in a confused, uncooperative athlete. Hyperinsulinemia due to the pump is the cause. A reduction of infusion by 50% is needed for longer bouts of exercise. A solid carbohydrate food will be absorbed too slowly to prevent potential serious CNS complications in this emergency. Resumption of exercise without adjusting the continuous pump plus a carbohydrate bolus will result in progressive hypoglycemia and CNS decline. Dehydration may exist for various reasons but carbohydrate fuel is absolute necessity in this situation.

A volleyball player presents with right shoulder pain after attempting to spike the ball in practice. The player is holding her arm in slight abduction and external rotation. The humeral head is palpated anteriorly. Before proceeding, it is important to first evaluate the: A. Supraclavicular nerve by testing sensation over the clavicular area B. Axillary nerve by testing sensation over lateral aspect of the shoulder C. Radial nerve by testing sensation over inferolateral arm D. Medial cutaneous nerve by testing sensation over medial aspect of arm

Correct: B Axillary nerve by testing sensation over lateral aspect of the shoulder Axillary nerve injury is a known complication of anterior dislocations of the shoulder. Before proceeding with x-ray and/or reduction, it is important to document neurovascular status by specifically checking sensation over the superior lateral aspect of arm (i.e. over deltoid).

Which pair of objective findings is most suggestive of increased intracranial pressure? A. Tachycardia, low blood pressure B. Bradycardia, elevated blood pressure C. Tachycardia, elevated blood pressure D. Bradycardia, low blood pressure

Correct: B Bradycardia, elevated blood pressure Signs and symptoms that suggest a rise in ICP including headache, nausea, vomiting, ocular palsies, altered level of consciousness, and papilledema. If mass effect is present with resulting displacement of brain tissue, additional signs may include pupillary dilatation, abducens (CrN VI) palsies, and the Cushing"s triad. The Cushing"s triad involves an increased systolic blood pressure, a widened pulse pressure, bradycardia, and an abnormal respiratory pattern.

A 12 year old Elite level gymnast that is home schooled presents to your office after three months of continued back and neck pain despite a thorough evaluation without findings and despite adequate radiologic and physical examination. After separating the child and parent, the child tells you that she just wants to spend time with her friends and she wants to go to the mall and be a normal 12 year old. Which of the following is true? A. Elite level gymnasts often present with back pain and should be pushed to "work through it" since she has a negative workup B. Burnout is common in elite level child athletes as they often are subjected to excessive training loads during peak emotional and physical development times in pre-adolescence and adolescence C. Pressure from coaches and parents rarely leads to burnout in elite child athletes and only pushes them to work harder D. Respecting the child's request but not discussing it with the parent is best for the patient's recovery as the parent wants the child to continue training if the workup is negative E. A psychological consult is indicated as the athlete is obviously depressed

Correct: B Burnout is common in elite level child athletes as they often are subjected to excessive training loads during peak emotional and physical development times in pre-adolescence and adolescence Overtraining or "burnout" is the result of excessive training loads, psychological stress, or inadequate recovery. Back pain that has a negative work up (A) needs to be evaluated for secondary concerns like psychological issues or overtraining. Burnout may occur in the elite child athlete when the limits of optimum adaptation and performance are exceeded. Clearly, excessive pain should not be a component of the training regimen. Elite level athletes often have a large amount of pressure from coaches and parents (C), and this will often lead to burnout if the child does not have the same goals as the parent or coach. Not discussing the child's concerns with the parent (D) would be detrimental to the child's care; psychosocial concerns should be discussed with the parent in order to approach her back pain from a multifaceted direction. A psychological consult is not indicated at this time (E), but if the child has depressive symptoms or is injuring herself for secondary gain, accessory consultation may be warranted.

A 15 year old rugby player presents with a left 4th finger injury. She is unable to flex the DIP and there is fullness along the flexor tendon. What is the appropriate course of treatment? A. Ice and NSAIDs B. Early surgical intervention C. Custom splint during games D. Buddy taping to left third finger

Correct: B Early surgical intervention A jersey finger injury is caused by the avulsion of the flexor digitorum profundus tendon, and the athlete would be unable to flex the DIP, most commonly occurring in the ring finger. The mechanism of injury would include hyperextension of the DIP joint on attempted flexion of the finger. There may be fullness at the flexor tendon sheath from hematoma formation. Treatment is operative and requires reattachment of the FDP tendon to its insertion in the distal phalanx. The flexion deformity of the DIP joint which presents as an inability to extend the DIP joint is called a mallet finger. This is usually caused by the sudden forceful flexion of the DIP joint. It can be treated non-operatively by splinting in complete extension for 6-8 weeks. Operative management is usually only with large fractures of the distal phalanx. Ice and NSAIDs and buddy taping would not be adequate treatment alone for this injury.

Pain from SI joint dysfunction can be found in all of the regions except: A. Buttocks B. Hip joint C. Pubic symphysis D. Lower abdomen E. Lateral thigh

Correct: B Hip joint In addition to the SI joint and the low back, pain can be felt in the locations in question except the hip joint.

A 21 year old female is brought to the medical tent near the finish line at your community's annual marathon after suddenly collapsing moments after completing the race. Her mental status is normal and her temperature is 38.9 C. She reports feeling slightly lightheaded and has difficulty standing up. Your intial treatment strategy should include which of the following: A. Provide the patient with walking assistance until she no longer feels it is difficult to stand or walk B. Place the patient in a supine position so that both her legs and pelvis are elevated C. IV fluid replacement with 5% dextrose in half normal saline D. IV fluid replacement with 5% dextrose in normal saline E. Active cooling with ice water tub immersion until her temperature drops below 38.0 C

Correct: B Place the patient in a supine position so that both her legs and pelvis are elevated Exercise-associated collapse (EAC) occurs in athletes who participate in endurance events. The onset of symptoms and signs of postural hypotension occur when the participant suddenly stops exercising. By definition, it is an athlete that requires assistance after or during an endurance event that is not orthopedic or dermatologic. Initially, one should not try to walk or assist the patient with ambulation as this may lead to further injury of the athlete or possibly the provider (Answer A incorrect). Instead, patients should be instructed to lie with their pelvis and legs elevated in a head-down position. Most patients will respond to this simple maneuver with rapid abatement of their symptoms in just a few minutes. This will allow blood that has pooled in the dilated veins within the lower extremities to return to the central circulating blood volume (Answer B, correct). IV fluids (Answers C,D incorrect) are not recommended as part of the initial management of EAC in a patient with normal mental status. Oral fluids are the preferred method of fluid replacement in all mild and moderate cases if tolerated by the athlete. A rectal temperature in addition to blood pressure and heart rate should be recorded. Hyperthermia defined as a body temperature >103F (39.5C) and hypothermia <97F (36.1C) should be be diagnosed and treated appropriately. This patient is normothermic (termperature between 97F and 103F) and should have her temperature monitored and maintained, not actively cooled (Answer E, incorrect).

Which statement below is true regarding preadolescents and well structured weight lifting programs? A. strength training increases both muscle strength and hypertrophy in preadolescents B. strength training increases muscle strength, but not hypertrophy in preadolescents C. strength training is considered harmful to maturation, but beneficial to growth in preadolescents D. strength training can have a negative impact on maturation and growth in preadolescents

Correct: B strength training increases muscle strength, but not hypertrophy in preadolescents Preadolescent resistance training programs that include protocols with weights and resistance machines, and have low instructor to participant ratio can have significant improvement in strength without hypertrophy of muscle or deliterious effects on growth or maturation.

Which of the exercise prescription below should you advise against for an HIV infected individual with mild to moderate symptoms or CD4 count < 200? A. moderate exercise (40 -60 % VO2max) B. weight training C. intense exercise (>75% VO2 max) D. Three times per week

Correct: C intense exercise (>75% VO2 max) Ullman reported an impaired ability to mobilize neutrophils and natural killer cells in response to 1h of exercise at 75% VO2 max. Otherwise, moderate exercise has been shown to increase CD4 counts and CD4:CD8 ratios. It has also been shown to lower anxiety and tension levels in this population by. Weight training may enhance muscle strength, bulk and function in HIV+ individuals and may mitigate muscle wasting.

Which of the following is NOT a property of anabolic steroids? A. Reverse the actions of glucocorticoids and help metabolize ingested proteins, converting a negative nitrogen balance into a positive one B. Gives the athlete a state of euphoria and decreased fatigue that allows the athlete to train harder and longer C. Anabolic effects increase the number of muscles in the body for larger size and strength and better performance D. May induce hypertension, liver tumors, hirsutism, and premature closure of growth plates E. Androgenic effects may increase or decrease libido along with other side effects like gynecomastia

Correct: C Anabolic steroids are testosterone derivatives with three main mechanisms of action. The anticatabolic effects reverse the actions of glucocorticoids and help metabolize ingested proteins, converting a negative nitrogen balance into a positive one. The anabolic effects directly induce skeletal muscle synthesis, but they do not increase the number of muscles in the body. When muscle synthesis is increased, athletes experience better strength and performance as well as larger mass of muscles. The "steroid rush" is a state of euphoria and decreased fatigue that allows the athlete to train harder and longer. A randomized double-blind study of 40 men examined the effects of supraphysiologic testerosterone doses and compared placebo with or without weight training with testosterone doses with or without weight training. The subjects in the exercise plus testosterone group had a 9% increase in mass and 23 % increase in strength compared with 3% and 9% in the exercise plus placebo group. These doses were comparable with the doses that many athletes who use steroids take. Adverse effects of steroids include: sexual side effects like decreased or increased libido, decreased sperm production, gynecomastia, and hirsutism; psychiatric effects like euphoria, aggression or personality disorders; and serious irreversible side effects including hypertension, severe tendon ruptures, liver tumors, psychosis, premature closure of growth plates and irreversible hirsutism and voice changes in women. Most sports organizations have rules that ban the use of anabolic steroids for any reason.

An 18 year old returns from a trip to Colorado with ankle pain and an antalgic gait. She was treated initially for a severe ankle sprain after eversion injury during snowboard lessons. Ankle radiographs reveal a lateral process fracture of the talus that is typical in snowboarding injuries, and a CT scan verifies the non-displaced position of the small fragment. Appropriate treatment consists of A. Ankle rehab and return to activity if the CT scan shows a Hawkin's sign B. Ankle splint, weight bearing as tolerated, and aggressive ankle rehabilitation C. Nonweightbearing in a cast for 4-6 weeks followed by progressive weight bearing and ankle rehabilitation D. Walking cast for 4-6 weeks, then ankle rehabilitation E. Emergent orthopedic consultation because of tenuous blood supply to the talus

Correct: C Nonweightbearing in a cast for 4-6 weeks followed by progressive weight bearing and ankle rehabilitation A small non-displaced fracture of the lateral process may be appropriately treated with cast immobilization for 4-6 weeks. Since the lateral process supports 16-17% of the body's weight through the leg, early weight bearing risks displacement and surgical fixation. Any option with early weight bearing should be excluded. The Hawkin's sign appears 6-9 weeks after trauma and is indicative of vascular viability. The presence of the subchondral radiolucent band of the talar dome is 100% sensitive, but only 57.7% specific to rule out avascular necrosis of the talus. The tenuous, retrograde blood supply of the talus is of greater concern with fractures of the talar neck.

Which of the following statements is true regarding hip flexor injury? A. In adolescents with the possible diagnosis of hip flexor pain and tenderness over the ischial tuberosity should have an x-ray to rule-out hip flexor origin avulsion B. A hop test with pain in the ipsilateral groin is indicative of a hip flexor strain C. Patients with large, palpable defects in the rectus femoris rarely need surgery D. Hip flexor strains are commonly accompanied by a tingling sensation in the anterior thigh because of irritation of the lateral femoral cutaneous nerve E. Significant weakness is usually seen on exam with most hip flexor strains

Correct: C Patients with large, palpable defects in the rectus femoris rarely need surgery Isolated deformities of the rectus femoris usually cause little to no functional disability and rarely need surgical intervention. The most common site of avulsion of hip flexors is the rectus femoris at the anterior inferior iliac crest, not the ischial tuberosity which is the origin of the hamstrings (a hip extensor). A positive hop test is suspicious for a femoral neck stress fracture. Meralgia paresthetica is a condition caused by irritation of the lateral femoral cutaneous nerve (often at the inguinal ligament). Meralgia paresthetica is not commonly associated with hip flexor strains. Because the hip flexors are very strong muscles and large number of hip flexors, most strains do not cause significant weakness, but instead have pain (and perhaps subtle weakness) with resistance testing.

A 54 year old gentlemen presents to your office today complaining of bilateral knee pain. He was diagnosed with osteoarthritis in both his knees after he was referred by his primary care provider to see an orthopedic surgeon. He was given a prescription for an antiinflammatory medication and told that he may need knee replacement surgery one day. He does not like taking medications and has come to see you regarding non-pharmacologic treatment options. Which of the following statements regarding exercise and osteoarthritis is true? A. Aerobic exercise should be discouraged because it will increase the patient's pain B. This patient's x-ray findings are moderate to severe therefore exercise is unlikely to be helpful C. Strengthening exercises may be helpful in preventing OA and may also alter disease progression D. Aquatic exercise has not been shown to be beneficial for patients with OA

Correct: C Strengthening exercises may be helpful in preventing OA and may also alter disease progression Answer A is incorrect: for people with OA, both high intensity and low intensity aerobic exercise have been shown to be effective in improving a patient's functional status, gait, pain and aerobic capacity. Different exercise types have different effects; thus, an individualized approach to exercise prescription is recommended, based on presenting symptoms, problems and the needs of the patient. For people with OA of the knee, land-based therapeutic exercise has been shown to reduce pain and improve physical function. Optimal exercise type or dosage has not clearly been defined. Supervised exercise classes appeared to be as beneficial as treatments provided on a one-to-one basis. Answer B is incorrect: the effectiveness of exercise is independent of the severity of x-ray findings. Answer C is correct: improvements in muscle strength and proprioception gained from exercise programs may prevent and reduce the progression of osteoarthritis. Answer D is incorrect because there is evidence to support aquatic exercise for the treatment of knee OA and/or hip, at least in the short-term. Although no long-term effects have been documented (very few studies performed at this point), the short-term benefits make it a viable option for your patients.

A 17 year old female presents after injuring her right knee. She was landing from a rebound and felt her knee "pop." She developed immediate swelling in the right knee and was unable to continue playing. On exam, the knee has a large effusion with positive Lachman and anterior drawer tests. Which is true regarding her diagnosis? A. ACL injuries are less common in female athletes B. Traditional surgical reconstruction of the ACL may be performed in children regardless of physeal status C. The ACL is the primary restraint to posterior translation of the tibia with respect to the femur D. A hemarthrosis would be expected with aspiration of the injured knee E.Findings on standard radiography are usually specific for ACL injury

Correct: D A hemarthrosis would be expected with aspiration of the injured knee ACL injuries are more common in female athletes. Surgical technique for reconstruction would depend on the physeal state with traditional approaches used if physes are closed or nearly-closed. The ACL is the primary restraint to anterior translation of the tibia. (Correct Answer: D) A hemarthrosis is suggestive for ACL injury. Standard radiographs are often normal or nonspecific.

A female cross-country runner presents early in the season complaining of heel pain. She states the pain has been present for two weeks. Initially the pain only occurred with long runs but now hurts most of the time. On exam, pain is elicited by squeezing the heel. X-rays are initially unremarkable. Repeat x-rays obtained two weeks later however confirm the diagnosis. Which statement about this condition is true? A. Surgical intervention is required B. Patient should be counseled that healing is expected to take 10-12 weeks C. Patient is a increased risk of plantar fascia rupture D. Patient can expect to return to activity in 4-6 weeks E. Patient's body habitus is not a factor in this diagnosis

Correct: D Patient can expect to return to activity in 4-6 weeks Explanation: Calcaneal stress fractures are not considered a high risk injury. They typically heal 4-6 week after injury with activity modification including crutches with weightbearing as tolerated. Surgery is usually not required and most improve prior to seasons end. Patient has a positive squeeze test suggesting bony rather than soft tissue pathology. Low weights, as often seen in cross country runners can increase the risk of stress fractures.

While treating a member of your university's women's cross-country team for a 5th metatarsal stress fracture, you suspect she may have female athlete triad. Which of the following statements would help confirm the diagnosis of anorexia nervosa? A. Bingeing and purging at least twice a week for 3 months B. Menses every 6 to 8 weeks in a postmenarchal female C. Normal body image D. A weight greater than 15% below ideal body weight

Correct: D A weight greater than 15% below ideal body weight Female athlete triad includes disordered eating, amenorrhea, and osteoporosis. Disordered eating encompasses a variety of harmful behaviors including anorexia nervosa and bulimia nervosa. Answer A is a diagnostic criterion for bulimia nervosa not anorexia nervosa. Secondary amenorrhea is defined as the three month absence of menstrual bleeding in a women with previously regular menses. Therefore answer B is incorrect. Answer C is incorrect as patients with anorexia nervosa have a disturbance in the way in which one's body weight or shape is experienced. Other diagnostic criteria for anorexia nervosa include failure to maintain body weight at or above a minimally normal weight for age and height (i.e., body weight less than 85% of expected weight, either from weight loss or because the individual failed to gain weight during a period of growth; intense fear of gaining weight or becoming fat, even though underweight; and amenorrhea in post menarchal females. Eating disorders are associated with ballet dancers, runners, wrestling, figure skating, and gymnasts.

A high school football player presents to your clinic with his parents. They seek information about nutrition and supplements for athletes. Which of the following statements is true regarding nutrition and high intensity exercise? A. Fat is broken down to glycogen during exercise B. In regards to training in a hot, humid environment, thirst is a sensitive and reliable indicator of dehydration and estimating fluid loss C. Due to the increased demand on an athlete's body, protein supplements are necessary in addition to a healthy diet D. An athlete's diet should consist of about 60 % carbohydrates

Correct: D An athlete's diet should consist of about 60 % carbohydrates During exercise, fats are broken down to fatty acids which are carried to muscles and converted to ATP. b) Because the thirst mechanism lags behind the body"s need for fluid replacement, thirst is not a good initial indicator of dehydration. Fluids should be ingested before, during, and after exercise. c) Although athletes need more protein than nonathletes, athletes consume more calories and thus consume more dietary protein, fulfilling the daily protein requirements. Supplements are not needed.

At a college tennis tournament, you are caring for a 22 year old male tennis player from Italy who passed out in the middle of his match. He denies chest pain. You order an EKG which shows some T-wave inversions in leads V1 through V3 and an incomplete right bundle branch block. When asked about family history, he recalls his grandfather died at a young age of some heart problem. You are most worried about sudden cardiac death in this patient from which of the following? A. Coronary artery disease B. Hypertrophic cardiomyopathy C. Prolonged QT syndrome D. Arrhythmogenic right ventricular dysplasia

Correct: D Arrhythmogenic right ventricular dysplasia The overall incidence of sudden cardiac death in athletes is fairly low. The most common cause for those over 35 years old is CAD. For younger patients in the US, the most common cause is HCM. However, European studies have shown very different statistics. One Italian study showed ARVC as the most common cause (22%), premature CAD (18%) was second, while HCM (2%) was very rare. With ARVC athletes can perform at high levels of exertion with ventricular fibrillation most likely secondary to ventricle irritation. the right ventricle is replaced with adipose tissue becoming very thin. The history is of syncope and positive family history of premature cardiac sudden death. The EKG can show: inverted T waves in the precordial leads, PVC's with left bundle-branch block and right bundle-branch block. Echocardiogram may show abnormal, hypokinetic right ventricular dilatation.

A 20 year old male patient presents to your office with a history of anterior shoulder dislocation which occurred during a pick-up basketball game last week. This was the athlete's first such injury, and the report from the emergency department stated that the dislocation was reduced without difficulty. Which of the following findings would lead you to recommend surgical evaluation for the patient? A. Persistent anterior capsular pain one week after the injury B. Decreased range of motion on your initial examination C. Positive apprehension test on your initial examination D. Avulsion of the anterior capsulolabral complex on radiographic evaluation

Correct: D Avulsion of the anterior capsulolabral complex on radiographic evaluation Traumatic shoulder dislocations normally occur in the anterior or inferior direction. After dislocation, the patient may experience pain for several weeks due to the accompanying stretching of the capsular and ligamentous structures that stabilize the shoulder. It is not uncommon during the initial healing phase to have decreased range of motion or a subjective sense of instability as manifested by a positive apprehension test. Management of first anterior dislocations is somewhat controversial, with some studies showing benefit from surgical stabilization and others showing no difference in outcomes between surgical and non-surgical management. However, radiographic evidence of anterior capsulolabral complex avulsion (Bankhart lesion) should lead the physician to at least recommend a surgical consultation for the patient.

A 20 year old female cross country runner developed right thigh pain 1 week ago. She describes the pain as feeling like a pulled muscle. She has not had an injury but has recently added sprint workouts to her training regimen. She is on birth control pills but no other medication. She reports normal menses, a normal diet and one previous stress fracture of her foot in high school. She has tenderness to palpation of the distal femur but no pain with firing the quadriceps muscle. She has pain with the single leg hop test but not with the fulcrum test. She has normal knee and hip joint exams. AP and lateral views of the right femur are negative. What diagnosis is most likely regarding her injury? A. Quadriceps muscle strain B. Adductor Longus Strain C. Patello-femoral pain D. Distal femoral Stress Fracture E. Quadriceps tendonopathy

Correct: D Distal femoral Stress Fracture Stress fractures are very common in track athletes, but are at higher risk in female athletes that have increased training, poor dietary intake, amenorrhea, and osteoporosis. This athlete has recently increased her workout by adding sprints to her usual training program. A previous stress fracture is also a clue to questionable training methods and possible previous history of components of the female triad—disordered eating, altered menstrual function and abnormalities in bone mineralization. These components are very important in diagnosing injury in female athletes. A quadriceps muscle strain is a possible etiology given the history, but she would have pain with firing of the quadriceps muscle and may have pain on the hop test. An adductor longus strain would present with muscular pain on adduction of the legs with no pain on the hop test. Patello-femoral pain would more commonly present with pain with long periods of sitting, poor quadriceps strength, and pain on change of leg positions. The single leg hop test would not be positive. Quadriceps tendonopathy would also present with pain on palpation, possible pain on hop test, and the knee exam may be abnormal second to the tendonopathy distally. The fulcrum test applies the force of the arm of the examiner under the suspected fracture site with a bending force that reproduces the athlete's pain and is most commonly used to evaluate a femoral shaft stress fracture. The hop test on the affected leg also reproduces pain at the fracture site with femoral shaft stress fractures. Other tests that are used for diagnosing stress fractures clinically are the stork test (pars interarticularis stress fractures) and the tuning fork test for any fracture site. The tuning fork test has a high rate of false positives. X-rays are usually negative and bone scan is nearly 100% sensitive but not specific. A triple phase technetium bone scan is usually positive in all phases with a stress fracture.

Which of the following statements is true regarding cubital tunnel syndrome? A. MRI studies are often not helpful in the diagnosis of cubital tunnel syndrome B. Electromyogram (EMG) and nerve conduction studies are rarely helpful in the diagnosis of cubital tunnel syndrome C. Patients will usually complain of paresthesias in the thumb and index finger D. Patients may have weakness in thumb-index finger pinch (Froment's sign) in chronic cases E. In throwing athletes, the first-line treatment for cubital tunnel syndrome is ulnar collateral ligament reconstruction

Correct: D Patients may have weakness in thumb-index finger pinch (Froment's sign) in chronic cases Cubital tunnel syndrome (a.k.a. ulnar nerve compression syndrome) is entrapment of the ulnar nerve at the elbow. Areas of entrapment include: 1) the arcade of Struthers; 2) hypertrophic medial head of triceps; 3) spurs from the medial epicondyle and olecranon groove; 4) anconeus epitrochlearis; 5) cubital tunnel retinaculum (a.k.a. Osborne's ligament); 6) stenotic cubital tunnel; and 7) the split of the humeral and ulnar heads of the flexor carpi ulnaris. It typically presents with paresthesias in the ulnar side of ring finger and in the small finger, but with no pain (Answer C is incorrect). Answer D is correct because the ulnar nerve innervates the adductor pollicis and deep head of the flexor pollicis brevis. Chronic ulnar neuropathy may lead to weakness in these muscle and decreased pinch strength (Froment's sign). Answer B is incorrect because an EMG/NCS usually shows slowing of the conduction velocity across the elbow and can be helpful in the diagnosis. Answer E is incorrect because relative rest is usually the initial treatment. Throwing athletes with recurrent episodes may need surgery.MRI can be helpful in the diagnosis of ulnar nerve entrapment at the ellbow with the finding of increased signal intensity better than nerve enlargement.

A 33 year old male who is preparing for his third half-marathon is determined to improve his time at this year's race so he decided to change several areas of his training that he thought would improve his performance, increasing: his overall mileage and hill running. Unfortunately, he developed substantial lateral knee pain. His physical exam demonstrates a positive Ober's test. He responded very well to stretching and strengthening exercises. What else on the history and physical would you have expected to discover before beginning treatment: A. Normal lower extremity alignment B. Strong abductor muscles C. Less pain with hill running D. Positive Noble's test E. Abnormal radiographs

Correct: D Positive Noble's test He has Iliotibial Band Syndrome (ITBS). Noble's test is pain elicited when the ITB is pressed against the femoral condyle near 30degrees of flexion, and is commonly found in ITBS, so Answer D is the best answer. Answer E is incorrect, because radiographs are typically normal, and are actually not indicated in clinically clear cases of ITBS. Answer C should read that the pain is worse with hill running which is common at presentation due to increased eccentric contraction. An increase in mileage is frequently identified as well. Answer B is incorrect. The abductors of the hip which include the tensor fascia lata, gluteus medius & gluteus minimus are often found to be weak upon investigation. The adductor muscles may frequently be tight. Contributing intrinsic factors in the lower extremity alignment that can contribute to ITBS include: ankle pronation including pes planus, forefoot varus, metatarsus adductus and tibial torsion. This alignment could be all normal, but the answer (A) is not the best answer to this question.

An afebrile patient with acute low back pain notices pain going down the posterior-lateral aspect of her right thigh and leg. It is noted on your exam that she has the following: (+) straight leg raise test, a slight sensory deficit over the lateral aspect of the right lateral foot, a diminshed ankle jerk and weakness with plantar flexion of the great toe. It is also noted that it is hard for her to walk on her toes. Which nerve root is most likely affected? A. L3 B. L4 C. L5 D. S1 E. L2

Correct: D S1 This question focuses on knowing nerve root enervation and the dermatomes of the lower extremity. The S1 nerve root supplies sensation to the lateral aspect of the foot, is responsible for the ankle reflex, and gives strength in plantar flexion.

A 25 year old male presents with thumb pain after a fall while skiing. On exam, his MCP joint is grossly unstable and MRI reveals a Stener lesion. Optimal management of this injury requires A. Thumb splinted in extension for 4 weeks B. Thumb spica splint x 6 weeks C. Short arm cast for 6 weeks D. Surgical repair

Correct: D Surgical repair A Stener lesion is an abnormality seen in as many as 29% of cases of Gamekeeper"s Thumb. In addition to disruption of the ulnar collateral ligament at the first MCP joint, there is an abnormal folded position of the torn end of the ulnar collateral ligament superficial to the adductor aponeurosis. Spontaneous ligament healing is inhibited by the interposition of the thumb extensor mechanism between torn fragments of the ulnar collateral ligament. Only operative intervention allows apposition and healing of the traumatically displaced ligament.

One of the new athletes to your college lists on his health history that he takes methylphenidate (Ritalin) for his attention deficit, hyperactivity disorder (ADHD). Regarding intercollegiate athletes taking stimulant medications, which of the following is a true statement (Select the best answer). A. The NCAA does not ban methylphenidate (Ritalin, Concerta) or amphetamine (Adderral) because their common use for the treatment of ADHD B. A medical exemption must be applied for and granted by the NCAA prior to athletic participation when stimulant medications are used for medical reasons C. The NCAA requires the institution maintain, in the student-athlete's on-campus medical record, a copy of the physician's signed prescription for dispensing the medication D. The NCAA requires the institution to maintain, in the student-athlete's on-campus medical record, documentation from the prescribing physician detailing medical history, diagnosis, verification of that diagnosis through standard assessment, and dosing E. The NCAA tests for only anabolic substances and not stimulant medications

Correct: D The NCAA requires the institution to maintain, in the student-athlete's on-campus medical record, documentation from the prescribing physician detailing medical history, diagnosis, verification of that diagnosis through standard assessment, and dosing information. Amphetamine and methylphenidate are banned substances by the NCAA and the U.S. Ant-Doping Agency (Olympic committee) and these substances are included in testing programs. The NCAA provides for medical exemption of stimulant medications as long as the institution maintains documentation from the prescribing physician that the standard assessment to diagnose ADHD as been completed. This documentation would be requested by the NCAA if there is a positive sample. Currently only anabolic and peptide hormone medications require approval by the NCAA prior to participation.

When evaluating anterior knee pain, the defining characteristics of patellar tendinitis include which one of the following? A. There are findings on imaging that are "pathognomic" for patellar tendinitis B. Surgery is more effective than rehabilitation C. Patellar tendinitis is common and rarely requires treatment D. Training errors are the most common cause

Correct: D Training errors are the most common cause Other than age range (teens to 40s) the most common identifiable risk factors are training errors, usually tight hamstrings and quadriceps. This is a clinical diagnosis, however characteristics when imaged suggesting Patello-femoral tendinitis include osteopenia at the distal pole of the patella; tractional osteophyte in proximal patellar tendon. Ultrasound, bone scan and MR imaging identify change in the posterior proximal 3rd of the tendon. Imaging is primarily useful to rule out more significant pathology within the knee or when considering surgery Surgery no better than conservative therapy. Surgical debridement of full-thickness abnormal tissue, then rehab to eccentric training compared with rehab to eccentric training alone showed no change in Jump height, leg press strength, pain scores, return to sports with or without pain, . Common complications range from inability to return to sport at 6 and 12 months to rare tendon rupture. Treatment includes relative rest and rehabilitation

Hypertension is the most common cardiovascular disease that the sports medicine physician will encounter. There are many aspects of both the patient and his or her chosen sporting activity to consider when selecting a pharmaceutical intervention in the management of the hypertensive athlete. From below, select the choice that represents the best antihypertensive for the given athlete A. White female biathlete (cross-country ski & riflery) - metoprolol B. White male Olympic weight-lifter - hydrochlorothiazide C. Black female swimmer with a history of cholinergic urticaria - lisinopril D. White male lacrosse player - valsartan E. White female marathoner with a prior history of thyrotoxicosis-related atrial fibrillation - diltiazem

Correct: D White male lacrosse player - valsartan Essential hypertension is by far the most common cardiovascular disease encountered by the sports medicine physician. In the management of the hypertensive athlete, several things must be considered including the severity of the hypertension (blood pressure classification), cardiovascular disease risk factors, comorbid conditions, and the athlete's chosen exercise or sporting activities. Aside from therapeutic lifestyle changes, the sports medicine physician may consider pharmaceutical intervention in the management of the hypertensive athlete. It is important to select the medications that would give the optimal therapeutic effect while minimizing adverse effects and adhering to any regulations set forth by the governing body of the athlete's particular sports. Beta blockers, such as metoprolol, have a negative inotropic and chronotropic effect and would likely suppress the cardiovascular performance necessary for aerobic exercise. They may also offer an unfair advantage in long range riflery and are prohibited by most shooting-sport governing bodies. Diuretics, such as hydrochlorothiazide, may mask the presence of androgenic steroids and are explicitly prohibited by the International Olympic Committee. Nondihydropyridine calcium channel blockers, such as diltiazem, also have negative inotropic and chronotropic effects, making them a suboptimal choice for endurance athletes. Angiotensin-converting enzyme (ACE) inhibitors, such as lisinopril, and angiotensin-receptor blockers, such as valsartan, are among the best tolerated by hypertensive athletes. However, their resulting increase of bradykinins may put the hypertensive athlete with a history of cholinergic urticaria at increased risk for exercise-induced anaphylaxis.

A college athlete presents with fever, myalgias, rhinorrhea for 3 days. Which of the following treatments are banned by NCAA standards? A. Phenylephrine B. Pseudoephedrine C. Antipyretic agents D. Ephedrine E. Antihistamines

Correct: D Ephedrine Answer D is specifically on the NCAA banned list and should not be used. The remainder may be used for symptom relief. A and B although considered stimulants they are not on the banned list.

You are evaluating a 27 year old recreational tennis player. She felt some searing chest wall pain on her dominant side while extending for a forehand shot three days ago. One her exam today, you notice substantial bruising along the anterior chest wall suggesting some soft tissue injury. You begin by palpating the pectoralis major muscle. Of the following points, which one is least helpful when trying to palpate the the pectoralis major: A. Sternum B. Clavicle C. 2nd-6th ribs D. Humerus E. Coracoid Process

Correct: E Coracoid Process Answers A & C are the origins of the sternal head of the Pectoralis major: sternum and ribs 2-6. Answer B, specifically, the medial clavicle is the origin of the clavicular head. The Humerus, Answer D, is the insertion of the muscle on the Intertubercular Groove (Outer Lip). Answer E refers to the insertion of the Pectoralis minor which has its origin on the 3rd to 5th ribs, and also inserts on the scapula

A 19 year old female tennis player comes to you for her PPE. She denies any cardiac symptoms and has always kept up with her peers. There is no history of heart disease or early death in the family. Examination is unremarkable except for a systolic ejection murmur that increases with Valsalva and standing, and decreases with fist clenching and squatting. Which is the most significant predictor of sudden cardiac death in this athlete? A. Sudden death in her brother B. Muscle fiber disarray on biopsy C. Septal thickness of >1.8cm D. Paroxysmal atrial fibrillation on Holter monitoring E. Resting BP 120/75, and BP 95/70 after six minutes of exercise

Correct: E Resting BP 120/75, and BP 95/70 after six minutes of exercise This athlete has physical findings concerning for hypertrophic cardiomyopathy. In an asymptomatic patient with hypertrophic cardiomyopathy, many potential predictors of sudden death have been described. The most widely recognized risk factors are: marked LVH (>3 cm), resuscitation from sudden death, multiple sudden deaths in the kindred, and (perhaps) non-sustained VT. Biopsy is usually normal, but may show myofibrillar disarray. None of these have been shown to be prognostic. The only prognostic sign that has been consistently shown to be present is a drop in blood pressure with exercise . The answer here is therefore E.

A 36 year old female recreational soccer player presents with insidious onset of left posterior heel pain and a limp. She is wearing flip flops because shoes make the pain worse. Examination reveals swelling and erythema of the posterior heel. There is no palpable defect in the Achilles tendon and a Thompson test is negative. The most likely diagnosis is: A. Stress fracture of the calcaneus B. Plantar fasciitis C. Achilles tendon avulsion D. Sural neuritis E. Retrocalcaneal bursitis

Correct: E Retrocalcaneal bursitis Retrocalcaneal bursitis (also called Haglund's syndrome) is associated with overuse and presents with pain behind the calcaneus. Examination reveals swelling and erythema of the posterior heel. A prominence, called a "pump bump" may be noticeable. Retrocalcaneal bursitis is associated with pain and tenderness anterior to the Achilles tendon, along the medial and lateral aspects of the posterior calcaneus. Plantar flexion of the foot and/or squeezing the bursa from side to side reproduces the patient's complaint.A stress fracture of the calcaneus produces mid-calcaneal bony tenderness and occurs with acute overuse. The symptoms of plantar fasciitis include tenderness and pain underneath (plantar surface), rather than behind the heel. A pop is generally heard and felt along with a palpable defect in the tendon and a positive Thompson test with an Achilles tendon avulsion injury. Sural neuritis is rare and the result of direct trauma. A positive percussion sign over the nerve lateral to the Achilles tendon is diagnostic of sural neuritis.

Which of the following is not felt to improve physical performance or considered an ergogenic aid? A. Caffeine B. Creatine C. Anabolic steroids D. Alcohol

D. Alcohol Caffeine can increase work and power via increased mobilization of free fatty acids, thus sparing glycogen and prolonging endurance. Caffeine also directly affects muscle contraction by potentiating calcium release from the muscle. Creatine is felt to increase the intramuscular concentration of phosphocreatine and therefore enhance anaerobic power, speed recovery from high intensity exercise, increase muscular strength and increase lean body mass. Anabolic steroids are well known to improve performance. The ingestion of alcohol has negative effects on psychomotor skills such as reaction time, hand to eye coordination, and balance. It does not improve muscular work capacity and may actually decrease performance level, and impair temperature regulation particularly in a cold environment.

Describe the arterial supply of the wrist scaphoid bone.

Describe the arterial supply of the wrist scaphoid bone The scaphoid bone is supplied by 2 major vascular pedicles. The volar branch of the radial artery enters the scaphoid tubercle and supplies its distal 20-30%. The dorsal scaphoid branch of the radial artery enters through numerous small foramina along the spiral groove and the dorsal ridge and supplies 80% of the blood supply to the scaphoid. This retrograde supply is felt to part of the reason for common non union and osteonecrosis of the scaphoid bone.

What phase of the baseball pitch causes the most distraction force to the medial elbow?

Early acceleration. The force at the ulnar collateral ligament in this phase can approach 60 newtons.

The femoral nerve arises from the __________ nerve root and supplies motor function to the (list at least 4) muscles.

Femoral L2-4 Psoas major, Sartorius, Articularis genus, Rectus femoris, Vastus lateralis, Vastus intermedius, Vastus medialis

On the way to a recompression chamber, what is the recommended initial medical treatment?

For severe decompression illness, aggressive IV hydration is recommended. For all cases breathing 100% oxygen by non rebreather mask helps reabsorb nitrogen bubbles in the tissue.

Describe the mechanism of injury (as it pertains to baseball), diagnostic imaging, and treatment for hamate hook fractures.

Hamate Fracture Discussion: - anatomy of hook of hamate: - is situated slightly distal and radial to the pisform; - forms lateral (radial) border of tunnel of guyon, which transports ulnar nerve and artery to hand; - vascular supply: vessels enter hook at two sites - hook radial base & hook ulnar tip; Hook of Hamate Fracture: - fx of the hook may result from athletic activity (swinging golf club, etc) but may occur from direct blow; - hook of the hamate is particularly at risk in batters and golfers; - avascular changes may follow fracture of hook in hamate, and these may lead to hook necrosis and non union; - pattern of vascular supply suggests that most acute hooks fx should have adequate blood supply to heal if well immobilized immediately; - exam: - pain is accentuated w/ axial loading of ring and little finger metacarpals; - dx is usually confirmed by point tenderness over hook 1 cm distal and radial to the pisiform; - almost all patients complain of pain and tenderness on ulnar side of palm or on the dorsoulnar aspect of the wrist; - most common symptom is pain in the palm aggravated by grasp; - diminished grip strength, dorsal wrist pain, ulnar nerve paresthesias or weakness, and mild carpal tunnel syndrome are frequent. - diff dx: - intra-articular injuries, though rare, may also occur in hamate; - occasionally longitudinal sprain between trapezoid & capitate or capitate & hamate gives rise to ill-defined pain in ulnar aspect of the wrist; Radiographs: - see 15 deg reversed oblique view: - fractures of the body occur more frequently than frx of hook; - fx of hamate are difficult to dx as routine AP & lateral films fail to show frx; - most of fx can be diagnosed conclusively on carpal tunnel view or on special oblique radiograph w/ wrist supinated- CT scan will also demonstrate this fracture; Treatment: - pattern of vascular supply suggests that most acute hooks frx should have adequate blood supply to heal if well immobilized immediately; - immediate immobilization of acute fx may promote fracture healing and obviate operative intervention; - origin of the flexor digiti minimi brevis and opponens digiti minimi may cause a failure of a hamate fracture to heal; - nonathletic injury or crush injury adversely affects outcome; - pts w/ excisions of hook of hamate usually return to their pre-injury level of activity; - ORIF is possible but offers little advantage over excision, which typically produces excellent results

A Trendelenburg gait would most likely be caused by which of the following lumbar conditions? 1. L3/4 far lateral disc herniation 2. L3/4 central disc herniation with impingement on the bilateral descending nerve roots 3. L4/5 far lateral disc herniation 4. L5/S1 far lateral disc herniation 5. L5/S1 paracentral disc herniation

L5/S1 paracentral disc herniation A Trendelenburg gait is caused by gluteus medius weakness. Gluteus medius is innervated by L5. Therefore a L5/S1 far lateral disc herniation could cause this condition. Gluteus medius originates for the dorsal ilium inferior to iliac crest and inserts to the lateral and superior surfaces of greater trochanter. It is the major abductor of thigh, and also functions to help to rotate the hip medially and laterally. Arterial supply is by the superior gluteal artery. It is mediated by the superior gluteal nerve, which is primarily innervated by L5. L5 also contributes to ankle dorsiflexion (combined with L4), great toe extension, and sensory over lateral calf and dorsal foot.

Your high school's stud point guard suffers a dislocation of the third finger PIP joint. X-rays define a nondisplaced fracture involving 20% of the articular surface. Would you recommend surgery? Why or why not?

No surgery is indicated. Phalangeal fractures with volar displacement of the fracture chip or involvement of more than 25-30% of the articular surface should be referred to a hand surgeon for possible operative repair.

In the shoulder, give the borders of the quadrangular space and the structures that exist within it.

Quadrangular space is bordered by the teres major, teres minor, long head of the triceps and the humerus. The axillary nerve, humeral artery and posterior circumflex arety exist within here.

What nerve(s) supply the rotator cuff muscles?

Supraspinatus and infraspinatus are innervated by the suprascapular nerve. Teres minor is innervated by the axillary nerve. Subscapularis is innervated by the upper and lower subscapular nerves.

Loss of lumbar lordosis, vertebral wedging, and Schmorl nodes in the lumbar spine are seen in what condition? A. spondylolysis B. spondylolisthesis C. Scheuerman disease D. all of the above

The answer is C, Scheuerman disease Scheuerman's disease is a self-limiting disease of childhood also known as idiopathic juvenile kyphosis of the spine. It describes a disease process where the verterbra grow unevenly in the sagital plane, where the posterior side grows faster than the anterior side, creating a vertical wedging between the vertebra and a kyphotic curvature to the spine. Excessive lumbar lordosis can also be seen as kyphosis progresses and Schmorl nodes or vertebral disc herniations can result as they are compressed by the vertebral wedging. Once the patient is fully grown, the bones will maintain their deformed structure and surgery is often warrented to correct the kyphosis.

What are the contents of each of the dorsal compartments of the wrist? What is the eponym for the bony protuberance that separates the 2nd and 3rd compartment?

The bony protuberance is called lister's tubercle.

When discussing concussion risk reduction with your patient and his/her parents, it is important to emphasize that: a. Wearing a helmet in hockey, baseball, football, or protective headgear will prevent concussions b. Wearing a mouthguard protects against concussion injury, especially the custom fitted guards c. Player safety rules regarding contact, leading with the head, overly aggressive play, have helped reduce the risk of concussion injury d. Use of tracking devices on helmets has increased the ability to diagnose concussions on the field

The correct answer is c. Player safety rules regarding contact, leading with the head, overly aggressive play, have helped reduce the risk of concussion injury Although protective helmets and headgear have definitively reduced the risk of major cranial and intracranial injury, there has yet to be seen a significant concussion risk reduction. Mouthguards have not yet shown any more protective effect other than dental trauma. Tracking devices are improving on a continuous basis; however, the the amount of force to generate a concussion injury is highly variable from one individual to another, so there is not yet a reliable normative database for this type of implementation

Please give 2 environmental risk factors for decompression sickness. Think of situations or characteristics of the dive for the enviromment and medical or personal issues or behaviors for the individual.

The following environmental factors have been shown to increase the risk of DCS: · the magnitude of the pressure reduction ratio - a large pressure reduction ratio is more likely to cause DCS than a small one. · repetitive exposures - repetitive dives within a short period of time (a few hours) increase the risk of developing DCS. Repetitive ascents to altitudes above 5,500 metres (18,000 ft) within similar short periods increase the risk of developing altitude DCS. · the rate of ascent - the faster the ascent the greater the risk of developing DCS. The US Navy Dive Manual indicates that ascent rates greater than about 20 m/min (66 ft/min) when diving increase the chance of DCS, while recreational dive tables such as the Bühlmann tables require an ascent rate of 10 m/min (33 ft/min) with the last 6 m (20 ft) taking at least one minute. An individual exposed to a rapid decompression (high rate of ascent) above 5,500 metres (18,000 ft) has a greater risk of altitude DCS than being exposed to the same altitude but at a lower rate of ascent. · the duration of exposure - the longer the duration of the dive, the greater is the risk of DCS. Longer flights, especially to altitudes of 5,500 m (18,000 ft) and above, carry a greater risk of altitude DCS. · underwater diving before flying - divers who ascend to altitude soon after a dive increase their risk of developing DCS even if the dive itself was within the dive table safe limits. Dive tables make provisions for post-dive time at surface level before flying to allow any residual excess nitrogen to outgas. However, the pressure maintained inside even a pressurized aircraft may be as low as the pressure equivalent to an altitude of 2,400 m (7,900 ft) above sea level. Therefore, the assumption that the dive table surface interval occurs at normal atmospheric pressure is invalidated by flying during that surface interval, and an otherwise-safe dive may then exceed the dive table limits. · diving before travelling to altitude - DCS can occur without flying if the person moves to a high-altitude location on land immediately after diving, for example, scuba divers in Eritrea who drive from the coast to the Asmara plateau at 2,400 m (7,900 ft) increase their risk of DCS. · diving at altitude - diving in water whose surface altitude is above 300 m (980 ft) — for example, Lake Titicaca is at 3,800 m (12,500 ft) — without using versions of decompression tables or dive computers that are modified for high-altitude.

What tendons pass through the first dorsal compartment of the wrist? What entity is commonly associated with difficulty with these tendons?

The tendons of the abductor pollicis longus and the extensor pollicis brevis pass through the first dorsal compartment. The abductor pollicis longus tendon is usually multistranded. The extensor pollicis brevis tendon is typically much smaller than even a single slip of the abductor pollicis longus tendon, and it may be congenitally absent. A septum separating the first dorsal compartment into distinct subcompartments for the abductor pollicis longus tendons and the extensor pollicis brevis tendon is often noted at surgery. De Quervain tenosynovitis is an entrapment tendinitis of the tendons contained within the first dorsal compartment at the wrist; it causes pain during thumb motion.

What is the sequence and timing of the different ossification centers in the pediatric elbow? Which 3 later fuse to form the largest epiphyseal center of the elbow?

The trochlea, capitellum and lateral epicondyle fuse to form the largest epiphysis. The olecranon, medial epicondyle and radial head are all their own epiphysis.

Describe the valgus extension overload syndrome in baseball pitchers.

VALGUS EXTENSION OVERLOAD (VEO): Repetitive stress of pitching leads to excessive shear forces in and pathology in posteromedial elbow including * shear forces on medial aspect of olecranon tip and olecranon fossa* lateral radio-capitellar compression * posterior extension overload * medial tension at MCL Pathophysiology * chondrolysis * osteophyte formation (posteromedial humerus and olecranon) * loose bodies * MCL can become attenuated with repetitive strain * Associated conditions * cubital tunnel syndrome * concurrent cubital tunnel syndrome in ~25% of cases Presentation -Symptoms * pain in posteromedial elbow with full extension of elbow * pain typically occurs in deceleration phase of pitch (sometimes during acceleration phase) -Physical exam * tender to palpation over posteromedial olecranon* crepitus * pain with forced elbow extension Imaging -Radiographs * recommended views * AP, lateral, oblique of elbow * findings * often show osteophyte formation in the posteromedial olecranon fossa * loose bodies - MRI* helpful in differentiating complete from partial tears of MCL - CT * shows pathology best Treatment - Nonoperative * NSAIDS, activity modification, steroid injections * indications * first line of treatment * technique * pitching instructions to correct poor technique -Operative * resection of posteromedial osteophytes, removal of loose bodies, debridement of chondromalacia * indications * persistent symptoms that fail to improve with nonoperative treatment * contraindications * MCL insufficiency is a relative contraindication for olecranon debridement alone * technique * may be arthroscopic or open * care must be taken to only remove osteophytes and not normal olecranon as this many result in a loss of bony restraint and increase the tension in the MCL Complications * Valgus instability * resection of too much olecranon may cause valgus instability