daily answer
Scott Rand
Give 3 examples of conditions that would warrant a therapeutic use exemption for the prescription of testosterone supplementation for an athlete
Genetic abnormalities such as Klinefelter’s syndrome
Congenital anorchia
Hemochromatosis leading to hypogonadism
Testicular absence from trauma or torsion
Severe orchitis
Pituitary disorders such as hyperprolactinemia, panhypopituitarism
This does not include functional androgen deficiency from severe emotional distress, obesity, malnutrition or overtraining, late onset hypogonadism, or alcohol excess.
Scott E Rand, MD FAAFP CAQSM
Director, Primary Care Sports Medicine Fellowship
Co Director of Sports Medicine, Houston Methodist Orthopedics and Sports Medicine Willowbrook
Assistant Professor of Clinical Family Medicine Houston Methodist Academic Institute
Adjunct Assistant Professor of Family and Community Medicine, Texas A&M University
Assistant Professor of Family Medicine in Clinical Medicine Weill Cornell Medical College.
13802 Centerfield Dr Suite 300
Houston, TX 77070
Scott Rand
What is Blount’s disease?
Blount's Disease (Tibia Vara)
- Overview: Tibia vara is a condition that involves a growth disturbance of the medial tibial physis (Fig. 8-6). It is most commonly seen in obese males age 10 to 14 but can been seen in children as young as 2 to 3; more common in African Americans. Blount's disease should be included in the differential diagnosis of any child presenting with a limp or bowlegs (genu varum) at any age.
- Presentation: Classic presentation is of an obese child with a chronic progressive limp and either a unilateral or bilateral bowing of the tibia. Knee pain may be present and often localizes to the medial tibia.
- Physical examination: Findings often include a leg length discrepancy, tenderness at the medial tibial physis, and tibial torsion associated with the tibia vara. Instability to valgus stress testing may be present. Gait is usually antalgic and is notable for a varus thrust.
- Diagnosis: Radiographs of the knee often reveal the tibia vara and demonstrate the growth arrest of the medial tibial physis with acute medial angulation of the proximal tibia. A standing bilateral lower extremity AP view showing pelvis to foot is the standard orthopedic view but it is often not obtained until after the diagnosis is made on standard knee radiographs.
- Treatment: Blount's disease patients should be referred to a pediatric orthopedic surgeon for definitive care. Surgical treatment options include an osteotomy to realign the tibia into slight valgus, thus eliminating the leg length discrepancy and bowing. Other options include a stapling procedure of the lateral tibial physis to stop the growth throughout the proximal tibia. This can result in a significant leg length discrepancy in comparison to the contralateral side and may lead to further complications. Weight management as part of the comprehensive treatment for obesity must be emphasized in these patients and primary care providers must be involved.
Figure 8-6 Blount's Disease.
Scott Rand
A 13 year old female with a history of Legg-Perthes disease as a child presents to your clinic with worsening chronic left hip and groin pain. She reports occasional catching or locking. On exam she has pain with passive range-of-motion and reduced internal rotation and abduction. On MRI of the hip, you find which of the following:
A. Osteochondritis Dissecans of the femoral head
B. Labral Tear
C. Normal hip
D. Arthritis
Correct: A
Legg-Calve-Perthes disease is idiopathic avascular necrosis of the femoral head in young people. It presents is at age 4 to 8 and is more common in males. It typically is self limited and undergoes resorption, collapse, followed by repair of the capital femoral epiphyses. The result is impaired development of the hip joint. Half of children who develop Legg-Perthes disease will develop osteoarthritis later in life. Additionally, some patients do not spontaneously resolve and develop an osteochondral fragment which fails to unite with the rest of the femoral head.
1. Kocker M, Tucker R. PediatricAthlete Hip Disorders. Clin Sports Med - 01-APR-2006; 25(2): 241-53, viii
2. Katz J, Siffert R. Osteochondritis Dissecans in Association with Legg-Calve-Perthes Disease. International Orthopaedics. 1979; 3(3), p189-195.
Scott Rand
A 12 year old girl with no previous hip problems suffers an injury immediately after landing in the sand pit following setting her personal record in the long jump.
She now has pain and tenderness deep within the hip over the proximal and medial femur.
There is pain with passive internal and external rotation of the involved hip and with active hip flexion. The examination of the other hip is normal.
The most accurate diagnosis is:
A. Avulsion of the apophysis over the ischial tuberosity
B. Avulsion of the apophysis over the anterior superior ischial spine
C. Avulsion of the apophysis over the anterior inferior ischial spine
D. Avulsion of the apophysis over the lesser trochanter
E. Avulsion of the apophysis over the greater trochanter
Correct: D
The most common sites of avulsion fractures of an apophysis near the hip in a skeletally immature athlete are: the anterior superior iliac spine (sartorius), the ischium (hamstrings), the lesser trochanter (iliopsoas), the anterior inferior iliac spine (abdominal rectus), and iliac crest (abdominal muscles).
These are injuries resulting from sudden mechanical force and from weakness at the secondary growth site. This type of maximal effort causing an injury in an adult would most often lead to a simple muscle strain, not a fracture of a mature bone.
These injuries occur in running and jumping sports during a maximal effort.
Avulsion of the apophysis over the greater trochanter is rare.
Presentation of apophyseal fractures is acute. Common bursitis reactions in the same areas present gradually, often with an overuse history.
Plain radiographs can demonstrate these apophyseal avulsion fractures.
1. DeLee, Jesse C, Drez, David, Jr. DeLee and Drez's Orthopedic Sports Medicine. 2nd. Philadelphia: Saunders Elsevier, 2003.
2. McKeag, Douglas B, Moeller, James L. ACSM's Primary Care Sports Medicine. 2nd. Philadelphia: Lippincott Williams and Wilkins, 2007.
3. Mellion, Morris et al. Team Physician's Handbook. 3rd. Philadelphia: Hanley & Belfus, Inc., 2002.
Scott Rand
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
Scott Rand
This 64 year old female presented to the clinic with severe pain and swelling in the left patella after a fall 1 day prior. Pain is worse with active extension of the knee.
There is a non displaced fracture of the inferior pole of the patella.. some comminution noted. No other obvious fractures seen.
Scott Rand
12 This 12 year old football player presented to clinic with complaints of pain in the left thumb after having it bent backward trying to catch a ball.
There is a minimally displaced salter Harris type 2 fracture of the proximal phalanx of the thumb. Minimal angulation noted. No other obvious fractures are seen.
Scott Rand
This 15 year old male presented to clinic with complaints of severe left elbow pain and limited ROM after a fall on an outstretched hand.
There is a moderately large joint effusion with evident anterior and posterior fat pad signs. No obvious fracture is seen. No mal alignment. Assume occult nondisplaced supracondylar or radial head fracture.
Scott Rand
. This 15 year old male presented with several months of recurrent pain and swelling in his right knee whenever he played soccer.
There is an osteochondral defect noted in the lateral to mid portion of the medial femoral condyle. No displacement is seen. No acute fracture is noted. Physes remain open.
Scott Rand
. This 12 year old male presented to the clinic with complaints of pain over the ulnar aspect of the right hand after hitting a tree when angry.
There is a fracture of the 5th metacarpal neck. There is palmar angulation of less than 15 degrees grossly. No other fractures are seen. Physes are open.
Scott Rand
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
Correct answer is C.
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
Scott Rand
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
This question focuses on knowing nerve root ennervation 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.
1. Clement's Anatomy, 2nd edition
Scott Rand
17 year old football player tackles an opposing player and sustains a flexion injury of his neck. He falls to the ground. The ambulance is summoned and he is boarded and taken to the hospital. He is found to have an injury to the anterior spinal cord of his neck. Which of the following clinical findings match this lesion?
A. Loss of motor function and position sense on the same side of the body as the lesion and loss of pain and sensation on the opposite side of the body as the lesion
B. Bilateral lower extremity paralysis that is greater than the upper extremity paralysis. Bilateral loss of pain and temperature sensation, vibratory and proprioception is intact
C. Weakness in both upper extremities that is more severe than the weakness in both lower extremities. Sacral function is spared
D. After the period of spinal shock has resolved, the patient has no motor or sensory activity below the level of the lesion
Correct: B
Selection A is incorrect as it describes a Brown-Séquard lesion. Only one side of the cord is affected and there is loss of motor function and position sense on the same side with pain and sensation on the opposite side. This is a fairly rare lesion but has the best prognosis as far as patient recovery.
Selection B is correct. Anterior cord lesion often happens after a flexion injury and unfortunately has a poor prognosis. Lower extremities are usually affected with paralysis greater than the upper extremities. Temperature sensation, vibratory sensation and proprioception are intact.
Selection C describes a central cord lesion. This type of lesion most often happens with the hyperextension, not a hyperflexion injury, and can happen in elderly people with spondylosis who falls.
Selection D is also incorrect and describes complete severing of the spinal cord. There is loss of both motor and sensory function below the level of the lesion. The bulbocavernosus reflex must be present to confirm that the spinal shock period is over.
1. Jon C Thompson (2002). Netter's Concise Atlas of Orthopaedic Anatomy. Teterboro, NJ: Icon Learning Systems LLC.
2. Arce D, Sass P and Abul-Khoudoud H. Recognizing Spinal Cord Emergencies. AFP. 2001 Aug; 74(4):631-638.
Scott Rand
The anterior tibialis is the main dorsiflexor of the ankle, it originates on the anterolateral tibia and interosseus membrane and inserts on:
A. Medial cuneiform and base of 1st metatarsal
B. All 3 cuneiform bones, and the base of the 2nd metatarsal
C. Navicular bone
D. Anterior talus
Correct: A
The anterior tibialis muscle is the largest muscle in the anterior leg, and the main occupant of the anterior compartment. In addition to dorsiflexing the ankle, the muscle also adducts and inverts the foot. The tendon crosses the anterior to the ankle joint just medial to the midline, then sweeps across the dorsum of the foot medially to insert on the plantar surface of the medial cuneiform and base of the 1st metatarsal. The muscle is innervated by the L4 nerve root contained in the deep peroneal nerve. Rupture of this tendon can occur and is typically seen in individuals over age 45 after a forceful plantarflexion of the foot.
1. Netter F: Atlas of Human Anatomy 4th edition. Philadelphia, Saunders Elsevier, 2006.
2. Keens, JS: Tendon injuries of the foot and ankle. In Delee JC, Drez D(ed): Orthopedic Sports Medicine. Philadelphia, Saunders, 2003, pp 2409-11.
Scott Rand
Which of the following is primarily associated with endurance training?
A. Ability to exert increased force
B. Increased protein content of muscle fibers
C. Fast to slow fiber transformation
D. Reduction of muscle capillary bed
E. Increased size of muscle fibers
Correct answer: (C) Fast to slow fiber transformation.
Explanation: There are specific long-term adaptations to exercise training related to endurance training and strength training. The type of training affects the type of of adaptation in skeletal muscle. Endurance training results in adaptations in muscle and cardiopulmonary function that increase both maximal oxygen uptake and lactate threshold. Endurance training results in skeletal muscle mitochondrial biogenesis, fast to slow fiber transformation, expansion of the muscle capillary bed, and changes in metabolism of substrates. Resistance training is associated with increased muscle fiber size. The protein content of muscle fiber also changes in resistance training, leading to the ability to increase force.
(A) This is associated with resistance training.
(B) Increased protein content of muscle fibers is associated with resistance training.
(D) The muscle capillary bed increases in size with endurance training.
(E) Increased size of muscle fibers is the result of resistance training.
https://www.uptodate.com/contents/exercise-physiology? source=search_result&search=exercise&selectedTitle=5~150#H4034285 (http://www.uptodate.com/contents/exercise-physiology?
Scott Rand
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.
https://www.unm.edu/~lkravitz/Article%20folder/physiologgfatloss.htmlMelby (http://www.unm.edu/~lkravitz/Article%20folder/physiologgfatloss.htmlMelby), C., Scholl, C., Edwards, G., and Bullough, R. (1993). Effect of acute resistance exercise on post-exercise energy expenditure and resting metabolic rate. Journal of Applied Physiology, 75, 1847-1853.Achten, J., & Jeukendrup, A.E. (2012). Optimizing fat oxidation through exercise. Nutrition. 20, 7-8.
Scott Rand
A 16 year old male snowboarder had an accident during the Olympic competition. It was significant enough that it was decided to transport him to the hospital. En route, he complained of left shoulder pain, but remained hemodynamically stable during transport. At the hospital, his hemoglobin remained normal and stable throughout. CT scanning with contrast revealed a Grade II Splenic injury. Things to consider during his initial evaluation, management and disposition include:
A. The spleen is rarely injured during sport
B. Non-operative management would be preferred
C. Splenic rupture is of minor concern in this patient
D. Ultrasound is the preferred method of imaging in stable patients
E. He should be vaccinated immediately
Correct: B
Answer A is not correct. The spleen is the most commonly injured abdominal organ in sports. Answer B is the best answer for several reasons. The predominant reasons include the fact that he is an adolescent who is hemodynamically stable. Preservation of the spleen is always preferable in the long term. And since his competitive season is likely over for a while after the Olympics, he would be an excellent candidate for non-operative management which is the currently preferred method of management. Healing can take several months. Answer C is incorrect because delayed splenic rupture is the greatest concern after 48 hours in the non-operatively managed patient. Answer D is incorrect because CT scanning has been shown to be superior to US. If the patient is unstable, portable ultrasound would then be the preferable imaging method, but is not pertinent in this scenario. Answer E is correct if the patient is thought to need an urgent splenectomy. There was no indication that emergent surgery was needed, and therefore is not the best answer.
1. Brown RL, Irish MS: Observation of Splenic Trauma: When Is a Little Too Much? Journal of Pediatric Surgery 34(7):1124-1126, 1999.
2. Rifat SF, Gilvydis RP: Blunt Abdominal Trauma in Sports. Current Sports Medicine Reports 2:93-97, 2003
3. Gravlee JR, Schwenk TL: Management Choices for Splenic Injury in a Collegiate Football Player. Current Sports Medicine Reports 2(4):211-212, 2007
Scott Rand
What is the most common cause of airway obstruction in an unconscious athlete?
A. Mouthguard
B. The tongue
C. Swelling from anaphylaxis
D. Inhaled foreign body
Correct: B
The tongue is the one answer that would be present in all athletes.
Answer a) a mouthguard would be present only in contact sports.
Answer c) is a valid answer, but it is not the most common cause.
Answer d) is also a valid option, but the inhalation of foreign bodies is not that common.
1. Eric A. Weiss, Wilderness 911: A Step-by-step Guide for Medical Emergencies and Improvised, Published 1998, The Mountaineers Books
2. American Heart Association, American Heart Association 2005 Guidelines for cardiopulmonary resuscitation and emergency cardiac care
Scott Rand
In the absence of direct physical trauma, the activities with the highest incidence of spontaneous pneumothorax include scuba diving and:
A. soccer
B. weight lifting
C. football
D. swimming
Correct: B
Spontaneous pneumothorax occurs due to bleb rupture in sports involving changes in intrathoracic pressure including weightlifting and scuba diving. Pneumothorax is rare in football or soccer and associated with trauma, usually rib fracture. It is unlikely in swimming.
1. Selke, Sabiston, Spencer; Surgery of the chest; etiology and diagnosis
2. Partridge RA - Ann Emerg Med - 01-OCT-1997; 30(4): 539-41
Scott Rand
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
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.
1. Physical Activity/Exercise and Diabetes. Diabetes Care 2004 27: S58-S62
2. Sonnenberg GE, Kemmer FW, Berger M. Exercise in type 1 diabetic patients treated with continuous subcutaneous insulin infusion. Prevention of exercise induced hypoglycemia. Diabetologia 1990; 33:696-703
Scott Rand
Which factor most
influences the effectiveness of extracorporeal shockwave therapy (ESWT) in
chronic tendinopathy?
A. Patient age alone
B. Energy dosage and adherence to post‑treatment loading
C. Use of shockwave therapy as a standalone treatment
D. Avoidance of mechanical loading after treatment
Correct Answer: B – Energy dosage and adherence to post‑treatment loading
Explanation:
ESWT effectiveness depends on proper energy parameters and integration into a
loading‑based rehabilitation plan. Evidence shows better outcomes when paired
with progressive tendon loading rather than used in isolation. [researchgate.net]
Scott Rand
Why is neuromuscular
electrical stimulation (NMES) commonly used early after knee injury or surgery?
A. It decreases quadriceps activation
B. It increases joint laxity
C. It improves motor unit recruitment and combats inhibition
D. It reduces the need for voluntary strengthening
Correct Answer: C
Correct Answer: C – It improves motor unit recruitment and combats inhibition
Explanation:
NMES counteracts arthrogenic muscle inhibition commonly seen after knee injury
or surgery. By improving early quadriceps recruitment, it supports restoration
of gait mechanics and functional strength, especially when paired with
voluntary exercise. [ijspt.scho...ticahq.com]
Scott Rand
Which of the following best explains
why blood flow restriction (BFR) training is an effective rehabilitation
modality for load‑compromised athletes?
A. It eliminates metabolic stress during low‑load exercise
B. It produces hypertrophy and strength gains comparable to high‑load training
C. It decreases muscle activation to reduce fatigue
D. It is only beneficial for upper‑extremity rehabilitation
Correct Answer: B
Explanation:
Blood flow restriction training allows patients to achieve significant muscle
hypertrophy and strength improvements while using low loads, making it
particularly beneficial when high‑load training is contraindicated. Systematic
reviews show BFR can enhance muscle strength and size in both post‑operative
orthopedic patients and athletic populations, with effects in some cases
comparable to high‑intensity resistance exercise due to increased metabolic
stress and altered muscle fiber recruitment. [arthroscop...tation.org],
[jsams.org]
Scott Rand
The most effective treatment for a symptomatic dorsal carpal ganglia is
A. Nothing as most ganglia resolve spontaneously and do not require treatment
B. Aspiration with corticosteroid injection
C. Aspiration without corticosteroid injection
D. Surgery
Correct: D
Ganglion cysts account for approximately 60 percent of soft tissue, tumor-like swelling affecting the hand and wrist. They usually develop spontaneously in adults 20 to 50 years of age. There is a female-to-male preponderance of 3:1. The dorsal wrist ganglion arises from the scapholunate joint and constitutes about 65 percent of ganglia of the wrist and hand. The volar wrist ganglion arises from the distal aspect of the radius and accounts for about 20 to 25 percent of ganglia. Flexor tendon sheath ganglia make up the remaining 10 to 15 percent. The cystic structures are found near or are attached to tendon sheaths and joint capsules. The cyst is filled with soft, gelatinous, sticky, and mucoid fluid.
INDICATIONS AND DIAGNOSIS
Cysts are self evident, being soft and ballotable, and occur along the dorsal and volar aspects of the wrist. Most ganglia resolve spontaneously and do not require treatment. If the patient has symptoms, including pain or paresthesias, or is disturbed by the appearance, aspiration with or without injection of a corticosteroid is effective (no recurrence of the cyst) in 27 to 67 percent of patients. However, a recent randomized controlled trial between surgery and aspiration combined with methylprednisolone acetate injection plus wrist immobilization in the treatment of dorsal carpal ganglion showed the success by excision was 81.8% and by aspiration combined with methylprednisolone acetate injection plus wrist immobilization was 38.46%. The p-value was 0.047 by Fisher exact test. The present study has clearly shown that surgical excision gave a better success rate in the treatment of dorsal carpal ganglion.
1. Talia AF, Cardone DA. Diagnostic and therpeutic injection of the wrist and hand region. American Family Physician 2003 ; 67 (4) 745-751.
Limpaphyayom N, Wilairatana V. Randomized controlled trial between surgery and aspiration combined with methylprednisolone acetate injection plus wrist immobilization in the treatment
Collina, Steven
Steven Collina, M.D.
Board Certified Sports Medicine
Sports Medicine of Central Pa - UPMC, Medical Director
Sports Medicine Fellowship Director
Bloom Outpatient Services Center
4310 Londonderry Road
Suite 1B
Harrisburg, PA 17109
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Rand, Scott M.D.
I would agree with you Steven. My current approach is to use direct pressure to try to collapse or explode the cyst then splint for a week or so and teach the patient to do that if it recurs. Not all of these questions have the best answer. It could have been worded differently
Scott E Rand, MD FAAFP CAQSM
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Scott Rand
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.
http://www.orthobullets.com/hand/6012/boutonniere-deformity.
Scott Rand
1. 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
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.
2. Peterson J. “Injuries of the Fingers and Thumb in the Athlete,” Clinics in Sports Medicine. July 2006; 25(3): 527-542.
Scott Rand
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
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.
1. Peterson JJ, Bancroft LW. Injuries of the Fingers and Thumb in the Athlete. Clin Sports Med 2006; 25:
Scott Rand
DeQuervain”s tenosynovitis involves which tendon
sheaths?
A. extensor digitorum profundus and extensor pollicis
B. flexor pollicis longus and abductor pollicis longus
C. flexor pollicis longus and abductor pollicis brevis
D. extensor pollicis brevis and abductor pollicis longus
Correct: D
DeQuervain”s results from swellng or stenosis of the
sheath around the extensor pollicis brevis and the
abductor pollicis longus, therefore answer d) is
correct. This can be deduced from recalling the motion
of the Finkelstein test which would stretch the
extensor and abductor tendons of the thumb
1. Griffin. Essentials of Musculoskeletal Care AAOS 3rd
Scott Rand
What sports commonly lead to talon noir and why?
Answer: Talon noir or black heel is caused by horizontal petechiae on the posterior or lateral heel. Commonly seen in sports that require sudden, frequent stops such as tennis, racquetball, and basketball.
Scott Rand
: Wrestlers with herpes gladitorum must have no lesions and have been treated with antiviral medications for ___ days before being allowed to participate
Answer: Wrestlers with herpes gladitorum must have no lesions and have been treated with antiviral medications for __5_ days before being allowed to participate
Scott Rand
Which of the following statements is true regarding skin infection in athletes?
A. Rifampin is the first line treatment for MRSA infections
B. Any skin wound that is suspicious for Staphylococcus infection should be cultured
C. The gold standard treatment of MRSA is appropriate oral antibiotics
D. First line treatment of MRSA should be topical antibiotics
E. Special cleaning of locker room, equipment and playing area is needed if MRSA is diagnosed in
F.
Correct: B
The best answer is B. Any wound that is suspicious for Staphylococcus infection should be cultured. Suspicious features include: chief complaint of “spider bite” or a non-healing wound and “pus under pressure” on examination. Generally CA-MRSA wounds are clinically indistinguishable from methicillin-sensitive S. aureus and streptococcal skin infections. Rifampin may be used in combination with other antibiotics for a synergistic effect, but should never be used alone. The gold standard treatment of CA-MRSA infections is incision and drainage. The transmission of MRSA is primarily skin-to-skin; not via fomites, thus good hygiene is most critical.
1. Benjamin HJ, Nikore V, Takagishi J. Practical management : community-associated methicillin-resistant Staphylococcus Aureus (CA-MRSA): The latest sports epidemic. Clin J Sports Med 2007; 15(5): 393-397.
Scott Rand
How do you advise your patient to avoid being this guy in the marathon
Answer: Jogger’s nipple is caused by chafing of skin rubbing against his shirt. The best prevention is a petroleum jelly over the nipple or a protective bandage or nipple cover to prevent chafing.
Scott Rand
What are Pieozogenic papules
Piezogenic papules are painful or asymptomatic papules of the feet and wrists that result from herniation of fat through the dermis. They are common, nonhereditary, and usually are not the result of an inherent connective tissue defect. Piezogenic papules of the wrist were reported in 1991. [1] They are found in a large number of asymptomatic people. See the image below.
Scott Rand
A 17 year old male high school baseball pitcher presents to your sports medicine clinic for review of a MRI ordered by another physician. The pitcher has pain in his throwing shoulder. The MRI demonstrates bone marrow edema and cortical flattening suggestive of a Hill-Sachs lesion in the proximal humerus with subchondral sclerosis in the posterosuperior aspect of the glenoid. You would anticipate which of the following physical exam findings based on the imaging study?
A. Visible atrophy of the supraspinatus and infraspinatus with muscular weakness on testing
B. Posterior shoulder pain with passive abduction and external rotation of the affected shoulder
C. Marked weakness of shoulder internal rotators
D. Enlarged cervical and peri-clavicular lymph nodes
Correct: B
The MRI findings of bone marrow edema and cortical flattening suggestive of a Hill-Sachs lesion in the proximal humerus with subchondral sclerosis in the posterosuperior aspect of the glenoid may be seen in patients with internal impingement of the shoulder. Internal impingement may be clinically assessed with the “relocation test of Jobe.” In patients with internal impingement abducting and externally rotating the affected shoulder produces posterior shoulder pain. Posteriorly directed humeral head pressure, “relocation”, with the patient’s shoulder in abduction and external rotation relieves the pain. Atrophy of supraspinatus and infraspinatus would not be expected findings. Internal impingement is typically seen in overhead throwers who generally have increased strength of shoulder internal rotators. Lymph node enlargement is not seen with this condition.
1. Moosikasuwan, Miller, Dines. Imaging of the painful shoulder in throwing athletes. Clinics in Sports Medicine, 25(2006) 433-443
Scott Rand
A 23 y/o mountain bike racer flips over his handlebars and lands on the posterior superior portion of his right shoulder. Evaluation in the medical tent demonstrates significant weakness with resisted extension of the shoulder when tested at 90 degrees flexion, 30 degrees lateral to the coronal plane, and with hand pronated (empty can test) as well as an inability to initiate abduction of the involved arm. The patient also has weakness with resisted external rotation. There are no sensory deficits to light touch or pin prick over the shoulder, arm, thorax or back. Which nerve has most likely been injured?
A. Axillary nerve
B. Subscapular nerve
C. Suprascapular nerve
D. Dorsal scapular nerve
Correct: C
All of the nerves in the answer could be damaged in an injury as described above. Therefore it is important to discern the specific nerve involved by muscle testing. The accident described could also cause damage to muscles of the shoulder joint and shoulder girdle innervated by the nerves listed. However, the description of the specific area of impact indicates that an injury to the muscles is less likely than direct injury to the suprascapular nerve or via a fracture in the suprascapular notch or via compression injury. Involvement of the supraspinatus and the infraspinatus suggests damage to the suprascapular nerve prior to the spinoglenoid notch. The absence of sensory findings also rules out the axillary nerve as well without specifically testing the deltoid. Weakness with external rotation and not internal rotation further clarifies that the subscapular nerve is not involved as there is no sensory components of this nerve.
1. Delee and Drez’s Orthopaedic Sports Medicine, 2nd edition.
2. Netter’s Atlas of Human Anatomy, 3rd edition
Scott Rand
The “clunk test” evaluates shoulder pathology caused by the following:
A. Impingement
B. Tendinopathy
C. Labral tears
D. Sliding Biceps tendon
E. Instability
Correct: C
Snapping shoulder syndrome may be related to an intraarticular or extraarticular pathological condition. The initial evaluation of a patient with snapping shoulder should include thorough examination for mild glenohumeral instability and labral defects, which can be evaluated by the “clunk” test. This test, as described by Andrews and Gillogly, is performed with the patient supine and the arm in full overhead abduction. One of the examiner”s hands is placed posterior to the humeral head to apply anterior pressure while the other hand is placed at the level of the humeral condyles to provide rotation and axial loading. A “clunk” or grinding may indicate a Bankart lesion or a labral tear caused by instability.
1. Canale: Campbell”s Operative Orthopaedics, 10th ed. 2003
Scott Rand
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
Correct: B
Answer: B
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.
1. McKeag, D and Moeller, J. ACSM’S Primary Care Sports Medicine 2nd edition.
Scott Rand
What is felt to be the function of Lister’s tubercle?
Lister’s tubercle is a bony prominence on the dorsum of the radius and functions a pulley for the EPL tendon. It is located just ulnar to the Extensor pollicis longus tendon in the 3rd dorsal compartment.
Scott Rand
A 27 year old white male complains of pain and numbness in his palm and 4th and 5th fingers after his recent karate tournament. There is a tender mass in his hypothenar area and an abnormal Allen’s test. You suspect damage to which of the following structures?
A. Thrombosis of ulnar artery
B. Thrombosis of radial artery
C. Thrombosis of median artery
D. Thrombosis of common palmar digital artery
Correct: A
Repetitive trauma to the hypothenar area can cause injury to the ulnar artery with subsequent construction, thickening, thrombosis and possible aneurysm formation. Ulnar nerve symptoms may present concurrently due to compression.
1. DeLee, Jesse C., Drez, David, jr, and Stanitski, Carl L., Orthopaedic Sports Medicine, , W.B. Saunders and Company, Volume 3, 1994
2. Baker, Champ L, The Hughston Clinic Sports Medicine Book, Williams and Willkins, 1995
3. Netter, Frank H., Atlas of Human Anatomy, Ciba-eigy, 1989
Scott Rand
A 22 year old male wrestler presents to your clinic after falling awkwardly in a match approximately 4 hours earlier in the day injuring his left wrist. The patient appears uncomfortable and states the pain has been getting worse since the time of the injury despite ice and immobilization. On exam, he has swelling and is tender over the distal radius. His neurovascular exam is intact but he is unwilling to allow extension of his wrist or fingers because of pain. An x-ray is done and shows a minimally displaced extraarticular fracture of the distal radius. Which of the following complications of this injury is most likely at this time?
A. Stretch injury of the median nerve
B. Compartment syndrome
C. Malunion
D. Complex regional pain syndrome
Correct: B
Correct answer B: Compartment syndrome of the antebrachium may present with pain out of proportion to the injury, tenseness of the forearm, swelling, and pain with passive movement of the fingers and wrist. Early on, the patient usually has an intact radial pulse and good refill as these changes tend to occur late after significant tissue damage has already occurred. Median nerve injury may occur as pressures within the compartment continue to rise.
The median nerve and extensor pollicis longus tendon may be damaged with this injury because of their close proximity to the distal radius. In this case, the patient has normal neurologic function therefore answer A is incorrect.
Answer C is incorrect, while malunion is a concern with any fracture, it is unlikely with minimal displacement noted on x-ray. This complication should be monitored with routine follow-up.
Answer D is incorrect: Complex regional pain syndrome (CRPS) can occur with a distal radius fractures. This complication is associated with lack of physical activity after a period of immobilization. CRPS should be monitored for during follow up visits and can usually be prevented with the appropriate ROM exercises during the complete treatment period.
1. Wheeless C. Compartment Syndromes of Hand and Forearm. Available at: http://www.orthopaediccare.net/view/templates/chapter_text.asp?chapterid=hndcs_jgs&p=5. Accessed July 7th, 2008.
2. Eiff MP, Hatch RL, Calmbach, WL. Fracture Management for Primary Care, 2nd Edition. Philadelphia: Saunders; 2003
Scott Rand
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
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
1. Clinics in Sports Medicine: Vol 11, #I: 57-76, January 1992
Scott Rand
What motor deficiency would be seen with a L4-5 disc herniation?
Weakness in dorsiflexion of the great toe and inability to heel walk.
Scott Rand
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. 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.
Scott Rand
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 |
Scott Rand
The "stinger" injury is (pick one):
A. traction or compression of the
brachial plexus
B. results in bilateral arm weakness and paresthesia
C. generally resolves in 6-8 hours
D. precludes return to participation in the same contest
Correct answer is: A.
Cervical neurapraxia results from traumatic self-limited deformation of the cervical spinal cord. Bilateral paresthesias are common manifestations as opposed to the unilateral findings in a brachial plexus injury. Cervical neurapraxia is not an absolute contraindication to return to play, and when present, is most commonly associated with cervical spinal stenosis rather than cervical disc disease.