daily question
Scott Rand
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
--
Director, Primary Care Sports Medicine Fellowship
Medical Director, Sports Performance
Assistant Professor, Weill Cornell Medical College
13802 Centerfield Dr, Suite 300
Houston, TX 77070
(281) 737-0902 Clinic
(281) 737-0926 Fax
Scott Rand
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
Scott Rand
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?
Scott Rand
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
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
Scott Rand
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
Scott Rand
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
Scott Rand
Scott Rand
Scott Rand
A. VSD
B. ASD
C. Coarctation of the aorta
D. Patent ductus arteriosus (PDA)
Scott Rand
1. Look at the attached ECG. What is the most likely diagnosis? What findings are indicative of that diagnosis?
Scott Rand
On physical exam, there is a snapping sensation at the lateral hip with rotation of the hip. She also experiences tenderness on palpation of the trochanteric bursa. Which of the following is the most likely diagnosis?
A. Anterior cruciate ligament tear
B. Iliotibial band syndrome
C. Lateral collateral ligament injury
D. Patellofemoral pain syndrome
E. Trochanteric bursitis
Scott Rand
What are the Ottawa rules for determining x-ray imaging of the acute knee?
What are the Pittsburgh Decision rules for determining x-rays of the knee, and is there a significant difference in sensitivity or specificity compared to the Ottawa rules?
Scott Rand
Your star quarterback gets sacked from behind, lands on a flexed knee with plantarflexed foot. He comes off the field limping, reporting a popping sensation at the time of the injury. What is the most likely injury based upon his history?
A. ACL tear
B. PCL tear
C. MCL tear
D. LCL tear
E. Meniscal tear
Scott Rand
Scott Rand
Which of the following is a known result of resistance training?
A. In elderly patients, improved balance, mobility, and strength to perform ADLs.
B. Decrease in bone mass and in strength of connective tissue.
C. Decrease in lean body mass.
D. Large improvement in cardiorespiratory fitness
E. Decrease in glucose tolerance and lipid profiles when resistance is a component of circuit training.
Scott Rand
Which of the following statements regarding sickle cell trait athletes is true?
A. Sickle cell trait, in contrast to sickle cell disease, has little to no mortality in athletes
B. Any cramping, struggling, or collapse in a sickle-trait athlete must be considered sickling – a medical emergency – until proven otherwise
C. The symptoms of exertional sickling and heat illness (heat stroke or heat cramping) are not distinguishable
D. Acclimation to intense training, increased hydration, and increased rest afford no protection to sickling in athletes
Scott Rand
You are seeing a new patient for a pre-participation exam and this athlete would like to be cleared to scuba dive. Which statement is true regarding scuba diving participation?
A. An athlete with a well-controlled seizure disorder who is on a stable dose of medication and has been seizure-free for 6 months is safe to be cleared
B. An athlete with a previous spontaneous pneumothorax can be cleared for shallow dives only
C. An athlete with sickle cell trait has no more risk of hypoxia than the average diver and is safe to be cleared
D. An athlete with myringotomy tubes in place for 3 months is safe to be cleared
E. An athlete with an active otitis media if treated with antibiotics is safe to be cleared
Scott Rand
Your patient, a 43 year old male with long-standing Type II Diabetes Mellitus, wishes to begin an exercise program. Which of the following are appropriate recommendations for this patient?
A. There is limited information regarding the benefit of exercise in Type II Diabetes
B. There is little risk of hypoglycemia in exercising diabetic patients
C. Patients with proliferative retinopathy are at no greater risk than those with normal funduscopic findings
D. Hypoglycemia is more likely to occur during morning exercise
E. The patient should undergo exercise electrocardiography before beginning an exercise program.
Scott Rand
- Name 2 beta-2 agonists that are not considered banned substances
Scott Rand
- Are there any narcotic substances that are not considered banned substances?
Scott Rand
- A 22 year old weight lifter on the US team is taking spironolactone for acne control. Is this a banned substance and how would you alter management if it is?
Scott Rand
- Give 3 examples of conditions that would warrant a therapeutic use exemption for the prescription of testosterone supplementation for an athlete
Scott Rand
A 14 year old boy nears the end of a 5 minute mile track race during an indoor track meet. He has sudden sharp pain over the left hip just proximal to the inguinal ligament. He has mild nausea and even one episode of emesis.
In the office his exam shows left low back tenderness and limited forward flexion at the waist without neurologic or radicular findings. He also has tenderness to direct and firm palpation over the left superior ilium along its anterior third.
His physical exam also reveals no hernia, and the abdomen is benign.
His plain radiographs and an abdominal CT in the emergency room are normal. MRI reveals a mild avulsion of the apophysis over the left superior ileum as well as some mild edema indicating injury to the left quadratus lumborum. The plain film was read again showing the bony avulsion found on his MRI.
Proper recommendations include:
A. No running until radiologic healing is proven by plain x-ray
B. Refer to orthopedic surgeon
C. Conservative care, relative rest, return to running when pain has resolved and a full range of motion has returned
D. Limit his passive hip flexion to allow healing
E. Advise no further sprinting or racing on the track during this Track and Field season
Scott Rand
A 16 year old male long jumper lands awkwardly with his R knee hyperextended, collapsing in the pit. He experiences acute swelling of the R knee immediately. PMH of resolved bilateral “jumper’s knee” and prominent tibial tubercles diagnosed two years ago. There is anterior deformity and swelling immediately distal to the patella. Which of the following statements is true regarding tibial tubercle apophyseal fracture?
A. patients with type 2 and 3 fractures of the tibial tubercle are able to actively extend the knee against gravity several degrees
B. Negative Lachman testing immediately after injury eliminates rupture of the anterior cruciate ligament as a possibility
C. Fracture at the tibial apophysis can be comminuted, displaced or involve the tibial articular surface
D. Osgood Schlatter’s disease is not associated with tibial tubercle fracture
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
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
Scott Rand
This 17 year old football player presented with a firm lump in the right biceps approximately 3 weeks after a football game where he took multiple hits to the right upper arm.
Scott Rand
This 44 year old male presented to clinic with complaints of a tender lump in the posterior aspect of his right heel. Present for years, but slowly worsening.
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.
Scott Rand
. This 36 year old male fell from a ladder and landed on his feet 2 days prior to presentation to the clinic. He complains of pain in the medial ankle area and is unable to bear weight without significant discomfort.
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
Scott Rand
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
Scott Rand
A. Medial border of the adductor brevis
B. Inguinal ligament
C. Medial border of the adductor longus
D. Medial border of the sartorius
Scott Rand
A. Pisiform and Triquetrum
B. Pisiform and Hamate
C. Hamate and Lunate
D. Triquetrum and Lunate
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
Scott Rand
Which of the following does not cause delayed onset muscle soreness (DOMS)?
A. Lactic acid accumulation in muscle tissues
B. Structural damage to muscle fibers
C. Eccentric exercise
D. Swelling on a cellular level which may activate and sensitize afferent nerve endings around damaged muscle fibers
E. Training at an intensity greater than customary
Scott Rand
Which statement is true regarding exercise-induced anaphylaxis?
A. Pre-treatment with anti-histamines is effective to reduce the occurrence rate
B. Pre-treatment with NSAID’s or aspirin is effective to reduce the occurrence rate
C. A common trigger is running within a couple of hours after ingesting a meal
D. Initial treatment is immediate administration of anti-histamines and steroids
E. Re-occurrence is rare so affected athletes can run alone with little risk
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
Scott Rand
During the second football practice of the day on day three of the college preseason football camp, an offensive lineman is found sitting on the ground unwilling to stand up. He states his left calf is cramping and that he feels lightheaded and exhausted. You suspect possible exertional heat stroke. Which of the following statements about this condition is true?
A. Axillary, oral, or a rectal temperature greater than 104 F (40C) establishes the diagnosis of exertional heat stroke
B. This condition occurs randomly without warning and can not be predicted
C. Cold/ice water immersion is an effective way to treat exertional heat stroke
D. There are two patterns of presentation: sodium depletion and water depletion
Webner, David
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Scott Rand
45 year old tennis player presents with 6 weeks of low back pain with radiation to the left big toe made worse with bending over to tie his shoes. He wants to do physical therapy and you write for which back program to reduce his current symptoms of pain?
A. McKenzie exercises
B. Williams exercises
C. Back school
D. Lumbar traction
Scott Rand
There are several different types of muscle stretching techniques. Using a partner to stretch the hamstring passively then pushing against the partner by contracting the muscle isometrically then stretching further in the same range of motion is an example of:
A. Static stretching
B. Dynamic stretching
C. Ballistic stretching
D. Proprioceptive neuromuscular facilitation
Scott Rand
Which of the following statements about open and closed kinetic chain exercises is correct?
A. Open kinetic chain exercises occur when the distal aspect of the extremity is fixed and cannot move
B. Closed kinetic chain exercises typically involve functional weight-bearing and sport-specific activities
C. Knee extensions and straight leg raises are examples of closed kinetic chain exercises
D. During open kinetic chain exercises, motion occurs simultaneously at all joints comprising the kinetic chain
E. Closed kinetic chain exercises produce shearing forces, while open kinetic chain exercises produce compressive forces
Scott Rand
The use of a TENS (transcutaneous electric nerve stimulation) unit:
A. Results in increased dorsal horn cell activity
B. Most likely relieves pain via endorphin release with high frequency, low intensity modalities
C. Is relatively contraindicated for a patient with an implantable cardiac defibrillator (ICD)
D. Has been proven to reduce fracture pain
E. Results in local analgesia that is typically long-lasting (> 1 hour) after stimulation is stopped
Scott Rand
Describe baseball finger and its treatment.
Scott Rand
Which of the following statements is true regarding metacarpal fractures?
A. Most metacarpal fractures in athletes will eventually need a surgical procedure in order to regain full function
B. 5th metacarpal fractures are called “Boxer” fractures because of their common occurrence in boxers
C. Splints and casts for metacarpal fractures should immobilize the proximal interphalangeal (PIP), metacarpophalangeal (MCP) and the wrist joint
D. Although up to 30° of angulation is acceptable for a 5th metacarpal fracture and may be treated non-operatively, fractures with malrotation should be referred for surgical reduction
E. Fractures of the hand should be treated with prolonged immobilization since early motion leads to significant risk of non-union and poor functional outcome
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
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
Scott Rand
Wrestlers with herpes gladitorum must have no lesions and have been treated with antiviral medications for ___ days before being allowed to participate
Scott Rand
1. Give the origin and insertion, action and innervation of the serratus anterior muscle
Scott Rand
Internal impingement commonly occurs in overhead athletes and is very common amongst elite baseball pitchers. In which phase of throwing does this pathologic process occur?
1. Wind-up
2. Early cocking
3. Late cocking
4. Deceleration
5. Follow-through
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
Scott Rand
Your patient presents to you for follow up of a FOOSH mechanism and radial sided wrist pain. He was seen in an urgent care at the time of the injury, had negative x-rays of the wrist, and diagnosed with a sprain. He is now 10 days out from the injury and is no better. Your exam suggests a scaphoid fracture.
Proper methods of diagnosis and treatment include all of the following EXCEPT:
- repeat plain films, including scaphoid view, of the wrist
- CT scan of the wrist if the plain films are normal/negative
- for a nondisplaced waist fracture can heal well, but will require 8-12 weeks of immobilization
- short arm thumb spica casting for distal or waist fractures
- operative fixation for proximal pole or displaced fractures of any zone
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
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