daily answer
Scott Rand
What is a selective androgen receptor modulator and What does it do?
Selective Androgen Receptor Modulators (SARMs) are a class of compounds that bind to androgen receptors (ARs) with high affinity and specificity, but unlike traditional anabolic steroids, they exhibit tissue-selective activity. This means they can stimulate anabolic activity in muscle and bone while minimizing androgenic effects in other tissues such as the prostate or skin
1
.
Mechanism of Action
SARMs function by:
- Binding to androgen receptors in a similar manner to endogenous androgens like testosterone.
- Inducing conformational changes in the receptor that selectively recruit coactivators or corepressors.
- Modulating gene expression in a tissue-specific manner, promoting anabolic effects (e.g., muscle protein synthesis) without the full spectrum of androgenic effects (e.g., prostate hypertrophy).
This selective modulation is achieved through non-steroidal chemical structures that allow for differential receptor interaction and distinct downstream signaling pathways compared to testosterone or dihydrotestosterone (DHT).
Clinical and Athletic Relevance
SARMs were originally developed for:
- Muscle wasting disorders (e.g., cachexia, sarcopenia)
- Osteoporosis
- Hypogonadism
- Certain cancers (e.g., breast and prostate)
In sports medicine, SARMs have gained attention for their potential to enhance lean muscle mass, strength, and recovery without the side effects typically associated with anabolic steroids. However, no SARMs are currently FDA-approved, and their use in competitive sports is banned by the World Anti-Doping Agency (WADA).
Benefits and Risks
Reported benefits among users include:
- Increased lean muscle mass
- Improved strength and endurance
- Enhanced recovery from training
Adverse effects can include:
- Suppression of endogenous testosterone
- Mood swings
- Acne
- Decreased testicular volume
- Potential hepatotoxicity
1
Key Academic Reference
A 2021 cross-sectional study published in IJIR: Your Sexual Medicine Journal surveyed over 500 SARM users and found that while over 90% reported increased muscle mass and satisfaction, more than half experienced significant side effects. The study emphasized the lack of clinical oversight and potential reproductive consequences of unsupervised SARM use
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
Explain how collagen peptide supplementation may function as an ergogenic aid in resistance training. Include at least two physiological outcomes supported by current research.
Model Answer:
Collagen peptide (CP) supplementation may act as an ergogenic aid by enhancing connective tissue remodeling and supporting muscle-tendon unit adaptations during resistance training. Research indicates that long-term CP intake is associated with improvements in fat-free mass, tendon morphology, and maximal strength 1. These effects are likely due to CP’s stimulation of collagen synthesis and its influence on muscle architecture and recovery following exercise-induced muscle damage 1. Additionally, CP may improve joint functionality and reduce soreness, contributing to better training consistency and performance 2.
1. Bischof, K., Moitzi, A.M., Stafilidis, S. et al. Impact of Collagen Peptide Supplementation in Combination with Long-Term Physical Training on Strength, Musculotendinous Remodeling, Functional Recovery, and Body Composition in Healthy Adults: A Systematic Review with Meta-analysis. Sports Med 54, 2865–2888 (2024).
Scott Rand
Question: What does Chromium Picolonate do? While it may be factual an answer of ‘nothing’ is not acceptable
Answer: Used by athletes to gain muscle and lose fat. When given to chromium deficient patients, it causes an increase in glycogen synthesis.
Scott Rand
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
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.
Scott Rand
. Which of the following best describes the windlass mechanism of the foot?
A. Dorsiflexion of
the ankle during gait
B. Plantarflexion of the toes increasing arch height
C. Extension of the toes tightening the plantar fascia and elevating the medial
longitudinal arch
D. Pronation of the subtalar joint flattening the arch
Correct Answer: C. Extension of the toes tightening the plantar fascia and elevating the medial longitudinal arch
Critique:
The windlass mechanism is critical for foot rigidity during toe-off in gait. It
involves dorsiflexion of the toes, which tightens the plantar fascia and raises
the arch, aiding propulsion
Scott Rand
In chronic Achilles tendinopathy, which histopathological feature is most commonly observed?
A. Acute inflammatory
infiltrate
B. Collagen fiber disorganization and neovascularization
C. Complete tendon rupture
D. Calcific deposits
Correct Answer: B. Collagen fiber disorganization and neovascularization
Critique:
Chronic tendinopathy is characterized by degenerative changes rather than
inflammation. Histology typically shows disorganized collagen, increased ground
substance, and neovascularization.
Scott Rand
Which muscle is primarily responsible for unlocking the subtalar joint during gait?
A. Tibialis anterior
B. Peroneus longus
C. Tibialis posterior
D. Flexor hallucis longus
Correct Answer: C. Tibialis posterior
Critique:
Tibialis posterior plays a key role in controlling pronation and unlocking the
subtalar joint during the stance phase of gait. Dysfunction can lead to
adult-acquired flatfoot deformity.
Scott Rand
How many bones does the navicular bone in the foot articulate with? Name them.
Navicular bone
The navicular bone is located medially in the midfoot between the talus posteriorly and the 3 cuneiform bones anteriorly (see the following image). It forms the uppermost portion of the medial longitudinal arch of the foot and acts as a keystone of the arch. It is a boat-shaped bone that sits between the talar head and the 3 cuneiform bones. The navicular bone has 6 surfaces.
Bones of the foot, larger lateral view.
Navicular bone, surfaces
The posterior navicular surface is oval, concave, broader laterally than medially, and articulates with the rounded head of the talus (see the image below).
Posterior surface of the navicular
bone.
The medial navicular surface slopes posteriorly to end in a rounded prominent tuberosity (see the image below), where a portion of the posterior tibial tendon is inserted. Much of the tuberosity accepts the attachment of the plantar calcaneonavicular (spring) ligament arising from the sustentaculum tali.
Superior view of the talus and
navicular bones.
The anterior navicular surface is convex from side to side, and subdivided by 2 ridges into 3 facets, for articulation with the 3 cuneiform bones. The dorsal surface is convex from side to side, and rough for the attachment of ligaments (see the following image). The plantar surface is irregular, and also rough for the attachment of ligaments. The lateral surface is rough and irregular for the attachment of ligaments and occasionally presents a small facet for articulation with the cuboid bone.
Dorsal surface of the navicular bone.
Navicular bone, articulations
The navicular articulates with 4 bones: the talus and the 3 cuneiforms. It occasionally articulates with a fifth, the cuboid.
Scott Rand
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.
Stuart Willick
This is a great example of uniformed question writing. Whomever wrote this question has little knowledge of Alpine ski racing. Of all the Alpine skiing disciplines (slalom, giant slalom, super-G and downhill), the slalom discipline require the most quickness. Elite ski racers who make it to age 30 are generally focusing on the speed events (super-G and downhill) by that time, and are no longer competitive in the technical events (slalom and giant slalom), because of decreasing quickness. The term “38-year-old competitive slalom skier” is a bit of an oxymoron.
The question is otherwise OK.
Ski boots can be a pretty effective brace. Skiers get in-boot injuries under two circumstances:
- Recreational skiers whose boots are not tight enough, allowing for excess motion within the boot; and
- Ski racers who have very stiff, tight-fitting boots but have enormous forces going through the foot, ankle and lower leg.
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Stuart Willick
Apologies – the below comments were meant for my fellows.
SW
Rand, Scott M.D.
Not at all. I appreciate the input from experts around the country. Thank you
Scott E Rand, MD FAAFP CAQSM
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On Behalf Of Stuart Willick
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Scott Rand
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
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.
1. Beckerman J, Wang P, Hlatky M. Cardiovascular Screening of Athletes. Clin J Sport Med. 2004;Vol 14, Number 3:127-133.
2. Maron, B. Sudden Death in Young Athletes. NEJM. 2003; Vol 349, Number 11:1064- 1075.
3. Pelliccia A, Maron B, et al. Remodeling of left ventricular hypertrophy in elite athletes after long-term deconditioning. Circulation 2002;105:944-949.
Scott Rand
A 19 year old basketball player has an episode of unexplained syncope during practice. Patient adamantly denies any previous cardiac history and believes he was just dehydrated. He does admit, however that a cousin died suddenly at age 20 of cardiac causes. An EKG is obtained. Which abnormality would be suggestive of right ventricular dysplasia?
A. normal EKG
B. T-wave inversion
C. Prolonged QT interval
D. Q waves with ectopy
E. Pre-excitation
Correct: B
Explanation: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a rare cause of sudden cardiac death in the United States but ranks much higher in European studies. An EKG is an appropriate first step in a cardiac work-up for this patient. Classic EKG findings include T-wave inversion v1-v3, left bundle branch block, and rarely an epsilon wave which is pathognomonic for this disease. The other choices listed can be seen in other diseases such as HOCM, myocarditis, mitral valve prolapse or supraventricular tachycardia to name a few, but not typically seen with ARVC.
1. Basilico F, Cardiovascular Disease in Athletes, American Journal of Sports Medicine 1999:27:108
Scott Rand
Which of the following is a current American Heart Association (AHA) recommendation regarding cardiac evaluation during the Preparticipation exam?
A. Auscultate for heart murmur during provocative maneuvers
B. Palpate bilateral brachial pulses
C. Obtain bilateral brachial blood pressure with the athlete standing
D. Perform electrocardiogram on all athletes
Correct: A
In addition to the preparticipation medical and family history screening, the current AHA recommendations for the cardiovascular screening physical exam include recognition of physical stigmata related to Marfan syndrome, seated brachial blood pressure, palpation of radial and femoral pulses, and ausculatory cardiac exam including provocative maneuvers for murmurs. ECG remains optional and is usually reserved for those found to have abnormal findings on screening history or exam.
1. Maron, B, et al. "Recommendation and Considerations Related to Preparticipation Screening for Cardiovasular Abnormalities in Competitive Athletes: 2007 update". A Scientific Statement From the American Heart Association Council on Nutrition, Physical A
Scott Rand
Which of the following ECG findings in a trained athlete is considered a normal physiological adaptation rather than a pathological abnormality?
A. T-wave inversions in V1–V3
B. ST-segment depression
C. Sinus bradycardia
D. Pathologic Q waves
E. Right bundle branch block
✅ Correct Answer: C. Sinus bradycardia
🩺 Critique: Sinus bradycardia is a common and benign finding in well-trained athletes due to increased vagal tone. It typically resolves with exercise and does not indicate underlying pathology. In contrast, ST-segment depression, pathologic Q waves, and persistent T-wave inversions may warrant further evaluation for cardiomyopathies or ischemia.
📚 Reference:
Sharma S, Drezner JA, Baggish A, et al. "International recommendations for electrocardiographic interpretation in athletes." Br J Sports Med. 2017;51(9):704–731.
Scott Rand
What is the primary physiological adaptation in an athlete's heart that leads to increased stroke volume?
A. Increased left ventricular wall thickness
B. Increased left ventricular cavity size
C. Decreased resting heart rate
D. Increased myocardial oxygen demand
· Correct Answer: B.
Increased left ventricular cavity size Critique: Increased left ventricular cavity size is a key adaptation in an athlete's heart, allowing for greater end-diastolic volume and stroke volume. This is a normal response to endurance training.
Reference: Pelliccia A et al. Eur Heart J. 2020;41(4):318–325.
Scott Rand
The trochlea, capitellum and lateral epicondyle fuse to form the largest epiphysis. The olecranon, medial epicondyle and radial head are all their own epiphysis.
Scott Rand
. What is the most common age for presentation for Legg Calve Perthes Disease
Legg-Calvé-Perthes disease (LCP) is a condition of unknown etiology that appears as avascular necrosis of the femoral head. It is commonly seen in children age 4 to 10 years, with a 4:1 male predilection and a 20% occurrence of bilateral cases
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
Correct: C
Type 2 fractures involve the inferior pole of the patella and Type 3 fractures include the anterior tibial epiphysis. They may also be Salter 3 or 5 fractures depending on extent of damage to the tibial articular surface and growth plate respectively.
Type 1 injuries involve the apophysis alone. The remaining patellar tendon / apophyseal unit allows terminal extension against gravity.
In types 2 and 3 active terminal extension is no longer possible due to complete disruption of tubercle / patellar anchor.
This mechanism of injury is compatible with severe injuries including ACL rupture, collateral ligament and meniscal injury.
Tibial apophyseal fractures and ACL rupture both may exhibit acute massive hemarthrosis. Complete assessment of suspected pediatric tibial tubercle avulsion requires MR imaging.
Osgood Schlatter’s disease may predispose to tibial tubercle fracture. Rosenberg demonstrated with imaging that OSD is caused by tendinopathy at the anterior ossification center of the tibial tubercle and not apophysitis.
One theory notes an association of OSD to subsequent comminuted fractures.
1. Green: Skeletal Trauma in Children, 3rd ed. Chapter 2 - Physeal Injuries Copyright © 2003 Saunders, An Imprint of Elsevier
2. Rosenberg Z.S., Kawerblum M., Cheung Y.Y.: Osgood-Schlatter lesion: Fracture or tendinitis? Scintigraphic, CT, and MR imaging features. Radiology 1992; 185:853-858.
3. Ogden J.A., Tross R.B., Murphy M.J.: Fractures of the tibial tuberosity in adolescents. J Bone Joint Surg Am 1980; 62:205-215.
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
Correct: C
There are five apophyses near the hip. These secondary growth centers fuse by about age 25. Forceful or sudden traction at these sites can cause an apophysitis with pain and limitation of motion. Injury can also cause an avulsion of the apophysis itself.
Treatment is conservative. There is no need to limit motion in general. Specific rehabilitation protocols have been described, and athletes have done well with them. Athletes may return to full activity with normal pain-free range of motion and normal strength.
This teen had imaging evidence of two separate conditions on his MRI: an avulsion of the apophysis and an acute muscle strain. These conditions may be handled by primary care physicians. Surgery is generally not required. An MRI is usually not necessary to make the diagnosis but may be helpful to diagnose or rule out other pathology.
Running the mile, bony injuries, and GI pathology can all cause nausea and vomiting.
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.
Scott Rand
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
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.
1. Mehlhoff TL, Bennett JB. Elbow Injuries. In Team Physician’s Handbook 3ed. Mellion MB, Walsh WM, Madden C, Putukian M, Shelton GL (eds). Philadelphia: Hanley & Belfus, 2002, pp 421.
2. Keefe DT, Linter DM. Nerve injuries in the throwing elbow. Clin Sports Med 2004; 23(4):732-736.
3. Wilhelmi BJ, Naffziger. Hand, nerve compression syndromes: Upper extremity. eMedicine (last updated Jun 2006); http://www.emedicine.com/plastic/topic300.htm; (accessed June 22, 2007)
Scott Rand
Scott Rand
1. Posterior dislocation of the sternoclavicular joint puts what structure(s) at risk?
The brachiocephalic vein is located directly posterior to the SC joint, but other structures, including the trachea, subclavian artery, lung and brachial plexus are all possibly impacted by a posterior dislocation. This is considered an emergency and requires urgent to emergent relocation.
Scott Rand
What are the muscles that perform internal rotation at the GHJ?
Answer Latissimus Dorsi, Teres Major, Pec Major, Subscapularis
Scott Rand
Posterior shoulder tightness can lead to a glenohumeral internal rotation deficit (GIRD). This has been linked most closely to which of the following shoulder pathologies?
1. Internal impingement
2. Humeral avulsion of the glenohumeral ligament
3. Subacromial impingement
4. Bicep tendinitis
5. Hill-Sachs lesion
Repetitive overhead throwing can lead to posterior capsular stiffness and
relative loss of internal rotation (GIRD). This may shift the contact point
posterior and superior on the glenoid, leading to internal impingement where
the greater tuberosity impinges on the posterosuperior labrum and posterior
rotator cuff when the arm is abducted and externally rotated. Initial treatment
involves posterior capsular stretching.
Courtesy of Orthobullets
https://www.orthobullets.com/sports/3055/glenohumeral-internal-rotation-deficit-gird