daily answer
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
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.
Courtesy of Orthobullets
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
You are covering a weightlifting tournament and the competitor "misses the snatch" (the olympic lift in which the athlete attempts to move a loaded barbell from the floor to an overhead postion in one fluid motion). You notice through your direct observation of the lift (and subsequent review of the video tape) that the loaded barbell (which weighed around 250 pounds) came down on the athlete's neck. The athlete was able to walk off the competition platform under their own power before you could reach the individual. Off the platform, the athlete complains of a sore neck and "nothing else." He denies radicular symptoms, limb weakness, headache, or parathesias. Your exam reveals normal peripheral neurological exam (DTR, sensation, strength) but some paracervical muscle sorenessand spinous process tenderness. Which of the following is most likely diagnosis?
A. C3-C4 cervical subluxation
B. Rupture of the Ligamentum Flava
C. Clay Shoveler's fracture
D. Paraspinal muscle strain
E. Thoracic Outlet Syndrome
Correct: C
Due to the ballistic nature of the lift and the weight of the loaded bar, one must consider all the above as possible diagnoses but must rule out the significant injuries first. The most serious are the subluxation and fracture. Thoracic outlet syndrome is a more chronic condition while the ligamnetum flava is virtually impossible to rupture. Cervical subluxation would present with limited ROM and significant neurlogical findings, while Clay shoveler's fracture would not. A simple radiograph would also confirm if either was present.
1. Eiff, Hatch, Calmbach, Fracture Management in Primary Care, 2nd ed. W.B. Saunders, 2003, p220.
Scott Rand
Which of the following cervical spine injuries are both considered stable non-emergent fractures?
A. Flexion teardrop fracture and clay shoveler fracture
B. Hangman fracture and posterior neural arch fracture
C. Simple wedge fracture and flexion teardrop fracture
D. Posterior neural arch fracture and simple wedge fracture
Correct: D
A flexion teardrop fracture occurs when flexion of the spine, along with vertical axial compression, causes a fracture of the anteroinferior aspect of the vertebral body. For this fragment to be produced significant posterior ligamentous disruption must occur. Since the fragment displaces anteriorly, a significant degree of anterior ligamentous disruption exists. This injury involves disruption of all 3 columns, making this an extremely unstable fracture that frequently is associated with spinal cord injury. A clay shoveler fracture occurs with abrupt flexion of the neck combined with heavy upper body and lower neck muscular contraction. The fracture may also occur with direct blows to the spinous process. The fracture is located at the base of the spinous process. This fracture is considered stable since the injury involves only the spinous process and is not associated with neurological impairment. A Hangman fracture results from a hyperextension injury that fractures both of the pedicles of C2. It is considered an unstable fracture, however it seldom is associated with spinal injury, since the anteroposterior diameter of the spinal canal is greatest at this level, and the fractured pedicles allow decompression. The posterior neural arch fracture occurs when the head is hyperextended and the posterior neural arch of C1 is compressed between the occiput and the strong, prominent spinous process of C2, causing the weak posterior arch of C1 to fracture. The transverse ligament and the anterior arch of C1 are not involved, making this fracture stable. A simple wedge fracture occurs with a pure flexion injury. The nuchal ligament remains intact. There is no posterior disruption making this a stable fracture. Answer D is the only pairing of two stable fractures in the choices above.
1. Moira Davenport, MD. “Fracture, Cervical Spine.” E medicine. April 1, 2008. http://www.emedicine.com/emerg/TOPIC189.HTM#Multimediamedia2.
Scott Rand
A 16 year old male football player presents to your office with acute onset of mid-thoracic back pain which began immediately after being struck in the back during a football game the previous evening. On exam, you note an area of point tenderness immediately lateral to the midline in the mid-thoracic region of the athlete’s back. Other than some moderate paravertebral muscle spasm, he has no other physical findings. Radiographic evaluation reveals a nondisplaced transverse process fracture. Which of the following are appropriate management options for this athlete?
A. Immediate immobilization on a back board and transfer to the hospital for neurosurgical evaluation
B. Referral for fitting of a clam-shell type back brace
C. Use of local ice, analgesics and anti-inflammatory medication, with return to activity as tolerated
D. MRI evaluation to assess spinal cord compromise
E. Disqualification from participation in collision sports for a minimum of six months
Correct: C
Transverse process fractures typically occur in sports as a result of a collision, usually involving rotation or extension. Athletes can typically relate immediate onset of sharp pain associated with the collision. Because of the relationship between the transverse process and other nearby structures such as ribs and paravertebral muscles, transverse process fractures are considered stable processes. As such, they require no further surgical intervention. Bracing is contraindicated in the management of these fractures, as it often adds to the patient’s discomfort. The diagnosis of transverse process fracture is made through plain radiograph or CT, and additional imaging is not necessary. Because of the stable nature of the fracture, treatment is designed to decrease discomfort, and athletes can return to play when they are comfortable, often using a flak jacket for additional protection.
1. Fractures of the transverse process. In Delee and Drez’s Orthopedic Sports Medicine, 2nd ed. 2003 (Online version).
Scott Rand
During a preparticipation examination on one of your female high school cross-country athletes, she admits to two episodes of fainting that occurred during last season’s racing. Further questioning of both her and her parents reveals that these episodes occurred after she crossed the finish line, never during actual running, and are not associated with any other symptoms. She has no post-episode confusion and recovers quickly with minimal assistance. No significant cardiac history exists in her or her family. She has never had any workup for this before and you are only able to do one test beyond a thorough history and physical examination, both of which are normal. The most helpful test at this point would be:
A. 12 lead EKG
B. Echocardiogram
C. Tilt table test
D. 24 hour event monitor
Correct: A
Any athlete found to experience syncope related to exertion should have an electrocardiogram (ECG) before being cleared to return to sport. In post-exertion syncope, the most common cause is neurocardiogenic syncope related to postural hypotension. This is easily treated with simple measures such as laying the athlete in the head down/leg up position. In a young person with no other risk factors, this situation can be easily diagnosed by a thorough history and physical examination along with an EKG. Conditions such as HCM, prolonged QT interval, heart block, and pre-excitation syndromes such as Wolff-Parkinson-White may have characteristic findings indicating an arrythmogenic or structural cause of the event. If the ECG is normal and the history and examination highly suggest neurocardiogenic syncope, no further testing is needed. On the otherhand, syncope occurring during active exercise has a greater likelihood of having structural or arrythmogenic causes and warrants complete cardiac evaluation.
McAward KJ, Moriarity JM. Exertional Syncope and Presyncope Faint Signs of Underlying Problems. Phys. Sport Med 33(11) 2005. Accessed via http://www.physsportsmed.com/issues/2005/1105/mcaward.htm on 5/20/2008
Scott Rand
Question: What is the most common congenital coronary anomaly in sudden cardiac death?
Answer: Origin of the left coronary artery from the right sinus of valsalva
Scott Rand
A. VSD
B. ASD
C. Coarctation of the aorta
D. Patent ductus arteriosus (PDA)
Objective: Understand commonly seen congenital heart disease findings and presentations.
Correct answer: (D) Patent ductus arteriosus (PDA).
Explanation: Many adult patients with patent ductus are asymptomatic, depending on the size of the left-to-right shunt and thsize of the ductus. Frequently, the condition is discovered by the unusual quality of a continuous murmur at the left upper sternal border that can sound like an innocent venous hum. Because a patent ductus is an aortopulmonary runoff, however, the pulse pressure frequently is widened, and the pulses are brisk to bounding. Today, most lesions of ductus can be closed in the catheterization laboratory without surgery.
Wolters Kluwer Health Lippincott Williams & Wilkins. The Cleveland Clinic Foundation Intensive Review of Internal Medicine Sixth Edition. Copyright 2014 All rights reserved.
Scott Rand
This ECG is indicative of hypertrophic cardiomyopathy. The deep inverted T waves lateraly and diffuse ST changes are characteristic.
Scott Rand
Please describe the diagnosis, initial management and potential complications of a knee dislocation.
Knee dislocations are devastating injuries that must be suspected with a mechanism involving a rotational component. By definition, three of the four ligaments are disrupted (combinations of ACL, PCL, MCL, LCL). Associated injuries are common. Vascular injuries occur in 5-15% of all dislocations, but 40-50% of anterior/posterior mechanisms, due to tethering at the popliteal fossa. Nerve injuries are also common, most often the common peroneal nerve (25%) of the time. Tibial nerve injuries are less frequent. Fractures are present 60% of the time, involving the tibia or femur, most commonly.
Complications are very common. It is unusual for the knee to recover to pre-injury state.
Diagnosis can be tricky, as the knee may reduce spontaneously (reported as 50%). Signs of trauma with swelling, etc., may be the only first cue.
If there is obvious deformity, reduce immediately, particularly if distal pulses are nonpalpable. If a dimple sign is seen (medial femoral condyle buttonhole through capsule medially), this is indicative of an irreducible posterolateral dislocation, so do not reduce closed.
Physical exam of the ligaments is crucial, as appearance can be normal.
Vascular exam is crucial PRE and POST reduction. Serial evaluations of pulses in dorsalis pedis and posterior tibialis is mandatory while under observation and perioperatively.
This is a true orthopedic emergency. If reduction is needed on site, check pulses and splint in slight flexion at 20-30 degrees. Consider CT angiography and/or Doppler vascular studies upon arrival to ED. Vascular surgical consult should be considered.
Vascular surgery takes priority if vascular compromise is present. If not compromised, monitoring pulses until considered stable, with knee immobilized, is appropriate, until reconstruction planning and surgery can take place.
Complications are common and include stiffness/arthrofibrosis (35-40%), laxity/instability (35-40%), peroneal nerve injury (25%), and vascular compromise.
http://www.orthobullets.com/trauma/1043/knee-dislocation
Scott Rand
1. Younger age
2. Increased Q-angle
3. Male gender
4. Previous patellar instability event
5.
Amount of lateral patellar tilt
Females (not males) have a higher incidence of patellofemoral instability due
to their increased Q-angle. The Q-angle or quadriceps angle is the angle formed
by the intersection of a line from the ASIS to the patella and from the patella
to the tibial tubercle. Normal Q-angle in males is 14 degrees and in females is
18 degrees. A higher angle means that there is a larger lateral vector force on
the patella, which predisposes to lateral patellar instability. While an increased q angle increases the
chance for dislocation, a previous history of dislocation is the strongest
predictor.
Fithian et al prospectively followed 189 patients for 2-5 years and found that
the risk was highest among females 10 to 17 years old and those with previous
instability episodes. Patients with a prior history had 7 times higher odds of
subsequent instability episodes during follow-up than first time dislocators.
Courtesy of Orthobullets
Scott Rand
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
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.
1. Fredericson M, Wolf C. Iliotibial Band Syndrome in Runners: Innovations in Treatment. Sports Med 2005; 35(5):451-459
2. Ellis R, Hing W, Reid D. Iliotibial Band Friction Syndrome: A Systematic Review. Man Ther 2007 Aug; 12(3):200-8
Scott Rand
Which of the following is correct regarding the patellar fat pad?
A. The infrapatellar fat pad is located anterior to the patellar tendon
B. Fat pad irritation is exacerbated by flexion of the knee
C. Fad pad impingement is painful because it is a highly innervated structure
D. Surgical excision is often necessary for definitive treatment of an irritated fat pad
Correct: C
The infrapatellar fat pad is a highly innervated structure located at the inferior pole of the patella, posterior to the patellar tendon. Irritation or impingement can be caused by either a direct blow or due to hyperextension of the knee. People with fat pad irritation have exacerbation of the pain with extension of the leg (straight leg raises, prolonged standing. Treatment is often taping the knee either at the superior aspect of the patella to lever the inferior pole anteriorly or just distal to the fad pad to help support it.
1. Peter Brukner, Karim Khan, et al. “Anterior Knee Pain.” Clinical Sports Medicine: 3rd Edition. McGraw Hill, 2006. 524.
Scott Rand
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
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.
1. Team Physician’s Handbook 3rd Ed, 2002, Mellion et al, Hanley & Belfus Inc. Philadelphia, PA pp 495-496, 501, 597.
2. http://www.medscape.com/viewarticle/460921_3: ACL Injury & Open Physes in the Young Athlete,
3. Rodenberg RE, Cayce K, Hall S. Your Guide to a Dreaded Injury: the ACL Tear, Contemporary Pediatrics July 1, 2006.
Scott Rand
List at least 3 effects of aging on physiologic systems as related to exercise or sport performance
- Cardiac:
decreases in maximal heart rate, stroke volume, maximal cardiac output,
maximal arteriovenous oxygen difference, and maximal oxygen uptake (
2 max); increase in systolic and diastolic blood pressure.
- Pulmonary: decrease in vital capacity; increases in residual volume, respiratory frequency, and work of breathing (related to increased rib cage rigidity and decreased lung tissue elasticity).
- Musculoskeletal: decrease in muscle mass (sarcopenia), including decreases in types I and II muscle fibers (type II decreases more than type I); decreases in bone mass and tensile strength of tendons and ligaments; increases in stiffness of muscles, tendons, and ligaments; articular cartilage weakness secondary to decreased mucopolysaccharides and increased water content.
- Hematologic: decreases in plasma volume, red cell mass, and blood volume.
- Neurologic: decreases in spinal motor neurons (contributing factor to decreased muscle strength), reaction times, coordination, balance, and proprioception.
- Metabolic: decreases in basic metabolic rate and glucose tolerance; increases in plasma triglycerides, total cholesterol, and low-density lipoprotein concentrations.
Scott Rand
. A 56 year old male patient with a history of hypertension, hyperlipidemia and a sedentary lifestyle has decided to sell his couch and begin a walking program. He can climb 2 flights of stairs without significant dyspnea or angina symptoms. Is an exercise stress test indicated for him prior to beginning this exercise program?
NO, but if he is planning a vigorous exercise program, then testing is indicated. Exercise testing can be used in the development of an exercise prescription as well.
BOX 11-2 Initial ACSM Risk Stratification
- Low risk: men < 45 years old and women < 55 years old who are asymptomatic and meet no more than one risk-factor threshold from Table 11-1.
- Moderate risk: men ≥ 45 years old and women ≥ 55 years old or adults who meet threshold for two or more risk factors from Table 11-1.
- High risk: adults with one or more signs/symptoms listed in Box 11-3 or known cardiovascular (cardiac, peripheral vascular, or cerebrovascular), pulmonary (chronic obstructive pulmonary diseases, asthma, interstitial lung disease, or cystic fibrosis), or metabolic (diabetes mellitus, thyroid disorders, renal or hepatic) disease.
Modified from American College of Sports Medicine: ACSM's Guidelines for Exercise Testing and Prescription, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.
Table 11-2 ACSM RECOMMENDATIONS FOR EXERCISE TESTING BEFORE PARTICIPATION IN MODERATE-TO-VIGOROUS EXERCISE PROGRAM
|
Low risk |
Moderate risk |
High risk |
|
|
Moderate exercise* |
Not necessary |
Not necessary |
Recommended |
|
Vigorous exercise† |
Not necessary |
Recommended |
Recommended |
*Defined as activities that are approximately 3-6 metabolic equivalents (METs). Alternatively defined as intensity well within person's capacity that can be sustained for prolonged period (~45 minutes), that has gradual initiation and progression, and is generally noncompetitive. If person's exercise capacity is known, relative moderate exercise may be defined by the range 40% to 60% of maximal oxygen uptake.
†Defined as activities > 6 METs. Alternatively defined as exercise intense enough to represent substantial cardiorespiratory challenge. If person's exercise capacity is known, vigorous exercise may be defined as intensity > 60% maximal oxygen uptake.
Modified from American College of Sports Medicine: ACSM's Guidelines for Exercise Testing and Prescription, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2000.
Scott Rand
. List 5 absolute contraindications to aerobic exercise in pregnant athletes
Absolute Contraindications
· Hemodynamically significant heart disease
· Restrictive lung disease
· Incompetent cervix/cerclage
· Multiple gestation at risk for premature labor
· Persistent second or third trimester bleeding
· Placenta praevia after 26 weeks gestation
· Premature labor during the current pregnancy
· Premature rupture of membranes (PROM)
· Pregnancy-induced hypertension (PIH)
Scott Rand
. List 5 benefits of exercise in pregnancy
Benefits of Exercise during Pregnancy
· Same benefits as in nonpregnant state
· Prevention of gestational diabetes, especially if BMI is greater than 33
· Decrease incidence of pregnancy-induced hypertension (PIH) and physical symptoms of pregnancy such as nausea, vomiting, etc.
· Improve or maintain fitness
· Decrease musculoskeletal complaints
· Decrease depression and anxiety
· Improve self-esteem
· Decrease maternal weight gain
· Decrease postpartum recovery time
Scott Rand
When discussing an appropriate exercise prescription with your patient, you include some of the general benefits that can be gained. Which of the following statements would you include in that discussion?
A. Resistance training does not help maintain fat-free mass
B. Benefits are only achievable at maximal intensity levels in the elderly
C. Resistance training is a primary means for increasing VO2max
D. Strength gains cannot be maintained with once weekly exercise
E. Age-related decline can be attenuated with regular exercise
Correct: E
Both aerobic and resistance training help to maintain the FFM (fat-free mass) so answer A is incorrect. Answer B is incorrect because various studies in multiple age groups, but especially in the elderly show the benefits are witnessed at even minimal intensities. Answer C is also incorrect. Even though resistance training can help with strength, endurance and maintaining one’s fat free mass amongst other things, it is not a primary means for increasing VO2max. Answer D is incorrect. The recommended number of days per week of exercise is 3 to 5 or “most days” of the week. Maintaining the effects can be had with as little as one day/week for strength and VO2max can be maintained with a 2/3rds reduction in frequency and duration if intensity is unchanged. Answer E is correct as it has been shown that strength and flexibility declines are attenuated with regular exercise.
1. Pollock ML, Gaesser GA, et al. American College of Sports Medicine Position Stand: The Recommended Quantity and Quality of Exercise for Developing and Maintaining Cardiorespiratory and Muscular Fitness, and Flexibility in Healthy Adults. Med Sci Sports
2. Pescatello LS, DiPietro L. Physical Activity in Older Adults: An Overview of Health Benefits. Sports Medicine 1993 Jun;15(6):353-64
Scott Rand
Question: Give 3 effects beta blockers have on the physiology of exercise
Answer: decrease cardiac output, reduce maximal heart rate, decrease VO2 max, may induce bronchoconstriction, decrease lipolysis, decrease glycogenolysis
Scott Rand
Which of the following acute headache medications is considered first-line prior to physical exertion in patients with primary exercise headache?
A. Acetaminophen
B. Ibuprofen
C. Oxycodone
D. Gabapentin
E. Indomethacin
Correct answer: E, indomethacin.
Primary exercise headache is similar in presentation to migraines, including nausea and photophobia, precipitated only by exercise. First line treatment prior to initiating medication includes improving cardiovascular fitness with exercise, gradual warm-up prior to working out, and monitor pulse rate or any other obvious trigger threshold so as to adjust the work out to avoid prompting the symptoms.
Initial pharmacologic treatment involves first the use of indomethacin or one of the triptans as a prophylactic or for acute treatment. Topiramate, amitriptyline and nortriptyline have also been suggested as daily use for prevention on a maintenance basis.
Kutcher, J., et al, Sports Medicine Study Guide and Review for Boards (ed by M. Harrast and J. Finnoff), second edition, 2017, pp.488-9
Scott Rand
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.
1. 2007-08 Drug-Testing Exceptions Procedures, Medical Exemptions “http://www.ncaa.org/wps/ncaa?ContentID=481”, last accessed on 10 June 2008.
2. NCAA Banned-Drug Classes 2007-2008, “http://www.ncaa.org/wps/wcm/connect/resources/file/eba7024a0e95dde/banned_drug_classes.pdf?MOD=AJPERES”, last accessed on 10 June 2008.
3. U.S. Anti-Doping Agency Drug Reference On-line, “http://www.usantidoping.org/dro/”, last accessed 10 June 2008.
Scott Rand
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
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.
Scott Rand
List three effects of hyaluronic acid in osteoarthritis
viscosupplementation.
1. Inhibition of macrophage phagocytosis and neutrophilic adherence
2. Reduction of arachidonic acid release from fibroblasts in synovial tissue
3. Reduction of pain either by direct pain receptor inhibition or binding of
substance P
Scott Rand
. Please list 2 radiolucent and 2 radiodense benign bone tumors in pediatric patients.
Radiolucent: Unicameral bone cyst, non ossifying fibroma and fibrous cortical defect
Radiodense: Enchondroma, osteocondroma, Langerhans cell histiocytosis
Scott Rand
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.
http://emedicine.medscape.com/article/1248267-treatment#a1128 (http://emedicine.medscape.com/article/1248267-treatment#a1128) http://emedicine.medscape.com/article/1007276-clinical#a0256 (http://emedicine.medscape.com/article/1007276-clinical#a0256)
Scott Rand
A 6-year-old boy presents to your office with foot pain that is increasing in severity. His parents state he has recently been limping. There is no history of trauma and he is otherwise healthy. Radiographs are shown in the attached files. Which of the following is the most appropriate treatment for this child?
1. Observation
2. Open biopsy and curettage
3. Long leg non-walking cast
4. Amputation
5. Short leg walking cast
The
history and radiographs are consistent with Kohler's disease, avascular
necrosis of the tarsal navicular.
It was thought
orginially that the changes in this disease might be the result of an abnormal
strain that acts on a weak navicular, but a definitive answer has not been
found. Among the theories to explain the nature of this lesion, a more
satisfactory one is a mechanical basis that is associated with a delayed
ossification. The navicular is the last tarsal bone to ossify in children. This
bone might be compressed between the already ossified talus and the cuneiforms
when the child becomes heavier. Compression involves the vessels in central
spongy bone, leading to ischemia, which then causes clinical symptoms.
Thereafter, the perichondral ring of vessels sends the blood supply, allowing
rapid revascularization and formation of new bone. The radial arrangement of
the vessels of this bone is of great importance in explaining why the prognosis
of this lesion is always excellent.
Kohler's disease tends
to affect boys more frequently than girls between ages 6-9. Treatment includes
immobilization for symptom relief and observation while the navicular
re-ossifies.
Scott Rand
Describe the salter harris classification of physeal fractures .
· Type I is a transphyseal injury.
· Type II is a transphyseal injury with metaphyseal extension.
· Type III is a transphyseal injury with epiphyseal extension into the joint space.
· Type IV has extension from the epiphysis through the physis and into the metaphysis.
· Type V fractures are rarely seen and involve a crush injury to the physis itself.
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
There is a subtle calcium density just anterior to and not attached to the midshaft of the humerus. No fracture is seen. Findings are consistent with myositis ossificans of the biceps muscle
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
. 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.
There is a non displaced intra articular fracture of the posterior malleolus of the tibia. The fracture line communicates with the articular surface of the tibia. Soft tissue swelling is noted. The mortise is intact.
Scott Rand
. This 40 year old female triathlete presented with several months of worsening low back pain without radiation, noted mostly during flip turns in the pool. Some pain with running. Feels best biking.
There is evidence of spondylolyis at the L5 Pars interarticularis with minimal grade 1 spondylolisthesis. No acute fractures seen. Alignment and disc spaces are otherwise well maintained.
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
A. Medial border of the adductor brevis
B. Inguinal ligament
C. Medial border of the adductor longus
D. Medial border of the sartorius
Correct: A
Several important structures lie in the femoral triangle, including the femoral artery, vein and nerve. It is also the location of compression for tamponade of the femoral artery to the leg where the femoral artery lies over the head of the femur. While the brevis does run in parallel to the adductor longus, it lies deep to the adductor magnus and therefore does not form a border of the triangle.
1. Netter, Frank H., Atlas of Human Anatomy, Ciba-Geigy, 1989
2. Hollinshead, Henry W., Rosse, Cornelius, Textbook of Anatomy, 4th Ed., J.B. Lippincott Company, 1985
Scott Rand
What component of the deep posterior compartment of the lower leg assists with plantar flexion?
A. Tibialis Posterior
B. Flexor Digitorum Longus
C. Soleus
D. Tibialis Anterior
Correct: A
The deep posterior compartment contains the Tibialis Posterior (TP), Flexor Digitorum Longus (FDL), and Flexor Hallucis Longus (FHL) and can be remembered by the mnemonic "Tom, Dick and Harry". The Tibialis Posterior inverts the foot and assists with plantar flexion. When the TP is weak or injured, a patient may have difficulty with performing a single-heel raise and may demonstrate a "too many toes" sign during inspection from behind. The soleus is part of the superficial posterior compartment. The tibialis anterior is part of the anterior compartment.
1. Thordarson D, Orthopaedic Surgery Essentials. 2004. p10, 25.
Scott Rand
What is the main arterial blood supply to the ACL in the knee?
A. Posterior tibial artery
B. Superior medial genicular artery
C. Anterior tibial artery
D. Middle genicular artery
Correct: D
The main blood supply of the ACL is the middle genicular artery after it leaves the popliteal artery. The major innervation is the posterior articular nerve.
1. Dienst M, et al. Anatomy and biomechanics of the anterior cruciate ligament. Orthopedic Clinics of North America. Vol 33(4). Oct 2002.
Scott Rand
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
Which of the following is ‘not’ a property of slow twitch (Type I) muscle fibers?
A. High mitochondrial density
B. Rely on aerobic metabolism
C. Lower rate of force production
D. Major storage fuel is glycogen
Correct: D
Slow twitch, or Type I fibers, are more efficient at using oxygen to generate ATP and they have higher mitochondrial densities and capillary to volume ratios. Their major storage fuel is triglycerides. This allows them to utilize ATP more slowly. They are known to fire more slowly than their fast twitch, Type II, counterparts. This type of muscle fiber is important in endurance type events such as distance running or cycling. Type II fibers, or fast twitch fibers, are broken down into Type IIa and Type IIx in humans. They are more reliant on anaerobic metabolism to create fuel through the use of glycogen and creatine phosphate. These fibers are utilized in short bursts such as with sprinting and weight lifting.
1. Physiology, Costanzo LS, ed. 2nd Ed., Philidelphia, Saunders, 2002.
Scott Rand
A. Females, on average, experience a relative decrease in body fat after puberty
B. Females, on average, have increased cardiac output compared to males
C. Females, on average, have larger muscle fiber area compared to males
D. Females, on average, have lower blood hemoglobin content
Correct: D
VO2 max is an estimation the body's ability to utilize oxygen for energy; measured by the volume of oxygen per body weight per time (mL/kg/min). VO2 max is dependent on the body’s ability to deliver oxygen to muscle and extract oxygen for utilization in energy production. Females, on average, have about 10% lower blood hemoglobin content. This translates into 10% lower oxygen transport capacity and lower VO2 max. The calculation is affected positively by an increase in lean body mass. Females, on average, experience a relative decrease in lean body mass after puberty due to an increase in body fat after puberty. Females, on average, have smaller hearts after puberty with resulting decreased cardiac output compared to males. This leads to lower maximal delivery of oxygen when compared to males. Females, on average, have smaller muscle fiber area compared to males, leading to decreased total extraction of oxygen for utilization
1. Reference 1: Luckstead E F, et al (ed): The Pediatric Clinics of North America. W.B. Saunders Company, Volume 49, Number 3, June 2002, pages 557-558
2. Reference 2: Costa D.M., Guthrie S.R., et al (eds): Women and Sport: Interdisciplinary Perspectives. Human Kinetics Publishers, 1994, pages 170-172
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
Correct: A
Delayed onset muscle soreness (DOMS) describes pain 24-72 hours after unaccustomed exercise. It usually resolves in several days to a week after onset. Previously, lactic acid accumulation at the muscle site was thought to cause DOMS but it is now known that lactic acid is rapidly cleared and is not present at the time of DOMS. Studies have demonstrated that eccentric activities produce more muscle damage and more DOMS than concentric activities and this damage has been shown to involve structural damage to muscle banding patterns including disruption of sarcomere Z lines. Prostaglandin induced swelling has been demonstrated to sensitize afferent nerve fibers of muscle connective tissue which transmit sensation of dull pain to the central nervous system.
1. Clarkson, Priscilla M. 2007. Muscle Soreness: Cause, Consequence and Cure – Joseph B. Wolfe memorial lecture. American College of Sports Medicine 54th Annual Meeting: New Orleans, LA. May 30, 2007.
2. Sellwood KL, Brukner P, Williams D, Nicol A, Hinman R. 2007. Ice-water immersion and delayed-onset muscle soreness: a randomized controlled trial. British Journal of Sports Medicine. 41:392-397.
Scott Rand
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
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.
1. Melinda M. Manore, PhD, RD, Exercise and the Institute of Medicine Recommendations for Nutrition, Current Sports Medicine Reports 2005, 4:193 – 198
2. Anna Robins, MD, Nutritional Recommendations for Competing in the Ironman Triathlon, Current Sports Medicine Reports 2007, 6:241–248
3. Casa, Douglas J. PhD, ATC, FACSM, American College of Sports Medicine Roundtable on Hydration and Physical Activity: Consensus Statements, Current Sports Medicine Reports. 4(3):115-127, June 2005.
Scott Rand
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
Cardiac acceleration, increased myocardial contractility, and lipolysis are beta1 receptor effects (B,C,E).
Bronchodilatation is a beta2 effect (D).
1. Brooke, GA, K Baldwin, TD Fahey (2004) Neural –endocine control of metabolism, Exercise Physiology, St Louis; McGraw-Hill: 152.
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
Correct: C
Answer C is correct. Cold/ice water immersion has received much critism from both medical professionals and industry that propose more superior cooling methods. Potential complications have been raised including cardiovascular shock, hypothermia due to excessive cooling, inadequate access for other medical interventions, peripheral vasoconstriction, and shivering. While important to consider these issues, none of them have been proven as valid reasons not to utilize rapid cooling via cold/ice water immersion to treat EHS.
EHS is defined as a rectal temperature greater than 40-C (104-F) accompanied by symptoms or signs of organ system failure, most frequently central nervous system dysfunction.
Answer A is incorrect because temperature devices that assess a site on the outside of the body should not be used for the diagnosis of EHS in an athlete who has been exercising in the heat as none have been proven to be accurate. Therefore, oral and axillary temperatures should not be used.
Two viable options to establish CORE body temperature currently exist:
1. Rectal Thermometer - Unfortunately, an obvious drawback to rectal temperatures is
the invasive nature and the lack of privacy to perform this technique on the athletic field.
2. The ingestible thermistor is a second viable field measure. These devices transmit a signal that is obtained by a receiver that is held near the athlete. They provide a rapid assesment of CORE temperature, but they are expensive and must be ingested before the problem arises.
Answer B is incorrect because studies of exertional heat stroke have identified multiple risk factors that can allow health professionals to recognize predictable patterns allowing for primary prevention of this condition. Common risk factors include low physical fitness or physical effort unmatched to physical activity, underlying illness, improper acclimatization, heat load corresponding to green flag or above WBGT >27C), training at hottest hours, dehydration and sleep deprivation.
Answer D is incorrect, this describes two patterns that can cause exertional heat exhaustion no stroke.
1. Casa DJ, Armstrong LE, Ganio MS, Yeargin SW. Exertional heat stroke in competitive athletes. Curr Sports Med Rep. 2005 Dec;4(6):309-17.
2. American College of Sports Medicine, Armstrong LE, Casa DJ, Millard-Stafford M, Moran DS, Pyne SW, Roberts WO. American College of Sports Medicine position stand. Exertional heat illness during training and competition. Med Sci Sports Exerc. 2007 Mar;39
3. Team Physician's Handbook, 3rd Edition, Mellion et al, 2002, pp:135-136.
Scott Rand
A 16 year old female soccer player receives a direct blow to the mouth from an opposing player’s elbow. She immediately comes to the sideline and is noted to have bleeding from her mouth. In her hand, she is holding an intact, avulsed tooth. Which of the following management options will help to ensure the best outcome?
A. Gently wipe away blood and tissue remnants from the tooth with sterile saline-moistened gauze, preserve in saline and refer to dentist immediately
B. Clean the tooth with sterile saline, protect it in dry sterile gauze, and follow-up with dentist within eight hours
C. Reimplantation of the avulsed tooth and immediate referral
D. Preserve the tooth in milk and ensure follow-up with her dentist within eight hours
E. Discard the tooth and salvage and stabilize the underlying tissue with a protective mouth guard
Correct: C
Answer: C
Explanation:
Emergency sideline treatment of dental injuries aims to maintain the viability of the pulp, to prevent abnormal root resorption, and to restore function and aesthetics. Immediate care of an avulsed tooth is essential to a good outcome. Specifically, reimplantation within two hours is highly successful (C) and should be follow-up with urgent referral to a dentist or other specialized provider. The avulsed tooth must be handled carefully, and efforts should be taken to avoid contact with the exposed root and periodontal ligments, so (A) is incorrect. When reimplantation is not possible, the tooth should be preserved in the patient’s buccal muscoa, sterile saline, milk, or other commercial medium such as Hanks’ Balanced Salt Solution. Milk may preserve a viable tooth for up to four hours, so the follow-up period in (D) is incorrect. (B) is incorrect since the tooth should not be allowed to dry. The tooth should never be discarded (E).
1. Echlin P, McKeag DB. Maxillofacial injuries in sport. Curr Sport Med Reports 2004;3:25-32.
Scott Rand
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
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.
1. Frostbite. UpToDate. February 11 2008. http://www.uptodate.com. Accessed May 2, 2008.
2. Petrone P, Kuncir EJ, Asensio JA. Surgical management and strategies in the treatment of hypothermia and cold injury. Emerg Med Clin North Am 2003;21:1165.
3. Simon TD, Soep JB, Hollister JR. Pernio in pediatrics. Pediatrics 2005;116:e472.
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
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
Correct: C
Correct answer is C. Cardiac pacemakers may be relatively resistant to TENS signals, but there is one published report of an ICD being triggered by use of a TENS unit. Other relative contraindications to using a TENS unit include local skin irritation and contact dermatitis. TENS results in decreased dorsal horn cell activity after stimulation. High frequency, low intensity stimulation most likely produces analgesia via the gate theory whereas high intensity, lower frequency signals work by endorphin release. Hypoanalgesia may persist for up to 5 minutes after cessation of stimulation.
1. O’Connor, FG, Wilder, RP, St. Pierre, P. Sports Medicine: Just the Facts. McGraw-Hill 2005, p. 410.
Scott Rand
When treating patients with osteoarthritis, what therapy program has been shown to be most effective in improving Western Ontario MacMaster (WOMAC) scores?
A. A Home Exercise Program to improve compliance
B. Water therapy in a group setting
C. Formal Physical Therapy for at least 4 weeks
D. Supervised Physical Therapy followed by a Home Exercise Program
Correct: D
Correct answer is D. Both supervised physical therapy and a home exercise program improve function and pain scores, but the combination of the two is most effective in improving WOMAC scores
1. Deyle GD. A Randomized Controlled Trial Comparison of Supervised Clinical Exercise vs a HEP. Phys Ther. 2005 Dec;85(12):1301-17
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
Correct: A
This patient likely has a herniated disc with radicular symptoms to the foot. Flexion maneuvers make his symptoms worse so Williams’ exercises will exacerbate his symptoms. Back schools in a recent review published in Annals of Internal Medicine showed no decrease in pain or recurrence of low back pain but improved short term recovery and return to work. The same review in addition to a Cochrane Review, found little evidence to support the use of lumbar traction to decrease pain. McKenzie exercises are hyperextension maneuvers that reduce symptoms associated with disc disease.
Reference 4: Clarke JA, van Tulder MW, Blomberg SEI, de Vet HCW, van der Heijden G, Brønfort G, Bouter LM. Traction for low-back pain with or without sciatica. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD003010. DOI: 10.1002/14651858.CD003010.pub4
1. Eddy D, Congeni J, Loud K. A Review of Spine Injuries and Return to Play. Clinical Journal of Sports Medicine 15(6): 453-458.
2. Standaert CJ, Herring SA. Expert Opinion and Controversies in Musculoskeletal and Sports Medicine: Core Stabilization as a Treatment for Low Back Pain. Arch Phys Med Rehabil 2007. 88: 1734-6.
3. Chou R, Huffman LH. Nonpharmacologic Therapies for Acute and Chronic Low Back Pain: A Review of the Evidence for an American Pain Society/American College of Physicians Clinical Practice Guideline. Annals of Internal Medicine. 2007. 147: 492-504.
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
Correct: D
This is an example of proprioceptive neuromuscular facilitation. Static stretching is performed by slowly moving into a stretched position and holding the stretch for 15-30 seconds. Dynamic stretching involves maximal joint motion secondary to muscle contraction. The athletes uses controlled swinging of a limb with gradually increasing distance speed and intensity without exceeding their range of motion. Ballistic stretching involved quick bouncing movements that use momentum to achieve greater range of motion. This form of stretching is not recommended.
1. Mckeag, Douglas and Moeller, ACSM’s Primary Care Sports Medicine 2nd edition pp134-135
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
Correct: B
Answer: B
Explanation:
Open kinetic chain exercises involve free movement of the distal segment and are typically non-weightbearing. Examples include knee extensions and straight leg raises. Conversely, closed kinetic chain exercises involve fixation of the distal aspect of the extremity, and they are important during functional weightbearing activities (B). (A) is incorrect because the answer choice describes closed kinetic chain exercises. (C) is incorrect because knee extensions and straight leg raises are examples of open kinetic chain exercises. (D) is incorrect since simultaneous motion at all joints occurs during closed kinetic chain exercises. (E) is incorrect because open chain exercises produce shearing forces, while closed chain exercises produce compressive forces.
Scott Rand
A football player attempts to tackle an opposing
player by grabbing at his jersey. He then develops severe finger pain with
inability to flex the DIP joint. What is the diagnosis?
Correct answer: jersey finger, or avulsion of the flexor digitorum profundus
tendon. Treatment usually requires surgical tendon reattachment after initial
x-ray and splinting in slightly flexed position. Presents initially with an
inability to flex the DIP joint.
Scott Rand
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.
Courtesy of Orthobullets:
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
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
1. 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 artery exist within here
Scott Rand
1. What nerve(s) supply the rotator cuff muscles?
Scott Rand
1. Give the origin and insertion, action and innervation of the serratus anterior muscle
Originates on ribs 1-8. Inserts on the anteromedial border of the scapula. It retracts the scapula and holds it to the posterior thorax. It is innervated by the long thoracic nerve. Muscle dysfunction or paralysis leads to medial winging of the scapula.
Scott Rand
SLAP type
II tears can be associated with increased
A. anterioinferior translation
B. multidirectional subluxation
C. posterior recurrent subluxation
D. all of the above
Answer: D
In vitro, creating a SLAP avulsion has been shown to increase anterior
translation with a Bankart lesion and SLAP repairs limit anterior translation.
MDI has symptomatic inferior subluxation. SLAP tears can be found in certain
shoulders with inferior and posterior instability. The superior structures act
as a secondary restraint in the adducted shoulder.
http://www.orthobullets.com/sports/3053/slap-lesion
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 bones articulate with the Capitate?
Hamate, Lunate, Scaphoid, Trapezoid, Metacarpals 2, 3, & 4
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
All of the above are true except for option 2. A repeat plain film at 10-14 days post injury may now demonstrate a fracture that was not visible initially. Although controversial to an extent, immobilizing the thumb to minimize articular movement at the scaphoid makes clinical sense over leaving the thumb out of the cast. It is not necessarily widely accepted any longer to immobilize in a long arm cast. Of the non displaced fractures, distal pole injuries can take about 6 weeks to resolve, waist injuries anywhere from 8-12 weeks, and proximal pole injuries from 12-24 weeks, with cast immobilization. Obviously, displaced fractures require anatomic reduction, and proximal pole fractures are inherently risky for AVN or nonunion due to lack of adequate vascular support. MRI is favored over CT imaging, as it is non ionizing, can identify occult fractures via marrow edema signal changes. MRI can approach 100% sensitivity and specificity for occult scaphoid fractures.
Courtesy of Clinics in Sports Medicine 39(2020): 339-351
Scott Rand
A. radial nerve
B. posterior cord
C. upper trunk
D. lower subscapular nerve
E. lateral cord
Correct: C
A stinger is defined as a stretch type injury to the brachial plexus caused by forceful downward distraction of the shoulder while the neck side bends to the opposite side. Symptoms resolve in less than one minute.
A radial nerve injury would cause sensory problems in the posterior arm and forearm and lateral aspect of the arm.
The posterior cord would cause sensory problems over the lateral arm and motor problems to the subscapularis, teres major, deltoid, teres minor and latissimus dorsi.
Upper trunk injury would cause sensory changes to the shoulder joint and weakness to the supraspinatus, infraspinatus, and subclavius muscles.
The lower subscapular nerve would innervate the subscapularis and teres minor but have no sensory innervation.
Lateral cord injury would cause weakness to the pectoralis major and minor and no sensation changes.
1. Wheeless Textbook of Orthopedics, “Brachial Plexus”, www.wheelessonline.com updated February 2008
Scott Rand
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
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
1. Greiner KA. Am Fam Physician 2002 ;65:1817-22.
2. SOSORT guideline committee. Indications for conservative management of scoliosis (guidelines). Scoliosis 2006;1:5.
Scott Rand
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
Answer a is correct. 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.
1. Boden, BP and CG Jarvis. Spinal injuries in sports. Neurol Clin. 2008;26:63-78.
2. Wennberg, RA, HB Cohen, and SR Walker. Neurologic injuries in hockey. Neurol Clin. 2008;26:243-255.
3. Slotkin, JR, Y Lu, and KB Wood. Thoracolumbar spinal trauma in children. Neurosurg Clin N Am. 2007;26:621-630.
Scott Rand
What factor has most contributed to the dramatic decrease in catastrophic cervical spine injuries since 1976?
A. Improved pre-participation physical exam screening
B. Mental conditioning prior to games
C. Improvement in helmet design
D. Banning of spear tackling or primarily striking with the crown of one’s head
Correct: D
Correct answer: D
The dramatic decrease in catastrophic cervical spine injuries since 1976 is attributed to the banning of spearing in football. The other choices have had less definitive impact.
1. Torg, JS. (2004). Cervical spine injuries. In J.G. Garrick (Ed.). Orthopaedic knowledge update: sports medicine 3 (p3-18). Rosemont, IL: American Academy of Orthopaedic Surgeons.
Scott Rand
1. What is a common name for the brace often used in football to prevent recurrent shoulder dislocation?
Sully brace. It limits abduction and external rotation of the shoulder.
Scott Rand
1. What moves will score points in intercollegiate and high school freestyle wrestling
Freestyle wrestling in the high school and college level scores points for takedowns, escapes, reversals, near falls (2 and 3 points) and in college points are awarded for riding time
Scott Rand
1. In soccer, what is the difference between a goal kick, a corner kick and a throw in?
A throw in happens when the ball goes out of bounds on a sideline.
A goal kick happens when a ball goes out of bounds over an endline and was last touched by an offensive player. It is kicked in from the goal box by defensive team
A corner kick occers when the ball goes out over the endline but was last touched by a defensive player. It is kicked from the corner of the field but the offensive team
Scott Rand
1. Describe a snowboarder’s ankle or snowboarder’s fracture
Fracture of the lateral process of the talus caused by sudden dorsiflexion and hindfoot inversion.
Scott Rand
1. With respect to boxing, what are some of the Queensbury rules?
24 foot ring
Padded gloves
3 minute rounds
1 minute rest between rounds
Elimination of clutching and wrestling
10 second down count
No spiked shoes
Scott Rand
1. What are the phases of the baseball pitch?
Windup
Cocking
Acceleration
Deceleration
Follow thru
All phases of the baseball pitch have different injury patterns and risks.
Scott Rand
1. What are the pitch limits according to Little League baseball by age
Age 17-18 105 pitches per day
Age 13-16 95 pitches per day
Age 11-12 85 pitches per day
Age 9-10 75 pitches per day
Age 7-8 50 pitches per day
Scott Rand
1. A volleyball player presents with presents with decreased sensation and paresthesias over the dorsoradial hand. What is the most likely etiology?
Repetitive impact to the superficial branch of the radial nerve by the ball impact on the dorsoradial forearm.
Scott Rand
1. What are some ways to optimize speed in swimming?
Streamlinig (mimicking a torpedo)
Sculling Moving the hand in an oblique angle to the direction of travel
S pattern of hand pull
Drafting
Scott Rand
1. What are the events in mens and womens artistic gymnastics?
Men Floor, Pommel horse, Still rings Vault, Parallel bars, High bar
Women: Floor, balance beam, vault, uneven bars
Scott Rand
1. What are the events in the heptathlon?
The heptathlon is a combined track and field event contested by women (and sometimes men indoors), consisting of seven events spread over two days. The events test a range of athletic skills including speed, strength, and endurance.
Women’s Outdoor Heptathlon Events:
Day 1:
- 100 meters hurdles
- High jump
- Shot put
- 200 meters
Day 2:
5. Long jump
6. Javelin throw
7. 800 meters
Athletes earn points in each event according to a standardized scoring table (not simply by placement), and the winner is the one with the highest total score after all seven events.
Scott Rand
What are the events in the pentathlon?
The pentathlon is a combined track and field event typically contested by women in indoor competitions, featuring five events. It differs from the heptathlon in the number of events and the format of competition.
Women’s Indoor Pentathlon Events:
- 60 meters hurdles
- High jump
- Shot put
- Long jump
- 800 meters
Like the heptathlon, athletes in the pentathlon accumulate points based on their performances in each event, and the athlete with the highest total score wins.
Note: The men's pentathlon (traditionally contested indoors) has a slightly different format, consisting of:
- 60 meters
- Long jump
- Shot put
- High jump
- 1,000 meters
Scott Rand
What are the events in the decathalon?
The decathlon is a combined track and field event contested by men (and sometimes women in some competitions, like the heptathlon) and consists of ten events spread across two days. It is one of the most physically demanding multi-event competitions, testing a wide range of athletic abilities including speed, endurance, strength, and skill.
Men’s Outdoor Decathlon Events:
Day 1:
- 100 meters
- Long jump
- Shot put
- High jump
- 400 meters
Day 2:
6. 110 meters hurdles
7. Discus throw
8. Pole vault
9. Javelin throw
10. 1500 meters
The decathlon requires versatility and endurance since athletes must excel across a variety of events, from sprinting and jumping to throwing and distance running.
Similar to the heptathlon and pentathlon, scoring in the decathlon is based on a points system derived from performance in each event. The athlete with the highest total score after all ten events is the winner.
Scott Rand
Has the marathon always been 26.2 miles?
No, the marathon has not always been 26.2 miles (42.195 kilometers). The distance of the marathon evolved over time, and the current length was standardized only in the early 20th century.
A Brief History of the Marathon Distance:
- Origins of the Marathon (Ancient Greece):
The marathon is based on the legendary run of the Greek soldier Pheidippides, who is said to have run from the battlefield of Marathon to Athens (approximately 25 miles or 40 kilometers) to bring the news of the Greek victory over the Persians in 490 BC. However, this run was likely an exception rather than a regular race distance. - The First Modern Marathon (1896):
When the marathon was included in the 1896 Olympic Games in Athens (the first modern Olympics), the distance was set at approximately 40 kilometers (24.85 miles), closer to the historical run of Pheidippides. This distance was used for the first few Olympic marathons. - The 1908 London Olympics:
The key turning point in establishing the modern marathon distance occurred during the 1908 Olympic Games in London. The original distance for the marathon was set at about 26 miles, but the race was lengthened so that the event could start at Windsor Castle and finish in front of the royal box at the London Olympic Stadium. The final distance for this race was 26.2 miles (42.195 km). - Standardization of the 26.2-Mile Marathon Distance:
The distance of 26.2 miles was adopted by the International Association of Athletics Federations (IAAF) in 1921, after the 1908 Olympic event. It became the standard for all marathon races, including the famous Boston Marathon, which first used the 26.2-mile distance in 1924.
Since then, 26.2 miles (42.195 km) has become the universally recognized distance for marathons worldwide.
Why 26.2 Miles?
The extra 0.2 miles (or 385 meters) was essentially a royal request during the 1908 London Olympics to ensure the royal family could have a good view of the finish. This historical quirk became the official marathon distance from then on.
Scott Rand
What are the different distances in triathlon racing?
Triathlon racing comes in various distances, each catering to different levels of fitness and competition. The distances are standardized in many events, but there are also some variations. Here's a breakdown of the most common triathlon distances:
1. Sprint Triathlon
- Swim: 750 meters (0.47 miles)
- Bike: 20 kilometers (12.4 miles)
- Run: 5 kilometers (3.1 miles)
This is the shortest and most accessible triathlon distance, often used for beginners or those looking for a less demanding race.
2. Olympic Triathlon (Standard Distance)
- Swim: 1.5 kilometers (0.93 miles)
- Bike: 40 kilometers (24.8 miles)
- Run: 10 kilometers (6.2 miles)
This is the distance used in the Olympic Games and is considered the standard competitive distance for many triathlons.
3. Half Ironman (Ironman 70.3)
- Swim: 1.9 kilometers (1.2 miles)
- Bike: 90 kilometers (56 miles)
- Run: 21.1 kilometers (13.1 miles, half marathon)
This distance is often called the Ironman 70.3, reflecting the fact that it's half the total distance of a full Ironman. It’s a challenging but popular event for more experienced triathletes.
4. Full Ironman
- Swim: 3.8 kilometers (2.4 miles)
- Bike: 180 kilometers (112 miles)
- Run: 42.195 kilometers (26.2 miles, full marathon)
The Ironman triathlon is the ultimate endurance challenge in triathlon racing. It consists of a full marathon after swimming and cycling the long distances. This is the longest and most grueling triathlon distance.
5. Ultra Triathlon (Beyond Ironman)
- Distances vary, but they go beyond the traditional Ironman distance, sometimes involving multiple laps or extremely long distances. Some examples include:
- Double Ironman (7.6 km swim, 360 km bike, 84.4 km run)
- Triple Ironman (11.4 km swim, 540 km bike, 126.6 km run)
These ultra-triathlons are for extreme endurance athletes looking for a monumental challenge.
6. Super Sprint Triathlon
- Swim: 400 meters (0.25 miles)
- Bike: 10 kilometers (6.2 miles)
- Run: 2.5 kilometers (1.55 miles)
A super sprint is an even shorter race, often used in youth or novice events. It’s a great introduction to the sport of triathlon, offering a less intense challenge.
Other Variations:
- Cross Triathlon:
Involves off-road disciplines, with a swim in open water, a mountain bike segment, and a trail run. - Aquabike:
This is a race that consists of just the swim and the bike segments, without the run portion, making it a good option for athletes with running injuries or those who prefer cycling. - Duathlon:
A race consisting of a run-bike-run format. Common distances are: - Short: 5 km run, 20 km bike, 2.5 km run
- Long: 10 km run, 40 km bike, 5 km run
Choosing a Distance
Triathletes typically progress from shorter distances (Sprint) to longer ones (Olympic, Half Ironman, Ironman) as their fitness and experience improve. Some prefer to specialize in shorter races, while others aim for the ultimate challenge with full Ironman races.
Scott Rand
1. At what wet bulb globe temperature would you, as race medical director, recommend canceling a race per IMMD guidelines
A WBGT greater than 82 degrees is recommended as the threshold for canceling races
Scott Rand
1. The banked track used in cycling is called a ___________________
Velodrome
Scott Rand
1. What is the minimal allowed body fat percentage in NCAA wrestling
5%
Scott Rand
1. What are the events in diving competition?
Spring board 1 meter and 3 meter
10 meter platform
Syncronized diving 3 meter and 10 meter