daily answer
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.
Director, Primary Care Sports Medicine Fellowship
Medical Director, Sports Performance
Assistant Professor, Weill Cornell Medical College
13802 Centerfield Dr, Suite 300
Houston, TX 77070
(281) 737-0902 Clinic
(281) 737-0926 Fax
Scott Rand
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
What are the contents of the tarsal tunnel?
Answer: The tarsal tunnel is bordered by the lacunate ligament superiorly, and by the plantar surface of the tarsal bones and the metatarsal heads distally. It contains the Tibialis posterior tendon, the flexor digitorum longus tendon, the flexor hallucis longus tendon.. (Tom, Dick, and Harry) and the tibial nerve and the posterior tibial artery and vein.
Scott Rand
Pain in the posterior ankle with running a steep downhill course is indicative of what problem?
Answer: Os Trigonum Syndrome or posterior impingement type syndrome.
Scott Rand
Which metatarsal is the most common to have a stress fracture.
Answer: second.
Scott Rand
: What is Freiberg’s infarction?
Answer: A vascular insult to the primary growth center of the second metatarsal head. This typically occurs in the second decade of life.
Scott Rand
: 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
Rand, Scott E., M.D.
Scott E Rand, MD FAAFP CAQSM
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Scott Rand
. A 20-year-old female who is joining an intramural team at her college was noted to have an unusual murmur on her sports physical before the season began. The doctor thought he heard a continuous murmur at the left upper sternal border associated with a slightly widened pulse pressure and brisk to bounding pulses. Which of the following is the most likely diagnosis?
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 the size 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
. Look at the attached ECG. What is the most likely diagnosis? What findings are indicative of that diagnosis?
This ECG is indicative of hypertrophic cardiomyopathy. The deep inverted T waves lateraly and diffuse ST changes are characteristic.
Scott Rand
What is the sequence and timing of the different ossification centers in the pediatric elbow? Which 3 later fuse to form the largest epiphyseal center of the elbow?
The trochlea, capitellum and lateral epicondyle fuse to form the largest epiphysis. The olecranon, medial epicondyle and radial head are all their own epiphysis.
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
Base of the 5th metatarsal Iselin’s disease
Calcaneal apophysis Sever’s disease
Tibial tubercle apophysis Osgood Schlatter’s disease
Inferior pole of the patella Sindig-Larson-Johanson disease
Scott Rand
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
The most common nerve injury in glenohumeral shoulder dislocations is the:
A. Suprascapular nerve
B. Axillary nerve
C. Long thoracic nerve
D. Radial nerve
E. Musculocutaneous nerve
Correct: B
The suprascapular nerve innervates the supra and infra spinatus muscles; injury is produced by stretching or compression, not dislocation.
The axillary nerve is the most common nerve injured by shoulder dislocation.
The long thoracic nerve is usually injured by a direct blow or compression which leads to paresis of the serratus anterior and scapular winging. The radial nerve - this nerve can be compressed at multiple sites along its course; even at the high axillary location it is not typically injured during shoulder dislocation. While injury to the musculocutaneous nerve due to dislocated shoulder is reported it is uncommon; more common is compression with excessive resistive elbow extension such as in bench press or pushups.
1. Hodge DK, Safran MR. Sideline management of common dislocations. Curr Sports Med Rep. 2002, I:149-155
Scott Rand
The “clunk test” evaluates shoulder pathology caused by the following:
A. Impingement
B. Tendinopathy
C. Labral tears
D. Sliding Biceps tendon
E. Instability
Correct: C
Snapping shoulder syndrome may be related to an intraarticular or extraarticular pathological condition. The initial evaluation of a patient with snapping shoulder should include thorough examination for mild glenohumeral instability and labral defects, which can be evaluated by the “clunk” test. This test, as described by Andrews and Gillogly, is performed with the patient supine and the arm in full overhead abduction. One of the examiner”s hands is placed posterior to the humeral head to apply anterior pressure while the other hand is placed at the level of the humeral condyles to provide rotation and axial loading. A “clunk” or grinding may indicate a Bankart lesion or a labral tear caused by instability.
1. Canale: Campbell”s Operative Orthopaedics, 10th ed. 2003
Scott Rand
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
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
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
Scott Rand
What phase of the baseball pitch causes the most distraction force to the medial elbow?
Early acceleration. The force at the ulnar collateral ligament in this phase can approach 60 newtons.
Scott Rand
A 35 year old male playing basketball falls and sustains an elbow injury. Clinical exam and radiographs reveal a completely nondisplaced fracture involving 65% of his coronoid process. He has no associated injuries or instability. The recommended treatment is which of the following?
A. immob in 90 deg flexion and neutral rotation
B. immob in 120 deg flexion and neutral rotation
C. immob in 120 deg flexion and supination
D. immob in 120 deg flexion and pronation
E. ORIF
Answer: E
Fractures of the coronoid are caused by humeral hyperextension and are
associated with dislocation of the elbow 10-33% of the time. Treatment of the
coronoid fracture depends on fracture stability pattern, which is defined by
amount of coronoid involvement. Greater than 50% involvement requires ORIF,
even for nondisplaced fractures; less than 50% may be treated with cast
immobilization if stable.
Scott Rand
During which phase of the overhead throwing cycle is a baseball pitcher most likely to rupture the medial ulnar collateral ligament complex of the elbow?
1. Follow-through
2. Ball release
3. Early acceleration
4. Early cocking
5. Wind-up
The medial UCL is subjected to
near-failure tensile stresses during the late cocking/early acceleration phase
of throwing.
The medial ulnar collateral ligament, or medial collateral ligament of the
elbow, is composed of three bundles: an anterior bundle, a posterior bundle,
and a variable transverse oblique bundle. The anterior bundle of the ulnar
collateral ligament is the primary restraint to valgus force of the elbow from
30 to 120 degrees of flexion. Biomechanical testing has shown that valgus forces
as high as 64 N.m at the elbow during late cocking and early acceleration
phases of throwing with compressive forces of 500 N at the lateral
radiocapitellar articulation as the elbow moves from 110 to 20 degrees of
flexion and velocities as high as 3000 deg/sec.
Courtesy of Orthobullets
Scott Rand
A. MRI studies are often not helpful in the diagnosis of cubital tunnel syndrome
B. Electromyogram (EMG) and nerve conduction studies are rarely helpful in the diagnosis of cubital tunnel syndrome
C. Patients will usually complain of paresthesias in the thumb and index finger
D. Patients may have weakness in thumb-index finger pinch (Froment’s sign) in chronic cases
E. In throwing athletes, the first-line treatment for cubital tunnel syndrome is ulnar collateral ligament reconstruction
Correct: D
Cubital tunnel syndrome (a.k.a. ulnar nerve compression syndrome) is entrapment of the ulnar nerve at the elbow. Areas of entrapment include: 1) the arcade of Struthers; 2) hypertrophic medial head of triceps; 3) spurs from the medial epicondyle and olecranon groove; 4) anconeus epitrochlearis; 5) cubital tunnel retinaculum (a.k.a. Osborne’s ligament); 6) stenotic cubital tunnel; and 7) the split of the humeral and ulnar heads of the flexor carpi ulnaris. It typically presents with paresthesias in the ulnar side of ring finger and in the small finger, but with no pain (Answer C is incorrect). Answer D is correct because the ulnar nerve innervates the adductor pollicis and deep head of the flexor pollicis brevis. Chronic ulnar neuropathy may lead to weakness in these muscle and decreased pinch strength (Froment’s sign). Answer B is incorrect because an EMG/NCS usually shows slowing of the conduction velocity across the elbow and can be helpful in the diagnosis. Answer E is incorrect because relative rest is usually the initial treatment. Throwing athletes with recurrent episodes may need surgery.MRI can be helpful in the diagnosis of ulnar nerve entrapment at the ellbow with the finding of increased signal intensity better than nerve enlargement.
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 424
2. Verheyden JR, Palmer AK. Cubital tunnel syndrome. eMedicine (last updated Feb 2007); http://www.emedicine.com/orthoped/topic479.htm
3. Keefe DT, Linter DM. Nerve injuries in the throwing elbow. Clin Sports Med 2004; 23(4):729-732. Waldman SD. Atlas of Pin Management Injection Techniques. Philadelphia: WB Saunders, 2000, pp 103-106
Scott Rand
What tendons pass through the first dorsal compartment of the wrist? What entity is commonly associated with difficulty with these tendons?
The tendons of the abductor pollicis longus and the extensor pollicis brevis pass through the first dorsal compartment. The abductor pollicis longus tendon is usually multistranded. The extensor pollicis brevis tendon is typically much smaller than even a single slip of the abductor pollicis longus tendon, and it may be congenitally absent. A septum separating the first dorsal compartment into distinct subcompartments for the abductor pollicis longus tendons and the extensor pollicis brevis tendon is often noted at surgery.
De Quervain tenosynovitis is an entrapment tendinitis of the tendons contained within the first dorsal compartment at the wrist; it causes pain during thumb motion.
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 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 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
A day after being struck with a pitched ball on the ulnar aspect of the left wrist and hand, a professional baseball player develops “pins and needles” in the small and ulnar half of his ring fingers. He finds it extremely difficult to grab the bat to participate in batting practice. After x-rays demonstrate no acute abnormalities of the left wrist and hand, he is diagnosed with Guyon’s canal syndrome. What two bones form Guyon’s canal?
A. Pisiform and Triquetrum
B. Pisiform and Hamate
C. Hamate and Lunate
D. Triquetrum and Lunate
Correct: B
Answer: B
Guyon’s canal syndrome is entrapment of the ulnar nerve as it passes through a tunnel in the wrist called Guyon’s canal. The canal is formed by the most lateral bones of the proximal and distal carpal rows, the pisiform and hamate respectively, and the ligament that connects them. The ulnar nerve is accompanied by the ulnar artery as it passes through this canal. Symptoms can include a sensation of pins and needles in the small and ulnar half of the ring fingers, decreased sensation in the same distribution as well as weakness of the small muscles of the palm and the muscle that pulls the thumb towards the palm.
1. McKeag, D and Moeller, J. ACSM’S Primary Care Sports Medicine 2nd edition.
Scott Rand
A 14-year-old female presents for a pre-sports physical. She complains of back discomfort when she "sits at school for a long time." Her exam reveals scoliosis with a left-sided curve. An MRI of the spine is indicated to rule out which of the following conditions?
A. Intraspinal syrinx
B. Narrowing of disk space
C. Schmorl nodes
D. Irregularities in vertebral endplates
E. Loss of anterior vertebral height
Correct answer: (A) Intraspinal syrinx.
Explanation: About 80% of scoliosis cases appear as a right thoracic curve. A left-sided pattern is associated with risk for intraspinal syrinx or tumor, which can be detected on MRI. The remainder of findings are associated with Schneurmann kyphosis, the 2nd-most common cause of spinal deformities in pediatrics. A scoliotic curve must measure greater than or equal to 10 degrees on a spinal radiograph via the Cobb method (a special tool that measures the angle on radiograph) to meet the criteria for diagnosing scoliosis, but most patients do not exhibit clinically significant respiratory symptoms until the curves measure 60 to 100 degrees.
The USPSTF states that treating idiopathic scoliosis during adolescence leads to health benefits in only a small fraction of patients. Most of the cases detected through screening do not become clinically significant, and scoliosis that requires aggressive treatment/operative treatment is likely to be detected without screening because these patients are eventually symptomatic.
Scott Rand
Loss of lumbar lordosis, vertebral wedging, and Schmorl nodes in the lumbar spine are seen in what condition?
A. spondylolysis
B. spondylolisthesis
C. Scheuerman disease
D. all of the above
The answer is C, Scheuerman's disease is a self-limiting disease of childhood also known as idiopathic juvenile kyphosis of the spine. It describes a disease process where the verterbra grow unevenly in the sagital plane, where the posterior side grows faster than the anterior side, creating a vertical wedging between the vertebra and a kyphotic curvature to the spine. Excessive lumbar lordosis can also be seen as kyphosis progresses and Schmorl nodes or vertebral disc herniations can result as they are compressed by the vertebral wedging. Once the patient is fully grown, the bones will maintain their deformed structure and surgery is often warrented to correct the kyphosis.
Scott Rand
A Trendelenburg gait would most likely be caused by which of the following lumbar conditions?
1. L3/4 far lateral disc herniation
2. L3/4 central disc herniation with impingement on the bilateral descending nerve roots
3. L4/5 far lateral disc herniation
4. L5/S1 far lateral disc herniation
5. L5/S1 paracentral disc herniation
A Trendelenburg gait is caused by gluteus medius weakness. Gluteus medius is
innervated by L5. Therefore a L5/S1 far lateral disc herniation could cause
this condition.
Gluteus medius originates from the dorsal ilium inferior to iliac crest and
inserts to the lateral and superior surfaces of greater trochanter. It is the
major abductor of thigh, and also functions to help to rotate the hip medially
and laterally. Arterial supply is by the superior gluteal artery. It is
mediated by the superior gluteal nerve, which is primarily innervated by L5. L5
also contributes to ankle dorsiflexion (combined with L4), great toe extension,
and sensation over lateral calf and dorsal foot.
Courtesy of Orthobullets
Scott Rand
An otherwise healthy 16 year old male gymnast presents with a three month history of non-radiating bilateral low back pain that worsens when he does back hand springs. On physical examination, his pain worsens with extension based maneuvers and he has markedly decreased bilateral hamstring flexibility. There is no evidence of spondylolisthesis on plain x-rays. A bone scan with SPECT and a thin-slice CT confirm your diagnosis. What rehab program would you prescribe?
A. Extension-biased spinal stabilization and quadriceps flexibility exercises
B. Flexion-biased spinal stabilization and hamstring flexibility exercises
C. Extension-biased spinal stabilization and hamstring flexibility exercises
D. Plyometric exercise program
E. A rehab program is not indicated for this condition
Correct: B
Correct answer is B. This athlete’s most likely diagnosis is lumbar spondylolysis, a stress fracture of the par interarticularis. The pars interarticularis is the region of the spinal lamina between the superior and inferior articulating processes. Spondylolysis often occurs due to repetitive hyper-extension and axial rotation stresses on the lumbar spine. This problem is very common in gymnasts. Lumbar spondylolysis most commonly occurs at the L5 level. Bilateral spondylolysis is more common than unilateral spondyloyisis and can lead to spondylolisthesis (slippage of one vertebral body on another). On physical examination the patient may have vertebral paraspinal muscle tenderness at the affected level, limited painful range of motion in both flexion and extension, and significant worsening of the low back pain with extension-based spine testing maneuvers. Up to 80% of patients with lumbar spondylolysis will have associated decreased hamstring flexibility. Initial treatment is conservative management including complete rest from the athlete’s sport, a therapy program focusing on core strengthening, flexion-biased spinal stabilization and hamstring flexibility and possibly lumbar spine bracing. An extension based therapy program may exacerbate the athlete’s symptoms.
1. Micheli LJ and Curtis C. Stress fractures of the spine and sacrum. Clin Sports Med. 2006 Jan; 25(1): 75-88.
2. Bono, CM. Low Back Pain in Athletes. J Bone Joint Surg Am. 2004 86(2): 382-96.
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).
Alessandra Posey
Good work!
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From: the-sports-medici...@googlegroups.com <the-sports-medici...@googlegroups.com>
On Behalf Of Scott Rand
Sent: Monday, September 25, 2023 9:30 AM
To: Daily Question <the-sports-medici...@googlegroups.com>
Subject: daily answer
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Scott Rand
Scott Rand
Scott Rand
Please identify the anatomic structures labeled. When performing a knee injection, where are you trying to place the needle?
Scott Rand
Please identify the anatomic structures labeled in the wrist. What is the condition seen if the cross sectional area of the structure with the solid arrow is greater than 13 mm squared?
Sonographic measurement of cross-sectional area of the median nerve in the diagnosis of carpal tunnel syndrome: correlation with nerve conduction studies.
Moran L1, Perez M, Esteban A, Bellon J, Arranz B, del Cerro M.
- 1Department of Radiology, Hospital Universitario Gregorio Marañon, Madrid, Spain.
Abstract
PURPOSE:
To assess the usefulness of sonographic measurement of the median nerve cross-sectional area (CSA) in the diagnosis of carpal tunnel syndrome (CTS) and grading of its severity using nerve conduction (NC) studies as the standard.
METHOD:
The CSA of the median nerve was measured at the tunnel inlet and outlet using the ellipse formula and automatic tracing in 72 hands with suspicion of CTS.
RESULT:
The lack of inter-reader reliability led to excluding CSA measurements obtained at the tunnel outlet. Based on the receiver operating characteristic curves, the following cut-off points for the CSA of the median nerve at the tunnel inlet was selected: 9.8 mm and 12.3 mm(2) for the ellipse formula and 11 and 13 mm(2) for automatic tracing. For the ellipse formula, a CSA less than or equal to 9.8 mm(2) excluded CTS whereas a CSA greater than or equal to 12.3 mm(2) was diagnostic of CTS with measurements between 9.8 and 12.3 mm(2) being indeterminate and requiring NC studies. For automatic tracing, the cutoff value of 11 mm(2) was excluded because of the high percentage of false negatives, whereas CSAs greater than or equal to 13 mm(2) were diagnostic of CTS. There were no statistically significant differences in CSA measurements between the various degrees of CTS severity determined by NC studies.
CONCLUSION:
Sonographic measurement of median nerve CSA at the tunnel inlet is a good alternative to NC studies as the initial diagnostic test for CTS, but it cannot grade the severity of CTS as well as NC studies.
Scott Rand
Scott Rand
This 17 year old male presented to clinic with complaints of a minimally painful lump on the medial side of the right knee for the past several months at least. No known injury.
3 views of the right knee reveal an osteochondroma arising from the medial metaphyseal area of the right proximal tibia. No fracture is seen. Physes are nearly closed. NO fracture is seen. No significant soft tissue swelling.
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 33 year old female presented 3 days after noting pain over the lateral side of the foot after doing cross fit box jumps. She notes sharp pain near the base of the 5th metatarsal.
There is a very subtle fracture line noted thru the proximal shaft of the 5th metatarsal, consistent with a Jones fracture.
Scott Rand
Dive medicine
Please give 2 environmental and 2 individual risk factors for decompression sickness. Think of situations or characteristics of the dive for the enviromment and medical or personal issues or behaviors for the individual.
- the magnitude of the pressure reduction ratio – a large pressure reduction ratio is more likely to cause DCS than a small one.[20][25][31]
- repetitive exposures – repetitive dives within a short period of time (a few hours) increase the risk of developing DCS. Repetitive ascents to altitudes above 5,500 metres (18,000 ft) within similar short periods increase the risk of developing altitude DCS.[20][31]
- the rate of ascent – the faster the ascent the greater the risk of developing DCS. The US Navy Dive Manual indicates that ascent rates greater than about 20 m/min (66 ft/min) when diving increase the chance of DCS, while recreational dive tables such as the Bühlmann tables require an ascent rate of 10 m/min (33 ft/min) with the last 6 m (20 ft) taking at least one minute.[32] An individual exposed to a rapid decompression (high rate of ascent) above 5,500 metres (18,000 ft) has a greater risk of altitude DCS than being exposed to the same altitude but at a lower rate of ascent.[20][31]
- the duration of exposure – the longer the duration of the dive, the greater is the risk of DCS. Longer flights, especially to altitudes of 5,500 m (18,000 ft) and above, carry a greater risk of altitude DCS.[20]
- underwater diving before flying – divers who ascend to altitude soon after a dive increase their risk of developing DCS even if the dive itself was within the dive table safe limits. Dive tables make provisions for post-dive time at surface level before flying to allow any residual excess nitrogen to outgas. However, the pressure maintained inside even a pressurized aircraft may be as low as the pressure equivalent to an altitude of 2,400 m (7,900 ft) above sea level. Therefore, the assumption that the dive table surface interval occurs at normal atmospheric pressure is invalidated by flying during that surface interval, and an otherwise-safe dive may then exceed the dive table limits.[33][34][35]
- diving before travelling to altitude – DCS can occur without flying if the person moves to a high-altitude location on land immediately after diving, for example, scuba divers in Eritrea who drive from the coast to the Asmara plateau at 2,400 m (7,900 ft) increase their risk of DCS.[36]
- diving at altitude – diving in water whose surface altitude is above 300 m (980 ft) — for example, Lake Titicaca is at 3,800 m (12,500 ft) — without using versions of decompression tables or dive computers that are modified for high-altitude.[33][37]
Atrial septal defect (PFO) showing left-to-right shunt. A right-to-left shunt may allow bubbles to pass into the arterial circulation.
The following individual factors have been identified as possibly contributing to increased risk of DCS:
- dehydration – Studies by Walder concluded that decompression sickness could be reduced in aviators when the serum surface tension was raised by drinking isotonic saline,[38] and the high surface tension of water is generally regarded as helpful in controlling bubble size.[31] Maintaining proper hydration is recommended.[39]
- patent foramen ovale – a hole between the atrial chambers of the heart in the fetus is normally closed by a flap with the first breaths at birth. In about 20% of adults the flap does not completely seal, however, allowing blood through the hole when coughing or during activities that raise chest pressure. In diving, this can allow venous blood with microbubbles of inert gas to bypass the lungs, where the bubbles would otherwise be filtered out by the lung capillary system, and return directly to the arterial system (including arteries to the brain, spinal cord and heart).[40] In the arterial system, bubbles (arterial gas embolism) are far more dangerous because they block circulation and cause infarction (tissue death, due to local loss of blood flow). In the brain, infarction results in stroke, and in the spinal cord it may result in paralysis.[41]
- a person's age – there are some reports indicating a higher risk of altitude DCS with increasing age.[14][31]
- previous injury – there is some indication that recent joint or limb injuries may predispose individuals to developing decompression-related bubbles.[14][42]
- ambient temperature – there is some evidence suggesting that individual exposure to very cold ambient temperatures may increase the risk of altitude DCS.[14][31] Decompression sickness risk can be reduced by increased ambient temperature during decompression following dives in cold water.[43]
- body type – typically, a person who has a high body fat content is at greater risk of DCS.[14][31] This is due to nitrogen's five times greater solubility in fat than in water, leading to greater amounts of total body dissolved nitrogen during time at pressure. Fat represents about 15–25 percent of a healthy adult's body, but stores about half of the total amount of nitrogen (about 1 litre) at normal pressures.[44]
- alcohol consumption – although alcohol consumption increases dehydration and therefore may increase susceptibility to DCS,[31] a 2005 study found no evidence that alcohol consumption increases the incidence of DCS.[45]
Scott Rand
. On the way to a recompression chamber, what is the recommended initial medical treatment?
For severe decompression illness, aggressive IV hydration is recommended. For all cases breathing 100% oxygen by non rebreather mask helps reabsorb nitrogen bubbles in the tissue.
Scott Rand
. What is the national organization that exists to help you manage divers with decompression sickness? How do you contact them?
Call the DAN Emergency Hotline
Call +1-919-684-9111 to talk to an expert in diving medicine. You may call collect. DAN medical staff is on call 24 hours a day to handle diving emergencies.
When You Call the DAN Emergency Hotline:
1. Tell the operator you have a diving emergency. The operator will either connect you directly with DAN or have someone call you back at the earliest possible moment.
2. The DAN staff member may make an immediate recommendation or call you back after making arrangements with a local physician or the DAN Regional Coordinator. DAN Regional Coordinators are familiar with chamber facilities in their area, and because they're qualified in diving medicine, they make recommendations about treatment.
3. The DAN staff member or Regional Coordinator may ask you to wait by the phone while he / she makes arrangements. These plans may take 30 minutes or longer, as several phone calls may be required.
This delay should not place the diver in any greater danger. However, if the situation is life-threatening, arrange to transport the diver immediately to the nearest local medical facility for immediate stabilization and assessment of his or her condition. Call the DAN Emergency Hotline (+1-919-684-9111) if you need evacuation assistance through DAN TravelAssist.
Scott Rand
Ciguatera fish poisoning (or ciguatera) is an illness caused by eating fish that contain toxins produced by a marine microalgae called Gambierdiscus toxicus. People who have ciguatera may experience nausea, vomiting, and neurologic symptoms such as tingling fingers or toes. They also may find that cold things feel hot and hot things feel cold. Ciguatera has no cure. Symptoms usually go away in days or weeks but can last for years. People who have ciguatera can be treated for their symptoms.
Scott Rand
Briefly differentiate type1 and type 2 decompression sickness
Type I decompression sickness
Type I DCS is characterized by one or a combination of the following: (1) mild pains that begin to resolve within 10 minutes of onset (niggles); (2) pruritus, or "skin bends," that causes itching or burning sensations of the skin; and (3) cutis marmorata.
Cutis marmorata, cutaneous DCS, is a rash that generally is widespread mottling and/or marbling of the skin or a papular or plaquelike violaceous (blue-red) rash. On rare occasions, skin has an orange-peel appearance. Cutis marmorata typically starts as an intense multifocal itching, then hyperemia develops, followed by the already-described purplish rash. [27] In the past, it was thought to be a benign disorder from bubble formation, with theories for its presence of vascular occlusion ranging from right-to-left shunt (eg, from a PFO), to supersaturation of subcutaneous fat tissues. [28] A newer theory is gas emboli amplification in cutaneous capillaries. [29, 30] One study reports a near 100% presence of PFO on contrast echocardiography. [31] However, similarities of this rash with livedo reticularis or livedo racemose (due to sympathetic overloads), along with a small number of divers with cutis marmorata who also have vague neurologic symptoms, has led to more recent theories of the rash being centrally mediated in DCS. [29, 31] Specifically, a newer hypothesized theory is for gas embolization of the brainstem affecting autonomic control of vasodilation and vasoconstriction. [31]
Lymphatic involvement is uncommon and typically causes painless pitting edema. The mildest cases involve only the skin or the lymphatics. Some authorities consider anorexia and excessive fatigue after a dive as manifestations of type I DCS.
Pain (the bends) occurs in most (70-85%) patients with type I DCS. Pain is the most common symptom of this mild type of DCS often described as a dull, deep, throbbing, toothache-type pain, usually in a joint or tendon area but also in tissue. The shoulder is the most commonly affected joint. The pain is initially mild and slowly becomes more intense. Because of this, many divers attribute early DCS symptoms to overexertion or a pulled muscle.
Muscle splinting causes decreased function. Upper limbs are affected about 3 times as often as lower limbs. The pain caused by type I DCS may mask neurologic signs that are hallmarks of the more serious type II DCS. Dysbaric osteonecrosis is a phenomenon that occurs in divers with high numbers of dives. This is a persistent problem, suggesting that the mechanisms involved in the disorder are not yet understood.
Cutaneous abnormalities, joint and muscular pain, and neurologic manifestations (covered in the next section) were the three most common symptoms. The initial symptoms started within 6 hours of surfacing in 99% of cases with an overall mean delay to onset of 62 minutes. The shorter the time to onset, the more serious the symptoms. [32]
Delineation of mild type I DCS symptoms and signs can be useful when considering treatment (refer to the later section on HBO therapy). General fatigue, nondermatomal distribution skin sensory aberrations, rash, pruritus, isolated limb pain (not symmetric), and subcutaneous edema that are not progressive out to 24 hours are all examples. It is important that there are no concomitant spinal or central neurologic symptoms or signs (see the next section on type II DCS for details). [33]
Type II decompression sickness
The following characterizes type II DCS: (1) pulmonary symptoms, (2) hypovolemic shock, or (3) nervous system involvement. Pain occurs in only about 30% of cases. Because of the anatomic complexity of the central and peripheral nervous systems, signs and symptoms are variable and diverse. Symptom onset is usually immediate but may occur up to 36 hours later.
Nervous system
The spinal cord is the most common site affected by type II DCS; symptoms mimic spinal cord trauma. Low back pain may start within a few minutes to hours after the dive and may progress to paresis, paralysis, paresthesia, loss of sphincter control, and girdle pain of the lower trunk. Patients with the worst outcomes (still having multiple neurological sequelae with less than 50% resolution after hyperbaric oxygen therapy) were those who had onset of symptoms within 30 minutes of surfacing. [34]
Vertebral back pain after a dive is a poor prognostic sign and can be a hallmark of spinal DCS with anticipated poor long-term outcome. [35, 36]
Dysbaric myelitis occurs in half of the cases of neurological DCS. Venous ischemia is the most likely cause. Bladder problems, such as neurogenic bladder, may be common in the acute phase of DCS, may be the primary presentation, and may be prolonged. Intraspinal pressure and perfusion appear to play important roles in the injury. Just as the cerebrum is contained in a confined, nonexpandable, space, so is the spinal cord. Decreases in blood pressure and/or increases in CSF intraspinal pressure can compromise circulation, thus increasing ischemic injury. Despite improvement in examination findings with treatment, it has been found that there can be significant cord damage as a result. Similar to intracerebral pressure monitoring and drainage, consideration should be given for similar intraspinal pressure monitoring and drainage. [37]
Pulmonary filtration protects the nervous system by stopping bubbles at the lungs. A shortcut, such as a PFO or ASD, can bypass this filtration. Additionally, hypoxia may open intrapulmonary anastomoses, thus also allowing venous bubbles to pass into arterial circulation. [38] This filtration is size dependent. Tiny bubbles, or microemboli, that escape entrapment and continue to the brain do not cause infarction. Normal cerebral circulation starts with the highly oxygenated arterial blood flowing through the gray matter where much of the oxygen is extracted. This less oxygenated blood then flows to the long draining veins that supply the white matter of both the cerebral medulla and the spinal cord. At this level, even small additional decreases of oxygen content by embolization can be enough to damage the blood-brain barrier and initiate a cascade that ends with axonal damage. The result can be perivenous syndrome. [39]
DCS can be dynamic and does not follow typical peripheral nerve distribution patterns. This strange shifting of symptoms confuses the diagnosis of differentiating DCS from traumatic nerve injuries. Neurological deficits after a spinal cord injury can be multifocal. Sensory and motor disturbances can present independently, often resulting in a situation of "dissociation." This dissociation is found in most cases of spinal cord DCS.
MRI studies have seemingly revealed arterial patterns of infarction in spinal DCS. [34]
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 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
A Segond fracture is pathogonomic for which ligamentous injury
A. Medial collateral ligament
B. Lateral collateral ligament
C. Anterior cruciate ligament
D. Posterior cruciate ligament
Correct: C
A Segond fracture is a vertical avulsion fracture of the lateral tibial condyle where the lateral capsular ligament attaches. It occurs with anterior cruciate ligament injuries.
1. Levandowshi, R and Cohen, P. (2004). Knee Injuries. In: Birrer, RB and O'Connor, FG Sports Medicine for the Primary Care Physician. 3rd ed. New York: CRC Press. 633-34.
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
When evaluating anterior knee pain, the defining characteristics of patellar tendinitis include which one of the following?
A. There are findings on imaging that are “pathognomic” for patellar tendinitis
B. Surgery is more effective than rehabilitation
C. Patellar tendinitis is common and rarely requires treatment
D. Training errors are the most common cause
Correct: D
Other than age range (teens to 40s) the most common identifiable risk factors are training errors, usually tight hamstrings and quadriceps.
This is a clinical diagnosis, however characteristics when imaged suggesting Patello-femoral tendinitis include osteopenia at the distal pole of the patella; tractional osteophyte in proximal patellar tendon. Ultrasound, bone scan and MR imaging identify change in the posterior proximal 3rd of the tendon. Imaging is primarily useful to rule out more significant pathology within the knee or when considering surgery
Surgery no better than conservative therapy. Surgical debridement of full-thickness abnormal tissue, then rehab to eccentric training compared with rehab to eccentric training alone showed no change in Jump height, leg press strength, pain scores, return to sports with or without pain, .
Common complications range from inability to return to sport at 6 and 12 months to rare tendon rupture. Treatment includes relative rest and rehabilitation
1. Cook, JL, Br J Sports Med 1997 Dec; 31(4):332
2. J Bone Joint Surg Am 2006 Aug; 88(8):1689
3. Am J Sports Med 2001 Mar-Apr; 29(2):190
Scott Rand
Question: Which has a more favorable prognosis, tension side or compression side femoral neck stress fractures
Answer: Compression side fractures have a more favorable prognosis. Tension side fractures should be referred for internal fixation.
Mellion MB et al. “Stress Fractures” Team Physician Handbook, 3rd Ed. pp 520-534; 2002.
Scott Rand
Pain from SI joint dysfunction can be found in all of the regions except:
A. Buttocks
B. Hip joint
C. Pubic symphysis
D. Lower abdomen
E. Lateral thigh
Correct: B
In addition to the SI joint and the low back, pain can be felt in the locations in question except the hip joint.
1. Brukner, Peter, Khan, Karim, Clinical Sports Medicine, 3rd Ed., McGraw hill, 2007
2. Mellion, Morris B., Walsh, Michael, Madden, Christopher, Putukian, Margot, Shelton, Guy, Team Physicians Handbook, 3rd Ed, Hanley and Belfus, Inc., 2002
Scott Rand
A 42 year old laborer and distance runner presents to clinic with a painful click in his right hip. Pain is deep in the anterior groin. Exam shows pain with flexion combined with either internal or external rotation. Plain radiographs are normal. The test most sensitive in attempting to establish the diagnosis in this patient is:
A. Ultrasound
B. Computed tomography (CT)
C. Magnetic Resonance Imaging (MRI)
D. Bone SPECT scan
E. Magnetic Resonance Imaging with Intra-articular contrast and intra-articular local anesthetic (MRI arthrogram)
Correct: E
In this series, clinical assessment accurately determined the existence of intra-articular abnormality but was poor at defining its nature. Magnetic resonance arthrography was much more sensitive than magnetic resonance imaging at detecting various lesions but had twice as many false-positive interpretations. Response to an intra-articular injection of anesthetic was a 90% reliable indicator of intra-articular abnormality.
1. Byrd JWT, Jones KS. Diagnostic Accuracy of Clinical Assessment, Magnetic Resonance Imaging, Magnetic Resonance Arthrography, and Intra-articular Injection in Hip Arthroscopy Patients. Am J Sports Med 2006.
Scott Rand
An avid 25 year old male cyclist cycling 120 miles/week complains of left testicular pain and some perineal numbness for the past two months. He has never experienced this before and reports no recent change in his equipment, training intensity or duration in the recent month. He reports his pain as 6-8 out of 10 and is relieved by standing or walking. He has discussed this with his cycling teammates and they have advised he consider changing his seat set-up and brand to a split seat to relieve his symptoms.
The likely cause of his symptoms is:
A. Pudendal Nerve Compression
B. Adductor Tendinopathy
C. Ischial Periositis
D. Scrotal Ischemia
E. Testicular Torsion
Correct: A
Perineal symptoms including numbness of the genitalia were reported in 50%-91% of all cyclists and erectile dysfunction was reported in 13%-24% of all cyclists. Causes are related to compression of blood flow, soft tissue or nerve compression. The interaction between the bicycle seat (saddle) and the perineum is the culprit in all cases of perineal symptoms in cyclists. The interaction is dependent on the vertical (downward) and shear (backward) force of the perineum on the saddle, the weight of the rider, the height and angle between the saddle and the handlebars, the saddle tilt angle, and the shape of the saddle. The narrow saddle is associated with more reduction of perineal blood flow ant therefore more symptoms.
In extreme cases of perineal pain, Pudendal Nerve entrapment can be a source of this pain. Some cyclists with induced pudendal nerve pressure neuropathy gained relief from improvements in saddle position and riding techniques or fluoroscopic guided injections.
1. Am J Phys Med Rehab 2003;82:479-484.
Scott Rand
Which of the following statements is true regarding hip flexor injury?
A. In adolescents with the possible diagnosis of hip flexor pain and tenderness over the ischial tuberosity should have an x-ray to rule-out hip flexor origin avulsion
B. A hop test with pain in the ipsilateral groin is indicative of a hip flexor strain
C. Patients with large, palpable defects in the rectus femoris rarely need surgery
D. Hip flexor strains are commonly accompanied by a tingling sensation in the anterior thigh because of irritation of the lateral femoral cutaneous nerve
E. Significant weakness is usually seen on exam with most hip flexor strains
Correct: C
The best answer is C. Isolated deformities of the rectus femoris usually cause little to no functional disability and rarely need surgical intervention. The most common site of avulsion of hip flexors is the rectus femoris at the anterior inferior iliac crest, not the ischial tuberosity which is the origin of the hamstrings (a hip extensor). A positive hop test is suspicious for a femoral neck stress fracture. Meralgia paresthetica is a condition caused by irritation of the lateral femoral cutaneous nerve (often at the inguinal ligament). Meralgia paresthetica is not commonly associated with hip flexor strains. Because the hip flexors are very strong muscles and large number of hip flexors, most strains do not cause significant weakness, but instead have pain (and perhaps subtle weakness) with resistance testing.
1. Rosenberg J. Hip Tendonitis and Bursitis. eMedicine electronic textbook. http://www.emedicine.com/sports/topic49.htm (3/31/08 update)
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
In the majority of people, the median nerve courses between the two heads of this muscle in the forearm:
A. Supinator
B. Pronator teres
C. Flexor carpi ulnaris
D. Pronator quadratus
Correct: B
The median nerve passes between the two heads of the pronator teres at the elbow. Entrapment at this area may lead to symptoms such as a dull ache like pain in the forearm, fatigue of the arm, and/or reduced sensation in the radial 3 and a half digits. This condition is called pronator syndrome since this is the most common location of a median nerve entrapment at the elbow.
The radial nerve passes between the two heads of the supinator, and this is an area of radial nerve entrapment about the elbow and forearm. The ulnar nerve passes through the ulnar and humeral heads of the flexor carpi ulnaris muscle after exiting the cubital tunnel. The pronator quadratus muscle is in the distal forearm and does not cause entrapment neuropathies.
1. Delee and Drez’s Orthopaedic Sports Medicine, 2nd edition.
2. Netter’s Atlas of Human Anatomy, 3rd edition.
Scott Rand
Skeletal muscles that function as a group to stabilize the scapula against the posterior thoracic wall during upper extremity overhead activities include:
A. Levator scapulae, rhomboid major, rhomboid minor, and serratus anterior
B. Supraspinatus, infraspinatus, subscapularis and teres minor
C. Thoracic paraspinals, trapezius, latissimus dorsi and posterior intercostals
D. Deltoid, triceps brachii, pectoralis major and pectoralis minor
Correct: A
Levator scapulae elevates the scapula. Serratus anterior protracts and laterally rotates the scapula. Rhomboid major and minor retract and elevate the scapula. These muscles work together to control the position of the scapula and stabilize it against the posterior thoracic wall, thus providing a stable base for the glenohumeral articulation during overhead activities involving the upper extremity.
1. . Interactive Shoulder - Sports Injuries Edition 2.0. Thorax and Arm. Available at http://www.anatomy.tv/home.aspx
2. Brukner P, Khan K. Clinical Sports Medicine. 2nd ed. Roseville (NSW): McGraw-Hill Book Company Australia; 2000: 69-75
Scott Rand
Which of these is true of normal tendon structure?
A. Vascular and lymphatic supply is contained in the loose connective tissue sheath of the endotenon
B. Collagen type III makes up about 80% dry weight of the tendon
C. Water accounts for about 70% of tendon mass
D. The osseotendinous junction is the weakest part of the muscle/tendon unit
E. The majority of the blood flow to the tendon midportion arises from vessels originating at the myotendinous junction
Correct answer is C.
Vascular supply is mostly in the paratenon/synovial sheath.
Collagen type I makes up 80% dry weight of the tendon
Myotendinous junction is the weakest region of the muscle-tendon unit
Scott Rand
In order to avoid overtraining, athletes can initiate training principles that include the use of microcycles, mesocycles and macrocycles. This type of training is called
A. Accommodation training
B. Periodization training
C. Progressive overload training
D. Optimization training
Correct: B
Periodization is a way to implement structural variation into a training program. In this form of training, one or more program variables are altered over time to maintain an optimum stimulus. Cycles of this training technique use differing amounts of rest and activity as well as intensity and duration of training to maximize performance.
1. ACSM's Resource Manual for Guidelines for Exercise Testing and Prescription, 5th Ed. Lippincott, Williams, and Wilkins, 2006
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 37 year old male who is otherwise healthy, but minimally active physically has signed up as a charity runner for a local marathon in August. He has been training well per Jeff Galloway’s training program for 1st-time marathoners. He comes to see you in June before the race with concerns about hydration for prevention of heat injury.
Appropriate recommendations for fluid hydration during endurance events include:
A. Drink at each water stop along the race course
B. Drink ad lib based on thirst
C. Drink an adequate amount of fluids to keep urine output pale
D. Alternate water and glucose-electrolyte solution according to a pre-planned schedule
Correct: B
Per a recent position statement on fluid replacement recommendations during marathon running, adequate hydration is very important for peak performance with exercise as well heat stress management. Numerous recent case reports of Exertional Hyponatremia (EH) during endurance events and in particular marathons have prompted changes in recommendations for hydration during these events. Most episodes of hyponatremia area associated with fluid overload or over consumption and therefore many races are even decreasing the number of water stops as well publishing many education flyers on hydration recommendations.
The old adage that when you are thirsty you are behind in fluid requirements has fueled this misconception. Drinking fluids ad lib has been demonstrated to be the best protection for fluid overload.
1. Noakes, Tim. Fluid Replacement during Marathon Running. Position Statement. Clinical Journal of Sport Medicine. 13(5):309-318, September 2003
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
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
You are evaluating an obtunded athlete who collapsed toward the end of a marathon. Physical exam is significant for a rectal temperature of 98.6°F, blood pressure of 110/60, heart rate of 110 and diffusely increased muscle tone. What is the most likely diagnosis as you prepare to have your athlete transported?
A. Heat stroke
B. Myocardial infarction
C. Rhabdomyolysis
D. Exercise associated collapse
Correct: C
Heat stroke is incorrect because it is an environmental injury associated with altered mental status and elevated core body temperature, usually above 39.4°C. A myocardial infarction can occur during a strenuous event like a marathon but should be associated with hypotension to cause the mental status changes seen in this athlete. Rhabdomyolysis is the correct answer because the athlete is normotensive, normothermic, and has increased muscle tone expected with severe muscle injury. Exercise associated collapse is not correct because it occurs at the end of the event when the athlete stops. At this point, the muscles are no longer pumping the blood back to the heart causing transient hypotension resulting in collapse of the athlete.
1. Muldoon S., et al. Exertional Heat Illness, Exertional Rhabdomyolysis, and Malignant Hyperthermia: Is there a Link? Current Sports Med Reports. 2008. 7(2): 74-80.
2. www.usuhs.mil/fap/resources/et/ExertionalRhabdomyolysis.ppt
Scott Rand
In the absence of direct physical trauma, the activities with the highest incidence of spontaneous pneumothorax include scuba diving and:
A. soccer
B. weight lifting
C. football
D. swimming
Correct: B
Spontaneous pneumothorax occurs due to bleb rupture in sports involving changes in intrathoracic pressure including weightlifting and scuba diving. Pneumothorax is rare in football or soccer and associated with trauma, usually rib fracture. It is unlikely in swimming.
1. Selke, Sabiston, Spencer; Surgery of the chest; etiology and diagnosis
2. Partridge RA - Ann Emerg Med - 01-OCT-1997; 30(4): 539-41
Scott Rand
A 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
Which pair of objective findings is most suggestive of increased intracranial pressure?
A. Tachycardia, low blood pressure
B. Bradycardia, elevated blood pressure
C. Tachycardia, elevated blood pressure
D. Bradycardia, low blood pressure
Correct: B
Signs and symptoms that suggest a rise in ICP including headache, nausea, vomiting, ocular palsies, altered level of consciousness, and papilledema. If mass effect is present with resulting displacement of brain tissue, additional signs may include pupillary dilatation, abducens (CrN VI) palsies, and the Cushing”s triad. The Cushing”s triad involves an increased systolic blood pressure, a widened pulse pressure, bradycardia, and an abnormal respiratory pattern.
1. Sanders MJ; McKenna K. Mosby”s Paramedic Textbook, 2nd. 2002.
2. Singh J; Stock A. 2006. "Head Trauma.” Emedicine.com. 2007
Scott Rand
Which statement is true regarding exercise-induced anaphylaxis?
A. Pre-treatment with anti-histamines is effective to reduce the occurrence rate
B. Pre-treatment with NSAID’s or aspirin is effective to reduce the occurrence rate
C. A common trigger is running within a couple of hours after ingesting a meal
D. Initial treatment is immediate administration of anti-histamines and steroids
E. Re-occurrence is rare so affected athletes can run alone with little risk
Correct: C
Affected athletes should never run alone as there are no proven measures to prevent an attack. NSAID’s/aspirin are common triggers for such an attack.and their use should be avoided before exercising. The initial step in management is always epinephrine – preferably IM.
1. O’ Connor, Francis et al., Sports Medicine – Just The Facts, 2005. pages 226-227.
2. Brooks, Carter et al., “Cutaneous Allergic Reactions Induced by Sporting Activities,” Sports Medicine, 2003, 33 (9): 699-708.
Scott Rand
Which of the following is primarily associated with endurance training?
A. Ability to exert increased force
B. Increased protein content of muscle fibers
C. Fast to slow fiber transformation
D. Reduction of muscle capillary bed
E. Increased size of muscle fibers
Correct answer: (C) Fast to slow fiber transformation.
Explanation: There are specific long-term adaptations to exercise training related to endurance training and strength training. The type of training affects the type of of adaptation in skeletal muscle. Endurance training results in adaptations in muscle and cardiopulmonary function that increase both maximal oxygen uptake and lactate threshold. Endurance training results in skeletal muscle mitochondrial biogenesis, fast to slow fiber transformation, expansion of the muscle capillary bed, and changes in metabolism of substrates. Resistance training is associated with increased muscle fiber size. The protein content of muscle fiber also changes in resistance training, leading to the ability to increase force.
Scott Rand
Which of the following is true of weight loss and metabolism during exercise?
A. Maximal fat oxidation occurs at high intensity exercise.
B At maximal exercise intensity, blood flow increases to adipose tissues.
C. Excess post exercise oxygen consumption is highest after long duration of low intensity exercise
D. Training adaptations lead to decreased use of fat at the same exercise intensity.
E. Fat utilization is decreased during high intensity exercise.
Correct answer: (E) Fat utilization is decreased during high intensity exercise.
Explanation: There is a counterintuitive drop in utilization of fat during high intensity exercise that is caused by several factors, including the shunting of blood flow away from adipose tissue during maximal exercise intensity. This causes trapping of fatty acids in the adipose capillary beds, preventing fatty acids from being carried to muscle to be used.
(A) Fat oxidation is maximal at low to moderate levels of exercise intensity.
(B) Blood is shunted from adipose tissues during exercise at maximum intensity.
(C) Excess post exercise oxygen consumption refers to an elevated metabolic rate after exercise that results from energy utilized for muscle cell recovery and glycogen replacement. It is greatest when exercise intensity is high and greater after high intensity interval training compared to exercise for a longer duration at lower intensity.
(D) Training adaptations lead to increased use of fat at the same exercise intensity.
https://www.unm.edu/~lkravitz/Article%20folder/physiologgfatloss.htmlMelbyScott Rand
What is the source of energy the body uses for immediate short burst activity during the first 5-6 seconds of activity?
The ATP/phosphocreatine system.
Scott Rand
An 800 meter open water swim is part of a short-course triathlon with over 800 registered athletes. It will be held in a shallow, protected lake that is usually calm but has been notorious for sudden weather changes. The race was cancelled the prior year because of excessive wave chop and poor visibility and a duathlon (bike & run race) was held in its place. Since that time, you have implemented some changes to improve safety in the case of any adverse events. Which of the following is an adequate safety measure for this race?
A. Local volunteer swim club members will be on hand at the finish to deal with common minor conditions
B. A "mass start" will begin the swim to assure the race finishes at an early time
C. There will be one certified lifeguard for every 50 swimmers in this non-ocean race
D. There will be large, highly visible buoys positioned 1000 meters or so apart and secured in a manner that will limit their movement in the most severe wave conditions in that body of water
E. A highly mobile, powered watercraft will be "on-call" in the area to facilitate any emergency plan that is implemented
Correct: C
USA Triathlon event sanctioning guidelines suggest that this ratio be no lower than
one lifeguard for every 50 athletes in non-ocean swims and one lifeguard for every
35 athletes in ocean swims. (Triathlon Canada guidelines recommend a minimum ratio
of one lifeguard for every 25 swimmers). "Wave" starts minimize the number of compettors in the water at any one time. The rescuers should ideally have lifeguard training and minimally first responder training. Several highly mobile watercraft should be on site to facilitate any emergency. Large, highly visable buoys every 100 meters should be secured in a manner to limit movement in severe conditions.
1. Dallam, Medical Considerations in Triathlon Competition; Recommendations for Triathlon Organizers, Competitors and Coaches; Sports Med 2005:35 (2): 143-161
2. Martinez J., Managing Triathlon Competition; Current Sports Medicine Reports 2003, 2:142-146.
Scott Rand
Which of the following is not listed as a Major criteria of Marfan's syndrome?
A. Ectopia lentis
B. Dilation of the ascending aorta
C. Lumbosacral dural ectasia
D. Scoliosis > 20 degrees
E. High-arched palate
Correct: E
Skeletal major criteria include: Scoliosis greater than 20°: more than 60% of patients have scoliosis. Progression is most likely with curvature of more than 20° in growing patients. A highly arched palate is a minor skeletal criterion. One of the major criterions for ocular findings includes ectopia lentis. About 50% of patients have lens dislocation. The dislocation is usually superior and temporal. This may present at birth or develop during childhood or adolescence. A major criterion for cardiovascular includes: Aortic root dilatation involving the sinuses of Valsalva: The prevalence of aortic dilatation in Marfan syndrome is 70-80%. It manifests at an early age and tends to be more common in men than women. A diastolic murmur over the aortic valve may be present. Only one major criterion is defined for dural findings: dural ectasia must be present and confirmed using CT or MRI. Dural ectasia most frequently occurs in the lumbosacral spine
1. 1996 Revised Criteria for Marfan's syndrome American Journal of Medical Genetics Volume 62 Issue 4 , Pages 327 - 444 (24 April 1996)
Scott Rand
Which of the following regarding injury prevention is correct?
A. Single hinge knee braces can prevent knee injuries in American football
B. Lace-up braces for ankles can reduce recurring ankle injuries in athletes with previous ankle injuries
C. Head gear (scrum caps) can decrease the incidence of concussions in rugby
D. Eyewear with corrective lenses can prevent injury to the orbit
Correct: B
Injury prevention is an important area of research but unfortunately, good quality, controlled and blinded studies are lacking. In addition, there are conflicting results within this area of research.
Hinged knee braces, overall have not been consistently shown to reduce knee injuries. Single hinge knee braces have actually been shown to increase injury to the ipsilateral ankle and foot. The effectiveness of custom functional knee braces has not been shown to consistently reduce injury as they offer little protection to rotational stress.
Protective head gear for soccer and scrum caps for rugby do not consistently prevent concussions. They may provide some reduction in facial trauma.
In order for eye wear to be protective for low-risk sports, certain specifications must be met. If using street-wear frames, they must meet American National Standards Institute (ANSI) standards with a securing strap and polycarbonite or CR-39 lenses. For high risk sports, the use of fitted goggles with polycarbonite lenses are recommended because they are stronger than CR-39.
Lace up braces have been shown to help reduce future ankle injuries, especially with athletes with previous ankle injuries. Proprioceptive training has also shown to be effective at reducing ankle injuries.
Other references:
BJSM 2005; 39(Suppl I); i40-8; Effectivness of Headgear in Football, Withall C, Shewchenko N, Wonnacott M, Dvorak J.
Joint Statement American Academy of Pediatrics 1996 and American Academy of Ophthalmology 1995
Evidence-based Sports Medicine 2nd Ed, 2007; MacAuley D, Best T. “Is it possible to prevent sports and recreation injuries: A systematic review of randomized controlled trials with recommendations for future work.” Jennifer M Hootman
1. Paluska, SA, McKeag, DB. Knee Braces: Current Evidence and Clinical Recommendations for Their Use. AFP 2000; 61:411-8, 423-4.
2. Pedowitz DI, Reddy S, et al. Prophylactic Bracing Decreases Ankle Injuries in Collegiate Female Volleyball Players. Am J Sports Med 2008 Feb; 36(2): 324-7
McIntosh AS, McCrory P. Effectiveness of Headgear in a pilot study of Under 15 Rugby Union Football. BJSM 2001; 35: 167-9.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
13. A 45-year-old male presents with altered sensation on the sole of his foot and has weakness in the ability to plantarflex his ankle. Which nerve is involved in his symptoms?
A. Sural
B. Superficial peroneal
C. Deep peroneal
D. Femoral
E. Tibial
ANSWER: E. EXPLANATIONS:
E. TRUE: The tibial nerve provides cutaneous sensation to the sole of the foot and innervates the muscles involved in plantar flexion of the foot at the ankle (the gastrocnemius and soleus). In the foot, the tibial nerve divides into medial and lateral plantar branches.
A. FALSE: The sural nerve is a sensory nerve in the leg made up of collateral branches from the tibial nerve and common fibular nerve. It has no motor function.
B and C. FALSE: The superficial and deep peroneal nerves are the two divisions of the common peroneal nerve. The superficial peroneal nerve innervates the peroneus longus and peroneus brevis muscles, as well as most the skin over the greater part of the dorsum of the foot. The deep peroneal nerve supplies muscular branches to the tibialis anterior and the extensors of the digits (which mediate dorsiflexion of the ankle and extension of the foot respectively). It provides sensory innervation to the ankle joint as well as to the webbing between the first and second digits. Damage to the deep fibular nerve, as occurs with traumatic injury to the lateral knee, results in foot drop.
D. FALSE: The femoral nerve is located more proximally. It provides motor innervation to the anterior and some of the medial compartments of the thigh. It provides cutaneous sensation to the anterior and lateral thigh via the anterior and lateral femoral cutaneous nerves, respectively.
1. Moore KL, et al. Clinically Oriented Anatomy. Philadelphia, PA: Lippincott, Williams, and Wilkins. 2014. 2. Image: http://commons.wikimedia.org/wiki/File:Gray834.svg#mediaviewer/File:Gray834.svg (http://commons.wikimedia.org/wiki/File:Gray834.svg#mediaviewer/File:Gray834.svg)
Scott Rand
Define the four criteria of the Ottawa Ankle Rules in determining when to obtain imaging of ankle injuries.
Ottawa Ankle Rules for ankle or foot X-ray include:
a. Inability to bear weight for four steps.
b. Age over 55 ( I add in age under 16 to include possibility of physeal injury -- "Braunreiter's fifth criterion")
c. Tenderness at the base of the 5th metatarsal.
d. Tenderness along posterior edge of either malleolus.
e. Tenderness over navicular.
Scott Rand
You have a 14
year old patient who suffered an ankle injury last night playing basketball.
Unable to weight bear at all. Because you follow the guidance of the Ottawa
Ankle Rules, you opt for radiographic evaluation and you see this (open
attached file):
1. What is the diagnosis?
2. What is your management strategy? Do you refer for surgery? If not, when
should you?
--------------------------------------------------------------------------------
- Discussion:
- SH III frx involving avulsion of anterolateral tibial epiphysis;
- occurs in older adolescents, after the middle and medial parts of epiphyseal plate has closed, but before the lateral part closes (usually 12 to 15 yrs of age);
- because this frx occurs in adolescents w/ relatively mature growth plates, there is minimal potential for deformity due to growth plate injury;
- Mechanism of Injury:
- external rotation force w/ stress placed on anterior tibiofibular ligament, causing avulsion of distal tibial epiphyseal plate anterolaterally;
- further lateral rotation causes displacement of fracture;
- frx occurs after medial part of the epiphyseal plate has closed, but before the lateral part closes;
- resultant frx thru epiphyseal plate runs across epiphysis and distally into the joint, creating SH type III or IV frx;
- Radiographs:
- AP and Oblique views are needed to distinguish from a triplane frx;
- note that the common triplane fracture will contain a tillaux fracture in addition to the tibial physeal frx;
- Non Operative Treatment:
- attempt closed reduction (internal rotation of ankle and supination of foot) but accept no displacement;
- the surgeon may perform direct pressure over the fragment inorder to effect the reduction;
- patients should initially be placed in a long leg cast;
- Operative Treatment:
- significantly displaced fragments require anatomic reduction & fixation to restore satisfactory function of the ankle joint
Scott Rand
Patient presents with midfoot pain after playing soccer. States his foot was planted and plantar flexed when stepped on from behind. Ankle exam does not reveal laxity, but he has a positive pronation-abduction stress test.
What is the likely diagnosis and how should you manage this injury?
Answer is.....Lisfranc injury
* A condition characterized by disruption between the articulation of the
medial cuneiform and base of the second metatarsal
* unifying factor is disruption of the TMT joint
complex
* injuries can range from mild sprains to severe
dislocations
* may take form of purely ligamentous injuries
or fracture-dislocations
* ligamentous vs. bony injury pattern has
treatment implications
* Epidemiology
* incidence
* account for 0.2% of all
fractures
* demographics
* more common in the third
decade
* more common in males
* Mechanism & Pathoanatomy
* causes include MVAs, falls from height, and
athletic injuries
* mechanism is usually caused by indirect
rotational forces and axial load through hyperplantar flexed forefoot
*
hyperflexion/compression/abduction moment exerted on forefoot and transmitted
to the TMT articulation
* metatarsals displaced in
dorsal/lateral direction
* Associated conditions
* proximal metatarsal fractures or tarsal
fractures
* Lisfranc equivalent injuries
can present in the form of continguous proximal metatarsal fractures or tarsal
fractures
* Prognosis
* missed injuries can result in progressive foot
deformity, chronic pain and dysfunction
* tarsometatarsal
fracture-dislocations are easily missed and diagnosis is critical
Anatomy
* Osteology
* Lisfranc joint complex consists of three
articulations including
* tarsometatarsal articulation
* intermetatarsal articulation
* intertarsal articulations
* Ligaments
* Lisfranc ligament
* critical to stabilizing the
second metatarsal and maintenance of the midfoot arch
* An interosseous ligament
that goes from medial cuneiform to base of 2nd metatarsal on plantar surface
* Lisfranc ligament tightens
with pronation and abduction of forefoot
* plantar tarsometatarsal ligaments
* injury of the plantar
ligament between the medial cuneiform and the second and third metatarsals
along with the Lisfranc ligament is necessary to give transverse instability.
* dorsal tarsometatarsal ligaments
* dorsal ligaments are weaker
and therefore bony displacement with injury is often dorsal
* intermetatarsal ligaments
* between second-fifth
metatarsal bases
* no direct ligamentous
attachment between first and second metatarsal
* Biomechanics
* Lisfranc joint complex is inherently stable
with little motion due to
* stable osseous architecture
* second
metatarsal fits in mortise created by medial cuneiform and recessed middle
cuneiform, "keystone configuration"
* in coronal
plane, second metatarsal base serves as the cornerstone in a "Roman
arch" configuration
* ligamentous restraints
* see
individual ligaments above
* Columns of the midfoot
* medial column
* includes first
tarsometatarsal joint
* middle column
* includes second and third
tarsometatarsal joints
* lateral column
* includes fourth and fifth
tarsometatarsal joints (most mobile)
Classification
* Multiple classification schemes described
* none proven useful for determining treatment
and prognosis
Physical Exam
* Symptoms
* severe pain
* inability to bear weight
* Physical exam
* inspection & palpation
* medial plantar bruising
* swelling throughout midfoot
* tenderness over
tarsometatarsal joint
* motion & stability
* instability test
* grasp
metatarsal heads and apply dorsal force to forefoot while other hand palpates
the TMT joints
* dorsal subluxation suggests instability
* if first and second metatarsals can be displaced medially and
laterally, global instability is present and surgery is required
* when
plantar ligaments are intact, dorsal subluxation does not occur with stress
exam and injury may be treated nonoperatively
* provocative tests
* may reproduce pain with
pronation and abduction of forefoot
* compartment syndrome
* always check for compartment
syndrome and take compartment pressures if high suspicion
Imaging
* Radiographs
* recommended views
* AP, lateral, obliques
* stress radiograph
* may be
helpful to show instability when non-weight bearing radiographs are normal and
there is high suspicion
* weight-bearing radiographs
with comparison view
* may be
necessary to confirm diagnosis
* findings
* five critical radiographic
signs that indicate presence of midfoot instability
* disruption
of the continuity of a line drawn from the medial base of the second metatarsal
to the medial side of the middle cuneiform
* widening
of the interval between the first and second ray
* medial
side of the base of the fourth metatarsal does not line up with medial side of
cuboid on oblique view
* metatarsal
base dorsal subluxation on lateral view
* disruption
of the medial column line (line tangential to the medial aspect of the
navicular and the medial cuneiform)
* lateral
* non
weight-bearing radiographs may show dorsal displacement of the proximal base of
the first or second metatarsal
* AP
*
malalignment of medial margin of the second metatarsal base and the medial edge
of the middle cuneiform diagnostic of Lisfranc injury
* may see
bony fragment (fleck sign) in first intermetatarsal space
* represents avulsion of Lisfranc ligament from base of 2nd
metatarsal
* diagnostic of Lisfranc injury
* oblique
*
malalignment of fourth metatarsal and cuboid
* CT scan
* useful for diagnosis and preoperative planning
* MRI
* can be used to confirm presence of purely
ligamentous injury
Treatment
* Stable injuries: cast immobilization for
8 weeks
*
* indications
* no
displacement on weight-bearing and stress radiographs and no evidence of bony
injury on CT (usually dorsal sprains)
* certain
nonoperative candidates
* nonambulatory patients
* presence of serious vascular disease
* severe peripheral neuropathy
* instability in only the transverse plane
* Operative
* open reduction and rigid internal fixation
* indications
* any
evidence of instability (> 2mm shift)
* favored in
bony fracture dislocations as opposed to purely ligamentous injuries
* outcomes
* anatomic
reduction required for a good result
* primary arthrodesis of the first, second and
third tarsometatarsal joints
* indications
* purely
ligamentous arch injuries
* outcomes
* level 1
evidence demonstrates equivalent functional outcomes and decreased rate of
hardware removal or revision surgery compared to primary ORIF
* primary
arthodesis is an alternative to ORIF in patients with any evidence of
instability with possible benefits
* medial
column tarsometatarsal fusion shown to be superior to combined medial and
lateral column tarsometatarsal arthrodesis
* midfoot arthrodesis
* indications
*
destabilization of the midfoot's architecture with progressive arch collapse
and forefoot abduction
* chronic
Lisfranc injuries that have led to advanced midfoot arthrosis and have failed
conservative therapy
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.
Syndesmosis injuries in athletes.
Clanton TO, Paul P.
Foot Ankle Clin. 2002 Sep;7(3):529-49
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
An otherwise healthy 16 year old male gymnast presents with a three month history of non-radiating bilateral low back pain that worsens when he does back hand springs. On physical examination, his pain worsens with extension based maneuvers and he has markedly decreased bilateral hamstring flexibility. There is no evidence of spondylolisthesis on plain x-rays. A bone scan with SPECT and a thin-slice CT confirm your diagnosis. What rehab program would you prescribe?
A. Extension-biased spinal stabilization and quadriceps flexibility exercises
B. Flexion-biased spinal stabilization and hamstring flexibility exercises
C. Extension-biased spinal stabilization and hamstring flexibility exercises
D. Plyometric exercise program
E. A rehab program is not indicated for this condition
Correct: B
Correct answer is B. This athlete’s most likely diagnosis is lumbar spondylolysis, a stress fracture of the par interarticularis. The pars interarticularis is the region of the spinal lamina between the superior and inferior articulating processes. Spondylolysis often occurs due to repetitive hyper-extension and axial rotation stresses on the lumbar spine. This problem is very common in gymnasts. Lumbar spondylolysis most commonly occurs at the L5 level. Bilateral spondylolysis is more common than unilateral spondyloyisis and can lead to spondylolisthesis (slippage of one vertebral body on another). On physical examination the patient may have vertebral paraspinal muscle tenderness at the affected level, limited painful range of motion in both flexion and extension, and significant worsening of the low back pain with extension-based spine testing maneuvers. Up to 80% of patients with lumbar spondylolysis will have associated decreased hamstring flexibility. Initial treatment is conservative management including complete rest from the athlete’s sport, a therapy program focusing on core strengthening, flexion-biased spinal stabilization and hamstring flexibility and possibly lumbar spine bracing. An extension based therapy program may exacerbate the athlete’s symptoms.
1. Micheli LJ and Curtis C. Stress fractures of the spine and sacrum. Clin Sports Med. 2006 Jan; 25(1): 75-88.
2. Bono, CM. Low Back Pain in Athletes. J Bone Joint Surg Am. 2004 86(2): 382-96.
Scott Rand
Which of these is considered a limited contact sport with high to moderate static and low dynamic demands?
A. Gymnastics
B. Baseball
C. cycling
D. Soccer
e. Weightlifting
The correct answer is A. Gymnastics. See tables below.
Table 3-3 CLASSIFICATION OF SPORTS BY CONTACT
|
Contact/Collision |
Limited contact |
Noncontact |
|
Basketball |
Baseball |
Archery |
|
Boxing* |
Bicycling |
Badminton |
|
Diving |
Cheerleading |
Body building |
|
Field hockey |
Canoeing/kayaking (white water) |
Canoeing/kayaking (flat water) |
|
Football, tackle |
||
|
Ice hockey |
Fencing |
Crew/rowing |
|
Lacrosse |
Field events (high jump and pole vault) |
Curling |
|
Martial arts |
Dancing (ballet, modern, and jazz) |
|
|
Rodeo |
||
|
Rugby |
Floor hockey |
|
|
Ski jumping |
Gymnastics |
Field events (discus, javelin, shot put) |
|
Soccer |
Handball |
|
|
Team handball |
Horseback riding |
|
|
Water polo |
Racquetball |
Golf |
|
Wrestling |
Skating (ice, in-line, and roller) |
Orienteering |
|
Power lifting |
||
|
Skiing (cross-country, downhill, and water) |
Race walking |
|
|
Riflery |
||
|
Rope jumping |
||
|
Skateboarding |
Running |
|
|
Snowboarding |
Sailing |
|
|
Softball |
Scuba diving |
|
|
Squash |
Swimming |
|
|
Ultimate Frisbee |
Table tennis |
|
|
Volleyball |
Tennis |
|
|
Windsurfing/surfing |
Track |
|
|
Weight lifting |
Table 3-4 CLASSIFICATION OF SPORTS BY STRENUOUSNESS
|
High-to-moderate dynamic and static demands |
High-to-moderate dynamic and low static demands |
High-to-moderate static and low dynamic demands |
|
Boxing* |
Badminton |
Archery |
|
Crew/rowing |
Baseball |
Auto racing |
|
Cross-country skiing |
Basketball |
Diving |
|
Field hockey |
Equestrian |
|
|
Cycling |
Lacrosse |
Field events (jumping) |
|
Downhill skiing |
Orienteering |
|
|
Fencing |
Ping-pong |
Field events (throwing) |
|
Football |
Race walking |
|
|
Ice hockey |
Racquetball |
Gymnastics |
|
Rugby |
Soccer |
Karate or judo |
|
Running (sprint) |
Squash |
Motorcycling |
|
Speed skating |
Swimming |
Rodeoing |
|
Water polo |
Tennis |
Sailing |
|
Wrestling |
Volleyball |
Ski jumping |
|
Water skiing |
||
|
Weight-lifting |
||
|
Low Intensity (Low Dynamic and Low Static Demands) |
||
|
Bowling |
Curling |
Riflery |
|
Cricket |
Golf |
|
Scott Rand
. What is the sensitivity of ECG in detecting hypertrophic cardiomyopathy?
Approximately 90%.
The “Italian Experience”
In Italy, a systematic, state-subsidized national program for mandatory annual PPPE of all athletes 12 to 35 years of age has been in place for about 30 years. Minimum annual tests include a general exam, and a 12-lead ECG. Elite competitive athletes receive a more comprehensive medical and physiologic evaluation that includes routine echocardiography; findings are as follows:
- Detection of few definitive examples of potentially lethal cardiovascular abnormalities remains the norm.
- 2.2% to 2.5% of athletes are disqualified (about 51% because of cardiovascular abnormalities).
- A study by Basso and colleagues suggests that the Italian national screening program can decrease the incidence of SCD among young athletes. During the study period, SCD occurred in 55 screened athletes versus 265 in nonscreened nonathletes.
- Right ventricular dysplasia causes more athletic deaths than HCM. Reasons for the discrepancy with North American data (where HCM causes more deaths in those less than 30 years old) are unresolved. Possible disqualification of athletes with screening may contribute to discrepancy.
With the rarity of potentially lethal cardiovascular abnormalities in young athletes and the overwhelming number of sports and athletic participants in the United States, screening of the Italian magnitude would be impractical in most settings.
In 2004-2005, the European Society of Cardiology (ESC) and International Olympic Committee (IOC) recommended combining noninvasive testing (e.g., a 12-lead ECG) with the standard history taking and physical examination for cardiovascular screening in large populations of young trained athletes.
ECG and/or echocardiogram should be considered in athletes with any significant cardiac symptoms or abnormal findings on exam or with a family history of sudden death (unknown cause), SCD, or other cardiac condition known to predispose to SCD (e.g., right ventricular dysplasia, HCM, long QT syndrome, Marfan syndrome) in a family member less than 50 years old, especially a first-degree relative. Ninety percent of people with HCM have abnormal ECG.
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.
1. 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
Scott Rand
A 21 year old female is brought to the medical tent near the finish line at your community's annual marathon after suddenly collapsing moments after completing the race. Her mental status is normal and her temperature is 38.9 C. She reports feeling slightly lightheaded and has difficulty standing up. Your intial treatment strategy should include which of the following:
A. Provide the patient with walking assistance until she no longer feels it is difficult to stand or walk
B. Place the patient in a supine position so that both her legs and pelvis are elevated
C. IV fluid replacement with 5% dextrose in half normal saline
D. IV fluid replacement with 5% dextrose in normal saline
E. Active cooling with ice water tub immersion until her temperature drops below 38.0 C
Correct: B
Exercise-associated collapse (EAC) occurs in athletes who participate in endurance events. The onset of symptoms and signs of postural hypotension occur when the participant suddenly stops exercising. By definition, it is an athlete that requires assistance after or during an endurance event that is not orthopedic or dermatologic.
Initially, one should not try to walk or assist the patient with ambulation as this may lead to further injury of the athlete or possibly the provider (Answer A incorrect). Instead, patients should be instructed to lie with their pelvis and legs elevated in a head-down position. Most patients will respond to this simple maneuver with rapid abatement of their symptoms in just a few minutes. This will allow blood that has pooled in the dilated veins within the lower extremities to return to the central circulating blood volume (Answer B, correct).
IV fluids (Answers C,D incorrect) are not recommended as part of the initial management of EAC in a patient with normal mental status. Oral fluids are the preferred method of fluid replacement in all mild and moderate cases if tolerated by the athlete.
A rectal temperature in addition to blood pressure and heart rate should be recorded. Hyperthermia defined as a body temperature >103F (39.5C) and hypothermia <97F (36.1C) should be be diagnosed and treated appropriately. This patient is normothermic (termperature between 97F and 103F) and should have her temperature monitored and maintained, not actively cooled (Answer E, incorrect).
1. Mellion, M.B., Walsh, W.M., Madden, C., Putukian, M., Shelton, G.L. (eds). Team Physician's Handbook, 3rd Edition. Hanley & Belfus, Philadelphia, 2002
2. Brukner, P., Khan, K. Clinical Sports Medicine. McGraw-Hill Sports Medicine, Australia, 2006