Daily answer
Scott Rand
Your 24-year-old stud baseball pitcher
complains of vague right shoulder pain. It is most noticeable at the late
cocking phase of windup. On physical exam the patient is noted to have weakness
with external rotation. EMG findings are consistent with quadrilateral space
syndrome. Along with the deltoid, what other muscle is affected?
1. Teres major
2. Teres minor
3. Pectoralis major
4. Supraspinatus
5. Subscapularis
The axillary nerve passes through the quadrilateral space on its path to
innervate the teres minor and deltoid and provide sensation to the lateral arm.
This syndrome is caused by compression of the posterior humeral circumflex
artery and axillary nerve or one of its major branches in the quadrilateral
space. Forward flexion and/or abduction and external rotation of the humerus
aggravate the symptoms. In some individuals, especially, throwers, the nerve
can become irritated from the repetitive motion leading to nerve dysfunction.
The condition is usually self-limited.
Scott E Rand, MD FAAFP CAQSM
Director, Primary Care Sports Medicine Fellowship
Co Director of Sports Medicine, Houston Methodist Orthopedics and Sports Medicine Willowbrook
Assistant Professor of Clinical Family Medicine Houston Methodist Academic Institute
Adjunct Assistant Professor of Family and Community Medicine, Texas A&M University
Assistant Professor of Family Medicine in Clinical Medicine Weill Cornell Medical College.
13802 Centerfield Dr Suite 300
Houston, TX 77070
Scott Rand
Which of the following statements is true regarding cubital tunnel syndrome?
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
In the context of posterior elbow dislocation, which of the following factors is most predictive of persistent instability requiring surgical intervention?
A. Presence
of a type I coronoid fracture
B. Isolated posterior dislocation without associated fractures
C. Associated radial head fracture with lateral ulnar collateral ligament
(LUCL) disruption
D. Early concentric reduction with full passive range of motion
Correct Answer:
C. Associated radial head fracture with lateral ulnar collateral ligament (LUCL) disruption
Explanation:
Posterior elbow dislocations are often managed non-operatively if concentric reduction is achieved and there is no mechanical block to motion. However, when associated with a radial head fracture and LUCL disruption, the elbow becomes unstable, often necessitating surgical intervention such as radial head replacement and ligament repair. This combination is part of the "terrible triad" injury pattern, which is known for its complexity and risk of chronic instability.
References:
- Blanda J, Alexeev M, Kane SM. Treatment of Chronic Radial Head Fracture/Dislocation With Radial Head Replacement. Journal of Orthopaedic Trauma. 2021. Link to full text
- Ring DM, Jupiter JB. Fracture-Dislocation of the Elbow. J Bone Joint Surg Am. 1998;80(4):566-580. Link to article
Scott Rand
The triangular fibrocartilage complex is composed of:
1. extensor carpi ulnaris tendon sheath
2. articular disc
3. ulnotriquetral ligament
4. all of the above.
Answer: 4. All of the above
Scott Rand
Describe the arterial supply of the wrist scaphoid bone
The scaphoid bone is supplied by 2 major vascular pedicles. The volar branch of the radial artery enters the scaphoid tubercle and supplies its distal 20-30%. The dorsal scaphoid branch of the radial artery enters through numerous small foramina along the spiral groove and the dorsal ridge and supplies 80% of the blood supply to the scaphoid. This retrograde supply is felt to part of the reason for common non union and osteonecrosis of the scaphoid bone.
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
What is the anatomy and function of Lister’s tubercle:
Lister's tubercle, also known as the dorsal tubercle of the radius, is a small but clinically significant bony prominence located on the dorsal surface of the distal radius, near the wrist joint. Here's a detailed overview of its anatomy and function:
Anatomy of Lister's Tubercle
- Location: Found on the dorsal distal radius, between the radial styloid process and the ulnar notch.
- Structure:
- It typically has two peaks: a radial peak and an ulnar peak.
- Its size and shape vary significantly among individuals:
- Height: ~2–6 mm (average ~3 mm)
- Length: ~6–26 mm (average ~13 mm)
- Compartments: It separates the 2nd extensor compartment (extensor carpi radialis longus and brevis) from the 3rd compartment (extensor pollicis longus, EPL)
1
.
Function of Lister's Tubercle
- Pulley Mechanism: Acts as a pulley for the extensor pollicis longus (EPL) tendon, allowing it to change direction by ~45° as it wraps around the tubercle
2
.
- Thumb Movement: This redirection is crucial for extension of the thumb, contributing to fine motor control.
- Surgical Landmark: It serves as a palpable landmark during wrist surgeries, arthroscopy, and injections
3
.
Clinical Significance
- Fractures: Hyperextension injuries can fracture the tubercle, potentially exposing the EPL tendon to rough bone edges and leading to delayed tendon rupture
Scott Rand
The instability pattern associated with tears of the lunotriquetral ligament is:
A. volar intercalated segment instabilty (VISI)
B. dorsal intercalated segment instability (DISI)
C. ulnar translocation (UT, NOT the university)
D. distal radioulnar joint instability
E. pisohamate instability
Answer: A
Injuries to the lunotriquetral ligaments may range from sprain to partial tear to complete tear with or without carpal malalignment. The carpal instability associated with this injury is a volar intercalated segment instability deformity.
Scott Rand
Describe the mechanism of injury (as it pertains to baseball), diagnostic imaging, and treatment for hamate hook fractures.
Hamate Fracture
Discussion:
- anatomy of hook of hamate:
- is situated slightly distal and radial to the pisform;
- forms lateral (radial) border of tunnel of guyon, which transports ulnar
nerve and artery to hand;
- vascular supply: vessels enter hook at two sites - hook radial base &
hook ulnar tip;
Hook of Hamate Fracture:
- fx of the hook may result from athletic activity (swinging golf club, etc)
but may occur from direct blow;
- hook of the hamate is particularly at risk in batters and golfers;
- avascular changes may follow fracture of hook in hamate, and these may lead
to hook necrosis and non union;
- pattern of vascular supply suggests that most acute hooks fx should have
adequate blood supply to heal if well immobilized immediately;
- exam:
- pain is accentuated w/ axial loading of ring and little finger metacarpals;
- dx is usually confirmed by point tenderness over hook 1 cm distal and radial
to the pisiform;
- almost all patients complain of pain and tenderness on ulnar side of palm or
on the dorsoulnar aspect of the wrist;
- most common symptom is pain in the palm aggravated by grasp;
- diminished grip strength, dorsal wrist pain, ulnar nerve paresthesias or
weakness, and mild carpal tunnel syndrome are frequent.
- diff dx:
- intra-articular injuries, though rare, may also occur in hamate;
- occasionally longitudinal sprain between trapezoid & capitate or capitate
& hamate gives rise to ill-defined pain in ulnar aspect of the wrist;
Radiographs:
- see 15 deg reversed oblique view:
- fractures of the body occur more frequently than frx of hook;
- fx of hamate are difficult to dx as routine AP & lateral films fail to
show frx;
- most of fx can be diagnosed conclusively on carpal tunnel view or on special
oblique radiograph w/ wrist supinated
- CT scan will also demonstrate this fracture;
Treatment:
- pattern of vascular supply suggests that most acute hooks frx should have
adequate blood supply to heal if well immobilized immediately;
- immediate immobilization of acute fx may promote fracture healing and obviate
operative intervention;
- origin of the flexor digiti minimi brevis and opponens digiti minimi may
cause a failure of a hamate fracture to heal;
- nonathletic injury or crush injury adversely affects outcome;
- pts w/ excisions of hook of hamate usually return to their pre-injury level
of activity;
- ORIF is possible but offers little advantage over excision, which typically
produces excellent results
Scott Rand
You have a patient who presents with a boxer's fracture. What are indications for referral for ORIF, and what is acceptable for alignment?
Metacarpal neck fractures most commonly involve the fifth
digit and are referred to as boxer's fractures. These fractures usually result
from punching a hard object, such as a wall or another person. The fracture
occurs just below the metacarpal head and the metacarpal head is displaced in a
volar direction. The distal fifth metacarpal takes the brunt of the impact and
breaks through the narrowest area near the neck, typically resulting in apex
dorsal angulation or displacement at the fracture site. Casting or splinting is
helpful to avoid further instability and to promote healing with stability at
the fracture site. Apex dorsal angulation up to 40 degrees is acceptable for
nonoperative management. Fractures in this location often heal with residual
apex dorsal angulation, which typically is not problematic. Fractures that are
markedly comminuted or angulated occasionally may require open reduction and
internal fixation.
Clinics in Sports Medicine
Volume 25, Issue 3 , Pages 527-542, July 2006
Scott Rand
Describe baseball finger and its treatment.
Mallet
Deformity: (Baseball finger)
Anatomy:
- terminal extensor
tendon is comprised of the convergence of lateral bands and more proximally by
terminal fibers of the oblique retinacular ligament
- Acute
Injury:
- from forcible flexion
of the extended DIP joint:
- following this injury
there is unopposed flexion from the FDP
- w/ severe flexion
deformity of DIP joint in mallet finger injury a secondary hyperextension
deformity of PIP (swan neck) joint may occur because of imbalance of the
extensor mechanism;
- as the conjoined
tendon slides proximally, the conjoined tendon becomes a secondary extensor of
the PIP joint;
- w/ closed injury,
extensive fraying of tendon ends usually occurs at point of separation, which
makes surgical repair difficult;
- radiographs:
- true lateral to r/o
avulsion frx or frx of articular surface;
- volar subluxation
along w/ a significant intra-articular frx (greater than 30% of joint surface)
is an indication for surgery;
- Rx:
(Acute Closed Injuries)
- the vast majority of
patients w/ closed mallet injuries (even those seen one month out from injury)
can be treated w/ splinting;
- continuous splinting
of only the DIP joint for 6 to 10 weeks is the usual treatment;
- note: that patients w/
ligamentous laxity and/or propensity for PIP joint hyperextension may be at
special risk for failure with non operative treatment;
- consider using a
thinly padded dorsal aluminum splint;
- remember that a poorly
fitting dorsal splint on an elderly pt, may worsen tendon vascularity;
- an alternative, is to
apply Coband wrap to the DIP joint, and then apply a bent paper clip to the
dorsal surface, followed by more Coband;
- try for mild
hyperextension, no pain should occur;
- avoid forced extension
in the acutely swollen finger, rather, position the finger in hyperextension
after the swelling has decreased;
- consider
hyperextending the digit to the point at which the skin blanches and then back
off extension by 50%;
- do not immobilized the
PIP joint;
- at no point should the
joint be allowed to fall into flexion for at least 6 weeks;
- after 6 weeks,
continue splinting if an extensor lag is present;
- if extensor lag is not
present, a night time splint is worn for 2-3 weeks;
________________________________
- Indications for
Surgery:
- Open Mallet Finger
Injury:
- consider direct
repair;
- anchor one end of a
4-0 nylon suture on skin & then run it as continuous suture, back &
forth through tendon ends from one side of finger to other;
- consider cross pin
fixation of DIP joint to maintain some hyperextension;
________________________________
- Closed Reduction / K
wire:
- insert 0.45 K wire
across the fully extended DIP joint;
- technically, it is
easier to place the K wire longitudinally (w/ the pin cut off beneath the
skin), but pts may complain of scarring at the pin entrance site;
- oblique placment of
the K wire across the DIP joint may be preferable by the patient, but is
technically more difficult;
- remove pin at 6 wks,
but continue night splinting for additional 4 wks;
- this method may cause
osteomyelitis;
________________________________
- Open Repair:
- may have high rate of
complications;
- prior to open repair,
many will insert a K wire to hold the joint in extension;
- open repair is most
indicated w/ open mallet finger injuries, however, many point out that due to
the flimsy nature of tendon at this level, open tendon repair will not be very
secure;
- some advocate washout
of the wound (and joint if indicated) but avoiding attempts at suture repair of
the tedon;
- others will attempt to
close the tendon and skin in one single layer, using a running simple suture
technique;
- sutures are removed at
2 weeks, but splint for atleast 6 weeks;
- alternatively the
extensor tendon can be repaired w/ 4-0 or 5-0 Vicryl figure of 8 sutures, w/
knot buried on the inside;
- w/ a displaced frx
fragment, expose joint thru dorsal zig-zag incision;
- insert a wire loop
through the fragment and into the distal phalanx, and tie over felt and a large
volar button;
- take care not to further
disrupt or comminute the frx fragment and/or extensor mechanism
- 41% surgically treated
mallet fractures developed postoperative complications;
- most common
complication was marginal skin necrosis on the dorsal aspect of the distal
phalanx, but recurrent extension lag, permanent nail deformities, transient
infections along the wires and pull-out steel wires and osteomyelitis were also
observed
- Late
Mallet Finger:
- may lead to swan neck
deformity;
- these pts will
probably not respond to splinting (w/ Swan neck);
- in pts w/o swan neck
deformity:
- DIP is splinted in
neutral or slight hyperextension;
- do not place too much
pressure on the dorsum of the finger;
- PIP is left free;
- consider splinting for
4 to 8 weeks;
- central slip tenotomy
Courtesy of
Orthobullets:
http://www.orthobullets.com/hand/6014/mallet-finger
Scott Rand
Which of the following statements is true regarding metacarpal fractures?
A. Most metacarpal fractures in athletes will eventually need a surgical procedure in order to regain full function
B. 5th metacarpal fractures are called “Boxer” fractures because of their common occurrence in boxers
C. Splints and casts for metacarpal fractures should immobilize the proximal interphalangeal (PIP), metacarpophalangeal (MCP) and the wrist joint
D. Although up to 30° of angulation is acceptable for a 5th metacarpal fracture and may be treated non-operatively, fractures with malrotation should be referred for surgical reduction
E. Fractures of the hand should be treated with prolonged immobilization since early motion leads to significant risk of non-union and poor functional outcome
Correct: D
The best answer is D. Most metacarpal fractures can be treated non-operatively exceptions include some intra-articular fractures, open fractures, unstable fractures (which usually include transverse and short oblique fractures), severely displaced fractures and fractures with rotational deformities. “Boxer” fractures almost never occur while boxing instead they typically occur from striking a solid object with a closed fist (a more typical fracture suffered while boxing is an index finger metacarpal fracture). When immobilizing the hand, the PIP joints should be allowed motion, while the MCP should be immobilized in 70-90° of flexion. Only small amounts of fracture angulation (<10°) are acceptable for the relatively immobile 2nd and 3rd metacarpals; however the more mobile 4th and 5th metacarpals can tolerate more angulation deformity (20° and 30° respectively) before surgical reduction is needed. Malrotation is an indication for surgical treatment. Early motion is essential to good outcome for hand fractures. Delaying motion beyond 3-4 weeks increases the risk of arthrofibrosis and poor functional outcome.
1. Reference: Dye TM. Metacarpal Fractures. eMedicine electronic textbook. http://www.emedicine.com/orthoped/topic193.htm (2/13/08 update)
Scott Rand
1. of dorsal carpal ganglion. Journal of Medicine Association Thailand 200
A 19 year old female basketball player tries to deflect a pass and sustains a hyperextension injury to the PIP joint of her middle finger. Her finger dislocates dorsally. You reduce the dislocation on the sideline. Radiographs taken after the game, are negative for bony injury and show good alignment.
Which of the following is the most appropriate next step?
A. No further treatment is necessary
B. The finger should be splinted in full extension
C. The finger should be splinted in 20-30 degrees of flexion
D. The finger and hand should be placed in a short arm cast
Correct: C
Due to the high likelihood of a volar plate rupture during the hyperextension injury
c) The finger should be splinted in 20-30 degrees of flexion to allow the volar plate to heal.
a) is incorrect because splinting is necessary.
c) splinting in extension would be correct for a volar dislocation at the PIP, but not for dorsal dislocation.
d) is incorrect because short arm casting is not indicated for a PIP dislocation.
2. Duncan K. Hodge, MD, Sideline Management of Common Dislocations, Current Sports Medicine Reports 2002, 1:149–155
3. Jeffrey C. Leggit, LTC, Acute Finger Injuries: Part II. Fractures, Dislocations, and Thumb Injuries, Am Fam Physician, 2006 Mar;73(5):827-34
Scott Rand
Scott Rand
1. Which spinal ligament prevents excessive extension of the vertebral column?
A) Anterior longitudinal ligament
B) Posterior longitudinal ligament
C) Ligamentum flavum
D) Interspinous ligament
✅ Correct Answer: A) Anterior longitudinal ligament
📘 Reference: Moore KL, Dalley AF. Clinically Oriented Anatomy, 7th ed.
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
Scott Rand
Scott Rand
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
. 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
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]
Eyes
Scott Rand
On physical exam, there is a snapping sensation at the lateral hip with rotation of the hip. She also experiences tenderness on palpation of the trochanteric bursa. Which of the following is the most likely diagnosis?
A. Anterior cruciate ligament tear
B. Iliotibial band syndrome
C. Lateral collateral ligament injury
D. Patellofemoral pain syndrome
E. Trochanteric bursitis
Correct answer: (B) Iliotibial band syndrome.
Explanation: Iliotibial band syndrome is the most common cause of lateral knee pain among athletes. It develops as a result of inflammation of the bursa surrounding the illiotibial band and usually affects athletes involved in sports that require continuous running or repetitive knee flexion and extension. This condition is most common in long-distance runners and cyclists. The illiotibial band is the condensation of fascia formed by the tensor fascia lata and the gluteus medius and minimus muscles. It is a wide, flat structure that originates at the iliac crest and inserts on the lateral aspect of the proximal tibia. Typically, the patient presents with an insidious onset of lateral knee pain that is present during running. Pain is localized over the lateral epicondyle, and the athlete is able to localize the lateral knee pain to approximately 2cm above the lateral joint line. Pain is experienced usually when the athlete climbs stairs or runs downhill. Early in the course of the injury, the pain usually resolves after running. Conservative measures such as stretching, foam roller exercises, rest, ice, and NSAIDS are the mainstay of treatment. If symptoms to do not improve, an MRI may be warranted to rule out other conditions such as a ligament tear.
(A) Anterior cruciate ligament tear commonly presents after a non-contact deceleration force or falling on a knee that is internally rotated. A popping sensation is often heard at the time of injury. Pain and swelling occur immediately after the injury.
(C) Lateral collateral ligament injuries result from a varus force across the knee. A contact injury, such as a direct blow to the medial side of the knee, or a noncontact injury, such as a hyperextension stress, may result in a varus force across the knee, injuring the lateral collateral ligament.
(D) Patellofemoral pain syndrome (also known as “runner’s knee”) is a common overuse injury often seen in athletes (mostly females). It is the most common form of knee pain seen in an outpatient setting. Patients with patellofemoral typically describe pain “behind,” “underneath,” or “around” the patella.
(E) Trochanteric bursitis presents with pain and tenderness at the lateral hip over the greater trochanter. Rising from a chair or sleeping on the affected side elicits the pain. Point tenderness is diagnostic. This can develop from illiotibial band tightness.
Kirk KL, Kuklo T, Klemme W. Iliotibial band friction syndrome. Orthopedics. Nov 2000;23(11):1209-14; discussion 1214-5; quiz 1216-7.
Scott Rand
The OARSI (Osteoarthritis Research Society International) in 2018 recommended which treatment as first line for osteoarthritis of the knee?
- Hyaluronan injections
- Corticosteroid injections
- NSAIDs/Acetaminophen
- Resistance/strength training of the lower extremities
- Non-NSAID analgesics
Correct answer is D. While the optimal dosing of frequency, repetitions, and amount of resistance is not clear, exercise to improve the physical support of the knee has been demonstrated to improve symptoms and quality of life. All of the other pharmacologic methods listed have merit in alleviating pain but should be considered adjunctive treatments.
https://doi.org/10.1016/j.joca.2019.06.011 Bannuru et al
OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis
Scott Rand
A 50 year old female patient presents to your office with exertional pain in her right calf. She has noted the pain during exercise for the past several weeks. Which of the following historical and physical findings would you expect with a diagnosis of popliteal artery entrapment syndrome?
A. Diminished foot pulses at rest
B. Pain more closely associated with volume of exercise rather than intensity of exercise
C. Slow resolution of symptoms at conclusion of exercise
D. Patients may have normal pulses that disappear or decrease with plantar flexion or dorsiflexion of the foot
E. Markedly elevated compartment pressure
Correct: D
Popliteal artery entrapment syndrome causes calf pain during exercise due to compression of the popliteal artery by an abnormal relationship of the artery to the gastrocnemius and/or plantaris muscles. Unlike exertional compartment syndrome, symptoms are associated with intensity of exercise rather than volume. In addition, symptoms tend to resolve quickly after the conclusion of exercise until very late in the disease, when sclerosis of the artery creates a more chronic condition. Foot pulses tend to be normal at rest, but can be abnormal with dorsi- and plantarflexion of the foot. For this reason, diagnostic workup for the disorder includes Doppler ultrasonography or angiography in neutral position, dorsiflexion and plantarflexion. Compartment pressures are usually normal or slightly elevated. This disorder is usually treated by cessation of causative activities followed by surgical release of the artery from the offending muscles. After surgical release, most patients can resume normal exercise.
1. Zetaruk M, Hyman J. Leg injuries, in Clinical Sports Medicine (ed. Frontera et al) 451, 2007.
2. http://radiographics.rsnajnls.org/cgi/content/full/24/2/467. Popliteal Artery disease: Diagnosis & Treatment. Wright LB et al, RadioGraphics, 2004; 24:467-479.
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
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
You are evaluating a 27 year old recreational tennis player. She felt some searing chest wall pain on her dominant side while extending for a forehand shot three days ago. One her exam today, you notice substantial bruising along the anterior chest wall suggesting some soft tissue injury. You begin by palpating the pectoralis major muscle. Of the following points, which one is least helpful when trying to palpate the the pectoralis major:
A. Sternum
B. Clavicle
C. 2nd-6th ribs
D. Humerus
E. Coracoid Process
Correct: E
Answers A & C are the origins of the sternal head of the Pectoralis major: sternum and ribs 2-6. Answer B, specifically, the medial clavicle is the origin of the clavicular head. The Humerus, Answer D, is the insertion of the muscle on the Intertubercular Groove (Outer Lip). Answer E refers to the insertion of the Pectoralis minor which has its origin on the 3rd to 5th ribs, and also inserts on the scapula
1. Williams PL, Warwick R eds. Gray’s Anatomy. 37th ed. Longman Gp UK Limited, 1989;610-611.
Scott Rand
Where is the purest area for sensory testing of the radial nerve on the hand located?
A. Dorsal web between the thumb and the index finger
B. Radial side of the hand
C. Dorsum of the wrist
D. The thenar eminence
Correct: A
The radial nerve provides sensation to the radial side of the hand. Thus, secondary to significant overlap the purest area for testing the radial nerve is the web space between the thumb and index finger. B is incorrect due to overlap. C is incorrect because the posterior interosseous nerve supplies this area. D. is incorrect because innervation to this area is supplied by the palmer cutaneous branch of the median nerve.
1. Puffer. 20 Common Problems Sports Medicine.76-78, 2002.
2. Doyle J, Botte M. Surgical Anatomy of the Hand and Upper Extremity. 2002. 214-218
Scott Rand
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Scott Rand
Pain originating from the facet joint complex is a common cause of back pain. The purpose of the facet joint in its protection of the lumbar intervertebral disk is best characterized as which of the following:
A. protection against axial rotation and loading
B. protection against shearing forces
C. protection against anterior translocation
D. protection against caudal translocation
Correct: A
Facet joints of the cervical region of the spine are oriented primarily in the coronal plane to resist axial rotation and loading. The thoracic spine lays in an intermediate position and the lumbar spine transitions to a sagittal orientation to protect against rotatory forces. The lumbar facets can resist rotation while the coronal position of the cervical facets allows a great deal of rotation
1. Berven, S., Tay, B., Colman, W. Hu, Serena, The Lumbar Zygapophyseal (Facet) Joints: A Role in the Pathogenesis of Spinal Pain Syndromes and Degenerative Spondylolisthesis, Seminars in Neurology 2002; Vol 22, pages 187-196
2. Edward Benzel, Biomechanics of Spine Stabilization,, 2001 Thieme, Chapter 1 page 3
Scott Rand
A marathon runner collapses at mile 20 with confusion, core temperature of 40°C, and tachycardia. Labs show elevated CK and mild
hyponatremia. Explain the physiological mechanism behind their condition and outline the
immediate exercise-related management strategy.
A) Administer antipyretics and observe
B) Rapid whole-body cooling and IV fluids
C) Provide oral hydration and rest
D) Delay cooling until hospital arrival
Correct Answer: B) Rapid whole-body cooling and IV fluids. This is exertional heat stroke due to
thermoregulatory failure; immediate cooling reduces mortality. Reference: Casa DJ et al. Exertional
Heat Stroke: Clinical Guidelines. Curr Sports Med Rep. 2015;14(2):105-113.
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
A 15 year old High School football player was hit on his blind side as he was running with the football. He landed on the side carrying the football, and the tackler landed on top of him. After needing assistance to the sideline, he became tachycardic, hypotensive and there was a clear change in his mental status. He was transported to the nearest hospital where he was re-evaluated.
The patient is initially stabilized with IV hydration. However, the patient's pain is persistent. From the list below, which testing type is LEAST appropriate?
CT Abdomen and pelvis
Peritoneal lavage
MR abdomen
Plain films of abdomen and chest
Abdominal ultrasound
Correct: C
In the acute setting, any testing needs to be quick, efficient, and provide information about the severity of injury. MR of the abdomen is not quick, and the other tests listed will help the clinician identify a possible need for surgery.
David V. Feliciano, MD, et. Al., EVALUATION OF ABDOMINAL TRAUMA © 2003 American College of Surgeons
Walter, Kevin D. MD, Radiographic Evaluation of the Patient with Sport-related Abdominal Trauma, Current Sports Medicine Reports. 6(2):115-119, April 2007.
Hoff et al. EAST Practice Management Guidelines Work Group. Practice Management Guidelines for the Evaluation of Blunt Abdominal Trauma, 2001. www.east.org.
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
A 29 year old hockey player complains of one day of eye pain. The pain began suddenly while he was sharpening his skates without using eye protection. Upon exam, his visual acuity is intact, as are extraocular movements. Seidel’s test is negative. Inspection shows scleral erythema and a ½ mm brownish staining at 12 o’clock superior to the iris. In addition to standard management and removal of this corneal foreign body, what steps must be taken in this case?
A. Expansion of microbial coverage to include atypical organisms
B. Patching for 1 week to decrease spreading inflammation
C. Removal of products of iron oxidation from the cornea
D. Repair of corneal perforation in the operating room
E. Prolonged course of mydriatics
Correct: C
The practitioner in this case has discovered a rust ring. This is the product of oxidation of iron materials that are embedded traumatically in the cornea. Not only must the iron shard be removed, but the rust ring must be removed to prevent vascularization degeneration of the cornea. There is no need presently to treat with expanded spectrum antibiotics. Patching is not necessary and may do harm. Seidel’s test is negative, which rules out corneal perforation. Prolonged mydriatics have no further role in management of rust rings.
1. Kabat AG, Sowka JW. Corneal atlas, part III: from abrasions to burns, how to manage corneal injuries. Review of Optometry. October 1999.
Scott Rand
Which statement below is true regarding preadolescents and well structured weight lifting programs?
A. strength training increases both muscle strength and hypertrophy in preadolescents
B. strength training increases muscle strength, but not hypertrophy in preadolescents
C. strength training is considered harmful to maturation, but beneficial to growth in preadolescents
D. strength training can have a negative impact on maturation and growth in preadolescents
Correct: B
Preadolescent resistance training programs that include protocols with weights and resistance machines, and have low instructor to participant ratio can have significant improvement in strength without hypertrophy of muscle or deliterious effects on growth or maturation.
1. Malina, R. "Weight Training in Youth-Growth, Maturation, and Safety: An Evidence Based Review". Clin J Sports Med. Vol 16, Number 6, Nov. 2006.
Scott Rand
An obese patient (BMI>30) without other comorbidities presents to your office. To improve compliance, one strategy for the patient’s exercise prescription could include which of the following:
A. Incorporating high-impact aerobic activities
B. Emphasizing exercising after their AM meal
C. Strict cardiovascular prescription at 85% maximum HR for at least 30 minutes five times per week
D. Increasing weight-bearing activities very rapidly to increase metabolism
E. Start with non-weight bearing activities such as swimming and recumbent bike
Correct: E
In 2006, 49 of 50 states had an obesity rate of >20% of the population according to the CDC. Exercise prescription remains extremely important for both the sports medicine specialist and the primary care provider for these patients. Guidelines are specific for a generalized exercise prescription. Cardiovascular exercise should take place at least 5 days per week with the patient maintaining 85% of their maximum predicted HR for at least 20 minutes. In addition, progressive resistance training should be performed 2-3 days per week.
Subsequent data also exists for patient’s with comorbidities. This specific case deals with an obese patient without other comorbidities. A provider should prescribe non-weight bearing activities at first to avoid the increase stress on the lower extremities. The compliance rate alone for obese patients is very poor secondary to either pain or discouragement. Thus, the patient should perform as much exercise as they can (not the firm 20 minutes as stated above) to increase compliance. In addition, the patient should exercise prior to the AM meal to help with digestion. The lower the impact of the exercise prescription, the higher the compliance.
1. American College of Sports Medicine. ACSM's Guidelines for Exercise Testing and Prescription. 7th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2006.
Scott Rand
Which of the exercise prescription below should you advise against for an HIV infected individual with mild to moderate symptoms or CD4 count < 200?
A. moderate exercise (40 -60 % VO2max)
B. weight training
C. intense exercise (>75% VO2 max)
D. Three times per week
Correct: C
Ullman reported an impaired ability to mobilize neutrophils and natural killer cells in response to 1h of exercise at 75% VO2 max.
Otherwise, moderate exercise has been shown to increase CD4 counts and CD4:CD8 ratios.
It has also been shown to lower anxiety and tension levels in this population by.
Weight training may enhance muscle strength, bulk and function in HIV+ individuals and may mitigate muscle wasting.
Scott Rand
A female cross-country runner presents early in the season complaining of heel pain. She states the pain has been present for two weeks. Initially the pain only occurred with long runs but now hurts most of the time. On exam, pain is elicited by squeezing the heel. X-rays are initially unremarkable. Repeat x-rays obtained two weeks later however confirm the diagnosis. Which statement about this condition is true?
A. Surgical intervention is required
B. Patient should be counseled that healing is expected to take 10-12 weeks
C. Patient is a increased risk of plantar fascia rupture
D. Patient can expect to return to activity in 4-6 weeks
E. Patient’s body habitus is not a factor in this diagnosis
Correct: D
Explanation: Calcaneal stress fractures are not considered a high risk injury. They typically heal 4-6 week after injury with activity modification including crutches with weightbearing as tolerated. Surgery is usually not required and most improve prior to seasons end. Patient has a positive squeeze test suggesting bony rather than soft tissue pathology. Low weights, as often seen in cross country runners can increase the risk of stress fractures.
1. Pfeffer GB, Plantar heel pain Am Fam Phys, 67(1):85-90, 2003
Scott Rand
A 36 year old female recreational soccer player presents with insidious onset of left posterior heel pain and a limp. She is wearing flip flops because shoes make the pain worse. Examination reveals swelling and erythema of the posterior heel. There is no palpable defect in the Achilles tendon and a Thompson test is negative. The most likely diagnosis is:
A. Stress fracture of the calcaneus
B. Plantar fasciitis
C. Achilles tendon avulsion
D. Sural neuritis
E. Retrocalcaneal bursitis
Correct: E
Retrocalcaneal bursitis (also called Haglund’s syndrome) is associated with overuse and presents with pain behind the calcaneus. Examination reveals swelling and erythema of the posterior heel. A prominence, called a “pump bump” may be noticeable. Retrocalcaneal bursitis is associated with pain and tenderness anterior to the Achilles tendon, along the medial and lateral aspects of the posterior calcaneus. Plantar flexion of the foot and/or squeezing the bursa from side to side reproduces the patient’s complaint.A stress fracture of the calcaneus produces mid-calcaneal bony tenderness and occurs with acute overuse. The symptoms of plantar fasciitis include tenderness and pain underneath (plantar surface), rather than behind the heel. A pop is generally heard and felt along with a palpable defect in the tendon and a positive Thompson test with an Achilles tendon avulsion injury. Sural neuritis is rare and the result of direct trauma. A positive percussion sign over the nerve lateral to the Achilles tendon is diagnostic of sural neuritis.
1. Snider, R. K. (1997). Essentials of musculoskeletal care. USA: American Academy of Orthopaedic Surgeons.
Scott Rand
Your high school soccer player reports proximal medial ankle pain that has developed gradually since the start of preseason training. You suspect she has a navicular stress fracture. Which of the following clinical clues besides the history would lead you to this conclusion? You may choose more than one answer
- Tenderness at the N spot
- significant pes planus
- normal/negative x-rays of the foot
- Pain when standing on toes
Tenderness at the N spot, which is the area of the navicular between the tibialis anterior and extensor hallucis longus tendons, corresponds to the central third of the bone, in the watershed vascular supply location. Tenderness here should raise your suspicion. This is the corollary to the anatomic snuffbox of the wrist and the scaphoid.
Pes cavus, with a restricted subtalar motion, may be a mechanical risk to develop this injury as a result of improper force distribution across the navicular, particularly in a loaded position to push off.
Pain reported in the N spot when asked to stand on toes, or with hopping on that foot, should elevate concern.
Normal/negative plain films of the foot do not definitively rule out stress fractures, in part due to the location of the foot and the technical challenge of providing enough radiation to identify the injury. A negative/normal foot x-ray should only provide confidence to rule out a different skeletal, or possibly a chronic unresolved injury to the navicular.
Scott Rand
A. Diminished foot pulses at rest
B. Pain more closely associated with volume of exercise rather than intensity of exercise
C. Slow resolution of symptoms at conclusion of exercise
D. Patients may have normal pulses that disappear or decrease with plantar flexion or dorsiflexion of the foot
E. Markedly elevated compartment pressure
Correct: D
Popliteal artery entrapment syndrome causes calf pain during exercise due to compression of the popliteal artery by an abnormal relationship of the artery to the gastrocnemius and/or plantaris muscles. Unlike exertional compartment syndrome, symptoms are associated with intensity of exercise rather than volume. In addition, symptoms tend to resolve quickly after the conclusion of exercise until very late in the disease, when sclerosis of the artery creates a more chronic condition. Foot pulses tend to be normal at rest, but can be abnormal with dorsi- and plantarflexion of the foot. For this reason, diagnostic workup for the disorder includes Doppler ultrasonography or angiography in neutral position, dorsiflexion and plantarflexion. Compartment pressures are usually normal or slightly elevated. This disorder is usually treated by cessation of causative activities followed by surgical release of the artery from the offending muscles. After surgical release, most patients can resume normal exercise.
1. Zetaruk M, Hyman J. Leg injuries, in Clinical Sports Medicine (ed. Frontera et al) 451, 2007.
2. http://radiographics.rsnajnls.org/cgi/content/full/24/2/467. Popliteal Artery disease: Diagnosis & Treatment. Wright LB et al, RadioGraphics, 2004; 24:467-479.
Scott Rand
A patient presents to your office unable to dorsiflex his great toe. Which of the following is true?
A. The extensor hallucis longus which inserts on base of the distal phalanx of the great toe is the muscle responsible for extending the great toe
B. The motor function for this is from L4 and L5
C. The muscles that allow this action are all contained in the lateral compartment of the lower leg
D. The muscles that allow this action are inervated by the tibialis anterior nerve
Correct: A
The extensor hallus longus originates on the medial fibula in the interosseous membrane and it inserts onto the base of the distal phalanx of the great toe. It is inervated by the deep peroneal nerve, not the tibialis anterior nerve and it is inervated by L5, not L4. The muscles that act as extensors of the foot and toe are the anterior compartment of the lower extremity. The lateral compartment contains the proneous longus, proneous brevis and the peroneal nerve.
1. Jon C Thompson (2002). Netter's Concise Atlas of Orthopaedic Anatomy. Teterboro, NJ: Icon Learning Systems LLC.