daily answer

[Scott Rand]

Give 3 examples of conditions that would warrant a therapeutic use exemption for the prescription of testosterone supplementation for an athlete

Genetic abnormalities such as Klinefelter’s syndrome

Congenital anorchia

Hemochromatosis leading to hypogonadism

Testicular absence from trauma or torsion

Severe orchitis

Pituitary disorders such as hyperprolactinemia, panhypopituitarism

This does not include functional androgen deficiency from severe emotional distress, obesity, malnutrition or overtraining, late onset hypogonadism, or alcohol excess.

 

--

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]

What is Blount’s disease?

 

Blount's Disease (Tibia Vara)

• Overview: Tibia vara is a condition that involves a growth disturbance of the medial tibial physis (Fig. 8-6). It is most commonly seen in obese males age 10 to 14 but can been seen in children as young as 2 to 3; more common in African Americans. Blount's disease should be included in the differential diagnosis of any child presenting with a limp or bowlegs (genu varum) at any age.
• Presentation: Classic presentation is of an obese child with a chronic progressive limp and either a unilateral or bilateral bowing of the tibia. Knee pain may be present and often localizes to the medial tibia.
• Physical examination: Findings often include a leg length discrepancy, tenderness at the medial tibial physis, and tibial torsion associated with the tibia vara. Instability to valgus stress testing may be present. Gait is usually antalgic and is notable for a varus thrust.
• Diagnosis: Radiographs of the knee often reveal the tibia vara and demonstrate the growth arrest of the medial tibial physis with acute medial angulation of the proximal tibia. A standing bilateral lower extremity AP view showing pelvis to foot is the standard orthopedic view but it is often not obtained until after the diagnosis is made on standard knee radiographs.
• Treatment: Blount's disease patients should be referred to a pediatric orthopedic surgeon for definitive care. Surgical treatment options include an osteotomy to realign the tibia into slight valgus, thus eliminating the leg length discrepancy and bowing. Other options include a stapling procedure of the lateral tibial physis to stop the growth throughout the proximal tibia. This can result in a significant leg length discrepancy in comparison to the contralateral side and may lead to further complications. Weight management as part of the comprehensive treatment for obesity must be emphasized in these patients and primary care providers must be involved.

Figure 8-6 Blount's Disease.

[Scott Rand]

 

A 13 year old female with a history of Legg-Perthes disease as a child presents to your clinic with worsening chronic left hip and groin pain.  She reports occasional catching or locking.  On exam she has pain with passive range-of-motion and reduced internal rotation and abduction.  On MRI of the hip, you find which of the following:

A.      Osteochondritis Dissecans of the femoral head

B.      Labral Tear

C.      Normal hip

D.      Arthritis

 

Correct: A

Legg-Calve-Perthes disease is idiopathic avascular necrosis of the femoral head in young people. It presents is at age 4 to 8 and is more common in males.  It typically is self limited and undergoes resorption, collapse, followed by repair of the capital femoral epiphyses.  The result is impaired development of the hip joint.  Half of children who develop Legg-Perthes disease will develop osteoarthritis later in life.  Additionally, some patients do not spontaneously resolve and develop an osteochondral fragment which fails to unite with the rest of the femoral head.

1.       Kocker M, Tucker R. PediatricAthlete Hip Disorders. Clin Sports Med - 01-APR-2006; 25(2): 241-53, viii

2.       Katz J, Siffert R.  Osteochondritis Dissecans in Association with Legg-Calve-Perthes Disease.  International Orthopaedics. 1979; 3(3), p189-195.

[Scott Rand]

A 12 year old girl with no previous hip problems suffers an injury immediately after landing in the sand pit following setting her personal record in the long jump.

 

She now has pain and tenderness deep within the hip over the proximal and medial femur.

 

There is pain with passive internal and external rotation of the involved hip and with active hip flexion. The examination of the other hip is normal.

 

The most accurate diagnosis is:

 

A.      Avulsion of the apophysis over the ischial tuberosity

B.      Avulsion of the apophysis over the anterior superior ischial spine

C.      Avulsion of the apophysis over the anterior inferior ischial spine

D.      Avulsion of the apophysis over the lesser trochanter

E.       Avulsion of the apophysis over the  greater trochanter

 

Correct: D

The most common sites of avulsion fractures of an apophysis near the hip in a skeletally immature athlete are:  the anterior superior iliac spine (sartorius), the ischium (hamstrings), the lesser trochanter (iliopsoas), the anterior inferior iliac spine (abdominal rectus), and iliac crest (abdominal muscles).

 

These are injuries resulting from sudden mechanical force and from weakness at the secondary growth site. This type of maximal effort causing an injury in an adult would most often lead to a simple muscle strain, not a fracture of a mature bone.

 

These injuries occur in running and jumping sports during a maximal effort.

 

Avulsion of the apophysis over the greater trochanter is rare.

 

Presentation of apophyseal fractures is acute. Common bursitis reactions in the same areas present gradually, often with an overuse history.

 

Plain radiographs can demonstrate these apophyseal avulsion fractures.

 

 

 

1.       DeLee, Jesse C, Drez, David, Jr. DeLee and Drez's Orthopedic Sports Medicine. 2nd. Philadelphia: Saunders Elsevier, 2003.

2.       McKeag, Douglas B, Moeller, James L. ACSM's Primary Care Sports Medicine. 2nd. Philadelphia: Lippincott Williams and Wilkins, 2007.

3.       Mellion, Morris et al. Team Physician's Handbook. 3rd. Philadelphia: Hanley & Belfus, Inc., 2002.

 

[Scott Rand]

Name 3 juvenile osteochondropathies of the lower extremity (with eponyms) in skeletally immature athletes

Base of the 5^th 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]

This 64 year old female presented to the clinic with severe pain and swelling in the left patella after a fall 1 day prior.  Pain is worse with active extension of the knee.

 

 

There is a non displaced fracture of the inferior pole of the patella..  some comminution noted.  No other obvious fractures seen. 

 

 

[Scott Rand]

12  This 12 year old football player presented to clinic with complaints of pain in the left thumb after having it bent backward trying to catch a  ball. 

 

 

 

There is a minimally displaced  salter Harris type 2 fracture of the proximal phalanx of the thumb.  Minimal angulation noted.  No other obvious fractures are seen. 

 

 

 

[Scott Rand]

This 15 year old male presented to clinic with complaints of severe left elbow pain and limited ROM after a fall on an outstretched hand. 

 

 

There is a moderately large joint effusion with evident anterior and posterior fat pad signs.  No obvious fracture is seen.  No mal alignment.  Assume occult nondisplaced supracondylar or radial head fracture. 

 

 

[Scott Rand]

.  This 15 year old male presented with several months of recurrent pain and swelling in his right knee whenever he played soccer. 

 

 

 

 

There is an osteochondral defect noted in the lateral to mid portion of the medial femoral condyle.  No displacement is seen.  No acute fracture is noted.  Physes remain open. 

 

 

[Scott Rand]

.  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 5^th metacarpal neck.   There is palmar angulation of less than 15 degrees grossly.  No other fractures are seen.  Physes are open. 

 

[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]

 

An afebrile patient with acute low back pain notices pain going down the posterior-lateral aspect of her right thigh and leg. It is noted on your exam that she has the following: (+) straight leg raise test, a slight sensory deficit over the lateral aspect of the right lateral foot, a diminshed ankle jerk and weakness with plantar flexion of the great toe. It is also noted that it is hard for her to walk on her toes.  Which nerve root is most likely affected?

A.      L3

B.      L4

C.      L5

D.      S1

E.       L2

 

Correct: D

This question focuses on knowing nerve root ennervation and the dermatomes of the lower extremity.  The S1 nerve root supplies sensation to the lateral aspect of the foot, is responsible for the ankle reflex, and gives strength in plantar flexion.

1.        Clement's Anatomy, 2nd edition

 

[Scott Rand]

17 year old football player tackles an opposing player and sustains a flexion injury of his neck.  He falls to the ground. The ambulance is summoned and he is boarded and taken to the hospital.  He is found to have an injury to the anterior spinal cord of his neck.  Which of the following clinical findings match this lesion?

A.      Loss of motor function and position sense on the same side of the body as the lesion and loss of pain and sensation on the opposite side of the body as the lesion

B.      Bilateral lower extremity paralysis that is greater than the upper extremity paralysis.  Bilateral loss of pain and temperature sensation, vibratory and proprioception is intact

C.      Weakness in both upper extremities that is more severe than the weakness in both lower extremities.  Sacral function is spared

D.      After the period of spinal shock has resolved, the patient has no motor or sensory activity below the level of the lesion

 

 

Correct: B

Selection A is incorrect as it describes a Brown-Séquard lesion.  Only one side of the cord is affected and there is loss of motor function and position sense on the same side with pain and sensation on the opposite side.  This is a fairly rare lesion but has the best prognosis as far as patient recovery.

 

Selection B is correct.  Anterior cord lesion often happens after a flexion injury and unfortunately has a poor prognosis.  Lower extremities are usually affected with paralysis greater than the upper extremities.  Temperature sensation, vibratory sensation and proprioception are intact.

 

Selection C describes a central cord lesion.  This type of lesion most often happens with the hyperextension, not a hyperflexion injury, and can happen in elderly people with spondylosis who falls.

 

Selection D is also incorrect and describes complete severing of the spinal cord.  There is loss of both motor and sensory function below the level of the lesion.  The bulbocavernosus reflex must be present to confirm that the spinal shock period is over.

 

1.       Jon C Thompson (2002). Netter's Concise Atlas of Orthopaedic Anatomy. Teterboro, NJ: Icon Learning Systems LLC.

2.       Arce D, Sass P and Abul-Khoudoud H.  Recognizing Spinal Cord Emergencies.    AFP.  2001 Aug; 74(4):631-638.

 

 

[Scott Rand]

The anterior tibialis is the main dorsiflexor of the ankle, it originates on the anterolateral tibia and interosseus membrane and inserts on:

A.      Medial cuneiform and base of 1st metatarsal

B.      All 3 cuneiform bones, and the base of the 2nd metatarsal

C.      Navicular bone

D.      Anterior talus

 

Correct: A

The anterior tibialis muscle is the largest muscle in the anterior leg, and the main occupant of the anterior compartment.  In addition to dorsiflexing the ankle, the muscle also adducts and inverts the foot.  The tendon crosses the anterior to the ankle joint just medial to the midline, then sweeps across the dorsum of the foot medially to insert on the plantar surface of the medial cuneiform and base of the 1st metatarsal.  The muscle is innervated by the L4 nerve root contained in the deep peroneal nerve.  Rupture of this tendon can occur and is typically seen in individuals over age 45 after a forceful plantarflexion of the foot.

1.       Netter F: Atlas of Human Anatomy 4th edition. Philadelphia, Saunders Elsevier, 2006.

2.       Keens, JS: Tendon injuries of the foot and ankle.  In Delee JC, Drez D(ed): Orthopedic Sports Medicine.  Philadelphia, Saunders, 2003, pp 2409-11.

 

 

[Scott Rand]

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.

(A)  This is associated with resistance training.

(B)  Increased protein content of muscle fibers is associated with resistance training.

(D)  The muscle capillary bed increases in size with endurance training.

(E) Increased size of muscle fibers is the result of resistance training.

 

https://www.uptodate.com/contents/exercise-physiology? source=search_result&search=exercise&selectedTitle=5~150#H4034285 (http://www.uptodate.com/contents/exercise-physiology?

[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.htmlMelby (http://www.unm.edu/~lkravitz/Article%20folder/physiologgfatloss.htmlMelby), C., Scholl, C., Edwards, G., and Bullough, R. (1993). Effect of acute resistance exercise on post-exercise energy expenditure and resting metabolic rate. Journal of Applied Physiology, 75, 1847-1853.Achten, J., & Jeukendrup, A.E. (2012). Optimizing fat oxidation through exercise. Nutrition. 20, 7-8.

[Scott Rand]

A 16 year old male snowboarder had an accident during the Olympic competition.  It was significant enough that it was decided to transport him to the hospital.  En route, he complained of left shoulder pain, but remained hemodynamically stable during transport.  At the hospital, his hemoglobin remained normal and stable throughout.  CT scanning with contrast revealed a Grade II Splenic injury.  Things to consider during his initial evaluation, management and disposition include:

A.      The spleen is rarely injured during sport

B.      Non-operative management would be preferred

C.      Splenic rupture is of minor concern in this patient

D.      Ultrasound is the preferred method of imaging in stable patients

E.       He should be vaccinated immediately

 

Correct: B

Answer A is not correct.  The spleen is the most commonly injured abdominal organ in sports.  Answer B is the best answer for several reasons.  The predominant reasons include the fact that he is an adolescent who is hemodynamically stable.  Preservation of the spleen is always preferable in the long term.  And since his competitive season is likely over for a while after the Olympics, he would be an excellent candidate for non-operative management which is the currently preferred method of management.  Healing can take several months.  Answer C is incorrect because delayed splenic rupture is the greatest concern after 48 hours in the non-operatively managed patient.  Answer D is incorrect because CT scanning has been shown to be superior to US.  If the patient is unstable, portable ultrasound would then be the preferable imaging method, but is not pertinent in this scenario.  Answer E is correct if the patient is thought to need an urgent splenectomy.  There was no indication that emergent surgery was needed, and therefore is not the best answer.

1.       Brown RL, Irish MS:  Observation of Splenic Trauma:  When Is a Little Too Much?  Journal of Pediatric Surgery 34(7):1124-1126, 1999.

2.       Rifat SF, Gilvydis RP:  Blunt Abdominal Trauma in Sports.  Current Sports Medicine Reports 2:93-97, 2003

3.       Gravlee JR, Schwenk TL:  Management Choices for Splenic Injury in a Collegiate Football Player.  Current Sports Medicine Reports 2(4):211-212, 2007

 

[Scott Rand]

 

What is the most common cause of airway obstruction in an unconscious athlete?

A.      Mouthguard

B.      The tongue

C.      Swelling from anaphylaxis

D.      Inhaled foreign body

 

 

 

Correct: B

The tongue is the one answer that would be present in all athletes.

Answer a) a mouthguard would be present only in contact sports.

Answer c) is a valid answer, but it is not the most common cause.

Answer d) is also a valid option, but the inhalation of foreign bodies is not that common.

 

1.       Eric A. Weiss,  Wilderness 911: A Step-by-step Guide for Medical Emergencies and Improvised, Published 1998, The Mountaineers Books

2.       American Heart Association, American Heart Association 2005 Guidelines for cardiopulmonary resuscitation and emergency cardiac care

 

 

[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 21 year old type 1 diabetic athlete begins training for a 50 mile bike ride with a partner. She uses an insulin pump and is experienced with running cross country in high school. During her first 30 mile ride she experiences symptoms of hypoglycemia at 25 miles and almost falls before stopping. She is confused and her BS is 40.

What is the most appropriate immediate action?

A.      Eat a banana or sports bar

B.      Administration of glucagon by her partner

C.      Drink a carbohydrate sports drink then quickly resume riding to reach a safe destination

D.      Drink 8 ounces of water to improve volume status

 

Correct: B

Glucagon has most rapid onset of action in a confused, uncooperative athlete.

Hyperinsulinemia due to the pump is the cause. A reduction of infusion by 50% is needed for longer bouts of exercise.

A solid carbohydrate food will be absorbed too slowly to prevent potential serious CNS complications in this emergency.

Resumption of exercise without adjusting the continuous pump plus a carbohydrate bolus will result in progressive hypoglycemia and CNS decline.

Dehydration may exist for various reasons but carbohydrate fuel is absolute necessity in this situation.

 

 

1.       Physical Activity/Exercise and Diabetes. Diabetes Care 2004 27: S58-S62

2.       Sonnenberg GE, Kemmer FW, Berger M.  Exercise in type 1 diabetic patients treated with continuous subcutaneous insulin infusion. Prevention of exercise induced hypoglycemia.  Diabetologia 1990; 33:696-703

[Scott Rand]

Which factor most influences the effectiveness of extracorporeal shockwave therapy (ESWT) in chronic tendinopathy?
A. Patient age alone
B. Energy dosage and adherence to post‑treatment loading
C. Use of shockwave therapy as a standalone treatment
D. Avoidance of mechanical loading after treatment

Correct Answer: B – Energy dosage and adherence to post‑treatment loading

Explanation:
ESWT effectiveness depends on proper energy parameters and integration into a loading‑based rehabilitation plan. Evidence shows better outcomes when paired with progressive tendon loading rather than used in isolation. [researchgate.net]

[Scott Rand]

Why is neuromuscular electrical stimulation (NMES) commonly used early after knee injury or surgery?
A. It decreases quadriceps activation
B. It increases joint laxity
C. It improves motor unit recruitment and combats inhibition
D. It reduces the need for voluntary strengthening
Correct Answer: C

Correct Answer: C – It improves motor unit recruitment and combats inhibition

Explanation:
NMES counteracts arthrogenic muscle inhibition commonly seen after knee injury or surgery. By improving early quadriceps recruitment, it supports restoration of gait mechanics and functional strength, especially when paired with voluntary exercise. [ijspt.scho...ticahq.com]

[Scott Rand]

Which of the following best explains why blood flow restriction (BFR) training is an effective rehabilitation modality for load‑compromised athletes?
A. It eliminates metabolic stress during low‑load exercise
B. It produces hypertrophy and strength gains comparable to high‑load training
C. It decreases muscle activation to reduce fatigue
D. It is only beneficial for upper‑extremity rehabilitation

Correct Answer: B

Explanation:
Blood flow restriction training allows patients to achieve significant muscle hypertrophy and strength improvements while using low loads, making it particularly beneficial when high‑load training is contraindicated. Systematic reviews show BFR can enhance muscle strength and size in both post‑operative orthopedic patients and athletic populations, with effects in some cases comparable to high‑intensity resistance exercise due to increased metabolic stress and altered muscle fiber recruitment. [arthroscop...tation.org], [jsams.org]