Sports medicine by xiuliliaofz


									Board Review

5. An 18-year-old female basketball player comes to your
office the day after sustaining an inversion injury to her ankle.
She says she treated the injury overnight with rest, ice,
compression, and elevation. You examine her and diagnose a
moderate to severe lateral ankle sprain. In addition to
rehabilitative exercises, you advise

A) a short-term cast
B) a posterior splint that allows no flexion or extension
C) a semi-rigid stirrup brace (Air-Stirrup)
D) an elastic bandage
E) no external brace or support

In acute ankle sprains, functional treatment with a
semi-rigid brace (Aircast) or a soft lace-up brace is
recommended over immobilization. Casting or
posterior splinting is no longer recommended.
Elastic bandaging does not offer the same lateral
and medial support. External ankle support has
been shown to improve proprioception.
37. A 20-year-old female long-distance runner
presents with a 3-month history of amenorrhea. A
pregnancy test is negative, and other blood work is
normal. She has no other medical problems and
takes no medications. With respect to her
amenorrhea, you advise her

A) to increase her caloric intake
B) that this is a normal response to training
C) to begin an estrogen-containing oral contraceptive
D) to stop running

Amenorrhea is an indicator of inadequate calorie intake,
which may be related to either reduced food consumption
or increased energy use. This is not a normal response to
training, and may be the first indication of a potential
developing problem. Young athletes may develop a
combination of conditions, including eating disorders,
amenorrhea, and osteoporosis (the female athlete triad).
Amenorrhea usually responds to increased calorie intake or
a decrease in exercise intensity. It is not necessary for
patients such as this one to stop running entirely, however
45. A 56-year-old African-American male has pain and
tingling in the medial aspect of his ankle and the plantar
aspect of his foot. He jogs 3 miles daily and has no history of
any injury. The symptoms are aggravated by activity, and
sometimes keep him awake at night. The only findings on
examination are paresthesias when a reflex hammer is used
to tap just inferior to the medial malleolus.

This patient probably has

A) a stress fracture
B) a herniated nucleus pulposus at L5 or S1
C) plantar fasciitis
D) diabetic neuropathy
E) tarsal tunnel syndrome

Entrapment of the posterior tibial nerve or its branches as the nerve
courses behind the medial malleolus results in a neuritis known as tarsal
tunnel syndrome. Causes of compression within the tarsal tunnel include
varices of the posterior tibial vein, tenosynovitis of the flexor tendon,
structural alteration of the tunnel secondary to trauma, and direct
compression of the nerve. Pronation of the foot causes pain and
paresthesias in the medial aspect of the ankle and heel, and sometimes
the plantar surface of the foot.

The usual site for a stress fracture is the shaft of the second, third, or
fourth metatarsals.
A herniated nucleuspulposus would produce reflex and sensory changes.
Plantar fasciitis is the most common cause of heel pain in runners and
often presents with pain at the beginning of the workout. The pain
decreases during running only to recur afterward.
Diabetic neuropathy is usually bilateral and often produces paresthesias
and burning at night, with absent or decreased deep tendon reflexes.
81. A 32-year-old female who is an avid runner
presents with knee pain. You suspect
patellofemoral pain syndrome. Which one of the
following signs or symptoms would prompt an
evaluation for an alternative diagnosis?

A) Peripatellar pain while running
B) Knee stiffness with sitting
C) A “popping” sensation in the knee
D) “Locking” of the joint
E) A positive “J” sign (lateral tracking of the patella
when moved from flexion to full extension)

Patellofemoral pain syndrome is a clinical diagnosis and is
the most common cause of knee pain in the outpatient
setting. It is characterized by anterior knee pain,
particularly with activities that overload the joint, such as
stair climbing, running, and squatting. Patients complain of
“popping,” “catching,” “stiffness,” and “giving way.” On
examination there will be a positive “J” sign, with the
patella moving from a medial to a lateral location when the
knee is fully extended from the 90° position. This is
caused by an imbalance in the medial and lateral forces
acting on the patella. “Locking” is not characteristic of
patellofemoral pain syndrome, so loose bodies or a
meniscal tear should be considered if this is found.
84. A 22-year-old male with no previous history of
shoulder problems is injured in a fall. He has
immediate pain and is unable to abduct his arm. He
goes to the emergency department and an MRI
reveals an acute tear of the rotator cuff. Which one
of the following is the best initial treatment for this

A) Observation without treatment for 1 month
B) Immobilization for 1 month
C) Physical therapy for 1 month
D) Corticosteroid injection
E) Surgical repair

An acute rupture of any major tendon should be
repaired as soon as possible. Acute tears of the
rotator cuff should be repaired within 6 weeks of
the injury if possible (SOR C). Nonsurgical
management is not recommended for active
persons. Observing for an extended period will
likely lead to retraction of the detached tendon,
possible resorption of tissue, and muscle atrophy.
131. You see a 5-year-old white female with in-
toeing due to excessive femoral anteversion. She is
otherwise normal and healthy, and her mobility is
unimpaired. Her parents are greatly concerned with
the cosmetic appearance and possible future
disability, and request that she be treated. You
recommend which one of the following?

A) Observation
B) Medial shoe wedges
C) Torque heels
D) Sleeping in a Denis Browne splint for 6 months
E) Derotational osteotomy of the femur

There is little evidence that femoral anteversion causes
long-term functional problems. Studies have shown
that shoe wedges, torque heels, and twister cable splints
are not effective. Surgery should be reserved for
children 8–10 years of age who still have cosmetically
unacceptable, dysfunctional gaits. Major complications of
surgery occur in approximately 15% of cases, and can
include residual in-toeing, out-toeing, avascular necrosis of
the femoral head, osteomyelitis, fracture, valgus deformity,
and loss of position. Thus, observation alone is appropriate
treatment for a 5-year-old with uncomplicated anteversion.
169. In a preadolescent athlete, sudden death from
a blunt injury to the chest (commotio cordis) is most
likely to occur in which one of the following

A) A pitcher is struck by a line drive
B) A basketball player is struck by the ball
C) A chest-to-chest collision occurs during a soccer
D) Hockey players skate into each other
E) A football player is struck by the shoulder pad of
a lineman

Commotio cordis usually results from impact with a
projectile in sports. Children and adolescents may
have increased risk due to a compliant chest wall.
Ventricular fibrillation is thought to result from the
impact. Softer “safety” baseballs are one
consideration in primary prevention.

Older competitors are at less risk. Large blunt
objects or body-to-body contact also carries less risk.
216. An overweight 13-year-old male presents with a 3-week
history of right lower thigh pain. He first noticed the pain when
jumping while playing basketball, but now it is present even
when he is just walking. On examination he can bear his full
weight without an obvious limp. There is no localized
tenderness, and the patella tracks normally without
subluxation. Internal rotation of the hip is limited on the right
side compared to the left. Based on the examination alone,
which one of the following is the most likely diagnosis?

A) Avascular necrosis of the femoral head (Legg-Calvé-Perthes
B) Osteosarcoma
C) Meralgia paresthetica
D) Pauciarticular juvenile rheumatoid arthritis
E) Slipped capital femoral epiphysis

This is a classic presentation for slipped capital femoral epiphysis (SCFE) in
an adolescent male who has probably had a recent growth spurt. Pain with
activity is the most common presenting symptom, as opposed to the
nighttime pain that is typical of malignancy. Obese males are affected
more often. The pain is typically in the anterior thigh, but in a high
percentage of patients the pain may be referred to the knee, lower leg, or
foot. Limited internal rotation of the hip, especially with the hip in 90°
flexion, is a reliable and specific finding for SCFE and should be looked for
in all adolescents with hip, thigh, or knee pain.

Meralgia paresthetica is pain in the thigh related to entrapment of the
lateral femoral cutaneous nerve, often attributed to excessively tight
clothing. Legg-Calvé-Perthes disease (avascular or aseptic necrosis of the
femoral head) is more likely to occur between the ages of 4 and 8 years.
Juvenile rheumatoid arthritis typically is associated with other
constitutional symptoms including stiffness, fever, and pain in at least one
other joint, with the pain not necessarily associated with activity.
237. A 7-year-old male is brought to your office after
hurting his hand when he fell on a wet kitchen floor. He is
unable to describe the mechanism of injury. On
examination the maximal point of tenderness is at the
third metacarpal-phalangeal joint, which also has some
generalized swelling but no ecchymosis. Range of motion
is limited in this joint due to pain. A radiograph of the
hand is shown in Figure 7. Which one of the following is
the most likely diagnosis?

A) Boxer’s fracture
B) Greenstick fracture
C) Salter type II fracture
D) Spiral fracture
E) No abnormality

Recognizing common fracture types is an important part of
determining how to proceed when caring for an injured
patient. Fractures in children can be different from those in
adults for several reasons, including the elasticity of
immature bone, the possibility of child abuse, and the
presence of growth plates. The radiograph shown with this
question is an example of a fracture through the growth
plate. Approximately 6%–7% of such fractures will cause a
restriction of growth. The Salter classification system was
developed to classify fractures into the growth plate and
can be used to estimate the risk of growth restriction. The
higher the classification, the greater the risk of
5. A 15-year-old white male complains of bilateral
foot pain. He does not recall any injury, and the
pain improves with rest. Examination reveals
tenderness over the lateral and anterior ankle,
along with a rigid flatfoot, peroneal tightness, and
pain on foot inversion. The most likely diagnosis is

A) tarsal coalition
B) stress fracture
C) plantar fasciitis
D) turf toe
E) foot sprain

Tarsal coalition is the fusion of two or more of the tarsal bones. It is congenital, and 50%
of the time is bilateral. It is asymptomatic until early adolescence. On clinical
examination there is tenderness over the subtalar joint (lateral and anterior ankle), rigid
flatfoot, limited subtalar motion, peroneal tightness, and pain on foot inversion.
Treatment is conservative.

A stress fracture would present with pain in the forefoot, warmth, mild swelling, and
point tenderness over the affected metatarsals, most commonly the second or third.
Radiographs are often negative initially, but a callus is usually evident by the third week
of symptoms.

Plantar fasciitis presents with pain in the heel or sole of the foot and is most painful with
the first step after arising from bed or prolonged sitting. It may be associated with pes
planus (flat foot), but in plantar fasciitis the flat foot is flexible, not rigid.

Turf toe is inflammation of the first metatarsophalangeal joint due to acute and/or
repetitive hyperextension injury resulting from sudden toe-off against an unyielding
surface, such as artificial turf. The patient may present acutely with a tender, red,
swollen first metatarsophalangeal joint, with pain on passive extension. Others may
develop a chronic condition and present with hallux rigidus. Foot sprain is a nonspecific
term for an acute ligamentous injury.
8. Which one of the following is characteristic of
osteoarthritis of the knee?

A) Greater frequency in men than in women
B) Increased pain with rest
C) A direct correlation between radiographic
changes and pain severity
D) Reduction of pain with repair of associated
meniscal tears
E) Reduction of pain with muscle strengthening

Osteoarthritis of the knee is more common in
women than in men. Rest improves the pain of
osteoarthritis, and increasing muscle strength
improves joint stability and reduces pain. Meniscal
tears are extremely common in advanced
osteoarthritis, but repairing them fails to improve
the course of the disease. Radiographic changes
correlate poorly with pain severity in osteoarthritis.
30. A 62-year-old white female presents to your office with
moderately severe knee pain. She has a history of osteoarthritis
and is not aware of any recent injury. The pain bothers her both
during the day and at night. Examination reveals a moderately
obese female with a normal knee examination except for
tenderness in the medial tibial plateau region, approximately 3
cm (1½ in) below the medial joint line of the knee. The area of
tenderness is about the size of a quarter. All ligaments of the
knee are intact on examination. There is no knee effusion. A
radiograph is negative except for minimal degenerative changes.
Which one of the following should you suspect?

A) De Quervain’s tendinitis
B) Prepatellar bursitis
C) Bursitis of the medial collateral ligament
D) Anserine bursitis
E) Medial meniscus tear

Anserine bursitis is characterized by pain, particularly at night, that
occurs in the medial knee region over the upper tibia. It is located about
2–3 cm below the medial joint line. It can be bilateral. A diagnosis of
anserine bursitis requires local tenderness confined to a quarter-sized
area of the medial tibial plateau, approximately 3 cm below the medial
joint line; a negative valgus stress maneuver, which indicates an intact
medial collateral ligament; and a normal radiograph of the tibia
indicating no underlying pathology. De Quervain’s tendinitis is located in
the wrist region, not the knee. Prepatellar bursitis is characterized by
knee swelling and pain over the front of the knee. Bursitis that occurs
adjacent to the medial collateral ligament typically presents with
tenderness over the medial aspect of the knee. Medial joint line pain is
characteristic of osteoarthritis, second and third degree medial collateral
ligament injuries, medial meniscal tears, and fractures of the tibial
49. A 14-year-old male who is active in sports most of the
year presents with bilateral anterior knee pain that is worse
in the right knee. An examination reveals tenderness and
some swelling at the tibial tubercles. Which one of the
following is true regarding this patient’s condition?

A) It is almost never seen in adults
B) Treatment with a straight leg cylinder cast for 6 weeks is
often needed
C) Corticosteroid injection of the tibial tubercle is a safe and
effective treatment
D) Radiographs should always be ordered to rule out other
E) Bilateral symptoms are unusual

Osgood-Schlatter disease is encountered in patients
between 10 and 15 years of age. These patients are often
active in sports that involve a lot of jumping. It is thought
to be secondary to repetitive microtrauma and traction
apophysitis of the tibial tuberosity. Bilateral symptoms are
present in 20%–30% of patients. Radiographs may reveal
abnormalities, but are rarely indicated in straightforward
cases. This condition is usually self-limited, and most
patients are able to return to full activity within 2–3
weeks. Treatment includes rest, ice, anti-inflammatory
medications, a rehabilitation program, and an infrapatellar
strap during activities. Casting and corticosteroid
injections are not indicated.
56. Which one of the following is a
contraindication to participation in contact

A) A single testicle
B) Fever
C) Documented scoliosis of 20º
D) Sickle cell trait

Having a single testicle is not a contraindication to contact sports, but it
does necessitate a discussion regarding the potential risk, as well as the
use of a protective cup. A single ovary is not a contraindication because
it is well protected.

Fever is a contraindication to participation since it increases
cardiovascular effort, as well as the potential for heatstroke and
orthostatic hypotension and dehydration. The rare possibility of an
associated myocarditis also should be taken into account. Carditis may
result in sudden death with exertion.

Scoliosis should be looked into prior to allowing a child to participate in
contact sports, but once the diagnosis is made it is rarely a
contraindication unless the curvature is greater than 40º.

Sickle cell trait is not a contraindication to contact sports, although
sickle cell disease can be a contraindication to
strenuous activities or sports associated with significant contact.
64. The most effective means of preventing
sudden death in high-risk patients with
asymptomatic hypertrophic cardiomyopathy is

A) amiodarone (Cordarone)
B) metoprolol (Lopressor)
C) verapamil (Calan, Isoptin)
D) chronic dual-chamber pacing
E) an implantable cardioverter-defibrillator (ICD)

Many patients with hypertrophic cardiomyopathy (HCM) never have any
clinical signs or symptoms. The major cause of mortality is sudden death,
which can occur in both asymptomatic and symptomatic patients, often
after physical exertion. Patients with HCM should be counseled about the
risk of competitive sports and dehydration. Medications such as
verapamil, ß-blockers, and diltiazem are used for symptom management,
but do not decrease the risk of sudden death. Because of its effects on
decreasing dysrhythmias, amiodarone may decrease the risk of sudden
death, which is supported by anecdotal data.
For most patients with HCM, the annual risk of dying is similar to that of
the normal adult population, or 1% per year. Patients most at risk for
sudden death include those with ventricular tachycardia on an ambulatory
monitor, marked left ventricular hypertrophy, abnormal blood pressure
response to exercise, syncope, and a family history of sudden death. At
present, the implantable cardioverter-defibrillator (ICD) is the most
effective modality for preventing sudden death in high-risk patients with
asymptomatic HCM. Pacing does not reduce risk significantly.
75. A 43-year-old house painter presents with chronic pain
in the radial aspect of the wrist, radiating down the thumb.
Her symptoms are worsened with pinching and with wrist
movement. She has had to quit her job due to the severity
of symptoms. On examination she has pain in the thumb
with opening and closing her hand, and a Finkelstein’s test
is positive. The most effective treatment for this patient
would be

A) rest
C) splinting
D) local corticosteroid injection

The history and physical findings are most
consistent with de Quervain’s tenosynovitis, which
affects the abductor pollicis longus and the
extensor pollicis longus and brevis tendons. Local
corticosteroid injection is the most effective
treatment. NSAIDs and splinting may be somewhat
effective for mild cases, but are less effective than
corticosteroids. Rest alone has not been shown to
be very helpful.
86. A 6-year-old female is brought to your office for recurring
limb pain. For the past 2 weeks she has complained of
cramping pain in her thighs and calves, which has caused
her to awaken at times. Massage and occasional
acetaminophen help. In the morning the symptoms are gone
and daily activity is unimpaired. Her physical examination is
normal. On examination she has no inflammatory signs and
no joint or muscle tenderness. Which one of the following
would be most appropriate at this point?

A) Radiographs of the hips and knees
B) An erythrocyte sedimentation rate
D) Antinuclear antibody (ANA) testing
E) No further testing

This patient is experiencing benign nocturnal pains of childhood,
formerly called “growing pains.” These are cramping pains of the
thigh, shin, and calf, and affect approximately 35% of children 4–
6 years of age. The pain typically occurs in the evening or at
night, may awaken the child from sleep, and disappears by
morning. This classic presentation in the absence of other
inflammatory or chronic signs and symptoms should reinforce the
benign nature of this condition. Physical findings are normal, so in
the absence of worrisome complaints or anatomic abnormalities
no further diagnostic testing is required. Parents should be
reassured that there are no long-term sequelae. If activity is
impaired, the physical examination is abnormal, or any
constitutional or systemic complaints are present, then further
evaluation with additional testing is indicated, and may include an
erythrocyte sedimentation rate, CBC, antinuclear antibody, or
radiographs of affected bones or joints.
90. A 5-year-old male is brought to your office with
forearm pain after a fall, and you diagnose a non-
angulated buckle fracture of the distal radius and
ulna. Which one of the following treatments has the
best functional outcome at 3–4 weeks?

A) An ACE wrap
B) A removable splint
C) A long arm cast
D) A thumb spica cast
E) Surgical reduction and internal fixation

Although casting for 3–4 weeks with a short arm
cast has been the traditional treatment for buckle
fractures of the wrist, functional outcome in the
short term is better with a simple removable
splint, and management is easier. Long-term
outcomes are good with either treatment. Rigid
splinting adds to short-term functional stiffness,
and a wet cast or foreign bodies placed between
the cast and skin necessitate additional visits.
Surgical approaches are contraindicated and
would not improve healing or position.
96. A healthy 25-year-old female runner presents
with a complaint of right heel pain for 2 months. The
pain is most pronounced with the first steps of the
day or after periods of rest, and is located around
the medial calcaneal tuberosity. Which one of the
following is NOT recommended for acute treatment?

A) Extracorporeal shock wave therapy
B) Prefabricated insoles (heel pad)
C) Night splints
D) Corticosteroid iontophoresis

These findings are classic for plantar fasciitis.
Treatments in the acute phase include insoles, night
splints, corticosteroid iontophoresis, and NSAIDs.
Based on current evidence, extracorporeal shock
wave therapy is recommended only after 12 months
of symptoms.
99. A 10-year-old male is brought to your office
with pain and swelling of the knee after falling out
of a tree. A physical examination is notable for
point tenderness and swelling at the proximal tibia.
A radiograph shows a displaced fracture of the
proximal tibia through the physis and epiphysis.
The most appropriate management is

A) a long leg cast
B) a rigid knee immobilizer
C) a functional (hinged) knee immobilizer
D) orthopedic referral

Physeal injuries are unique to children, and account for approximately one-fourth of
all pediatric fractures. This child has a Salter-Harris fracture that requires referral to
an orthopedist. Salter-Harris type I injury is a fracture through the hypertrophic
cartilage that causes widening of the physeal space. These fractures
are difficult to diagnose radiographically, but their clinical hallmark is point
tenderness at the epiphyseal plate. Type II fractures are the most common, and
extend through both the physis and metaphysis. Although these fractures may
result in some shortening, they rarely cause functional deformities. Type III injuries
extend through the physis and epiphysis, disrupting the reproductive layer of the
physis. These injuries may cause chronic sequelae because they disrupt the
articular surface of the bone, but they do not produce deformities and generally
have a good prognosis. Type IV injuries cross through the epiphysis, physis, and
metaphysis. These fractures are also intra-articular, increasing the risk for chronic
disability. They can disrupt the proliferative zone, leading to early fusion and growth
deformity. Type V fractures are the least common but most difficult to diagnose,
and have the worst prognosis. The classic mechanism of injury is an axial force that
compresses the epiphyseal plate without an overt fracture of the epiphysis or
105. A 76-year-old male has fallen twice as a result of buckling of the
left knee during ambulation. Neither fall resulted in injury, and he is
advised to use an offset walking cane. The patient is left hand–
dominant and has normal strength in all four extremities. Crepitus is
present in both knees, but is much more pronounced in the left knee.
Which one of the following describes the best method for use of a cane
by this patient?

A) Place the cane in the left hand and advance it at the same time as
the left leg
B) Place the cane in the left hand and advance it at the same time as
the right leg
C) Place the cane in the right hand and advance it at the same time as
the left leg
D) Place the cane in the right hand and advance it at the same time as
the right leg
E) Switch the cane between hands at intervals of several hours to
distribute the load equally

The standard walking cane generally is designed as a
tool to aid in balance and, to a lesser degree, reduce
weight bearing on a specific leg. The offset cane
design results in the downward force vector being
placed directly over the shaft, making this choice
ideal where improved balance and reduction of
weight bearing on a particular leg is desired.
Mechanical advantage produces maximum benefit
when the cane is placed in the hand opposite the
most severely affected leg, and the movement of the
cane tracks the movement of the affected leg,
consistent with normal gait.
122. Little League elbow refers to a problem
located over the

A) medial epicondyle
B) lateral epicondyle
C) olecranon
D) capitellum
E) ulnar groove

Little League elbow is an apophysitis of the medial
epicondyle of the elbow. It occurs in throwing
athletes between 9 and 12 years of age, and
causes elbow pain during throwing. It may also
affect velocity and control. It may cause pain and
swelling in the arm and/or elbow, but the diagnosis
should be considered in throwing athletes with
elbow pain even if symptoms are minimal.
127. A 72-year-old white female is experiencing pain due to
a vertebral compression fracture. Pain control with opioid
analgesics and calcitonin therapy is not adequate. Which
one of the following would make vertebroplasty an
appropriate option?

A) Fracture duration <6 months
B) Degree of vertebral collapse 80%
C) Radiologic evidence of destruction of the posterior
vertebral wall
D) New-onset bladder dysfunction thought to have a
neurologic etiology
E) New-onset bilateral lower-extremity paresis

Vertebroplasty is a reasonable therapeutic consideration for
vertebral compression fractures if pain is not adequately controlled
with analgesics and conservative therapy. Some studies indicate a
better response with less chronic fractures. Treatment of fractures
less than 6 months old is acceptable. More prolonged conservative
therapy with an inadequate response is not appropriate. Neurologic
dysfunction, including bladder dysfunction, paralysis, and sensory
deficits, is a relative contraindication to vertebroplasty. Spinal cord
compression requires other treatment, and high degrees of
compression (>67%) are not amenable to this therapy. Destruction
of the posterior wall is a contraindication to this therapy because
the injected polymethyl methacrylate should not directly contact the
spinal cord. Coagulopathies and infectious processes are also
138. A high-school gymnast presents to your office with a
history of back pain for the past 3–4 weeks. She reports that
symptoms are worse with any hyperextension activity.
Examination demonstrates a hyperlordotic posture with mild
tenderness in the lower lumbar spine. Radiographs
demonstrate the classic “Scotty dog with a collar” appearance
of spondylolysis. Which one of the following statements about
this diagnosis is true?

A) Most athletes can resume full activity in 4–6 weeks
B) Spondylolisthesis >25% requires referral to a spine surgeon
C) Inadequate treatment can lead to complete fracture and
spondylolisthesis with prolonged disability
D) Adolescents should be followed with serial CT every 6
months until they reach skeletal maturity

Complete fracture and spondylolisthesis with prolonged
disability may occur if spondylolysis is not diagnosed early
and treated appropriately. Most athletes respond to
conservative management and return to full activity
approximately 6 months after diagnosis. Treatment for low-
grade spondylolisthesis (up to 50% slippage) is similar to
treatment for spondylolysis. Patients should be followed
with serial radiographs at 6-month intervals until they reach
skeletal maturity. Patients with a high-grade slippage
(>50%) may need to be comanaged by an orthopedic or
spine surgeon to guide treatment and assist in
return-to-play decisions.
   Graded according to its
    degree of severity. The
    Myerding grading system
    measures the percentage
    of vertebral slip forward
    over the body beneath.
    The grades are as follows:

   Grade 1: 25%
    Grade 2: 25% to 49%
    Grade 3: 50% to 74%
    Grade 4: 75% to 99%
    Grade 5: 100%*
143. A 70-year-old retired farmer presents with an
angulated right knee and a painful hip. He asks you
about the possibility of “getting a new knee,”
although he is not eager to do so. You would advise
him that the major indication for knee replacement is

A) severe joint pain at rest
B) marked joint space narrowing seen on radiologic
C) destruction and loss of motion of the contralateral
D) an acutely infected joint

The major indication for joint replacement is severe
joint pain, usually pain at rest. Loss of joint function
and radiographic evidence of severe destruction of
the joint may also be considered in the decision.
The appearance of the joint and the status of the
contralateral joint may be minor considerations.
Surgical insertion of a foreign body into an infected
joint is contraindicated.
155. You see a 16-year-old white female for a
preparticipation evaluation for volleyball. She is 183
cm (72 in) tall, and her arm span is greater than her
height. She wears contacts for myopia. Which one
of the following should be performed at this time?

B) Echocardiography
C) A stress test
D) A chest radiograph
E) Coronary MRI angiography

Marfan’s syndrome is an autosomal dominant disease manifested by
skeletal, ophthalmologic, and cardiovascular abnormalities. Men taller than
72 in and women taller than 70 in who have two or more manifestations of
Marfan’s disease should be screened by echocardiography for associated
cardiac abnormalities.

Any of these athletes who have a family history of Marfan’s syndrome should
be screened, whether they have manifestations themselves or not. If there is
no family history, echocardiography should be performed if two or more of
the following are present: cardiac murmurs or clicks, kyphoscoliosis, anterior
thoracic deformity, arm span greater than height, upper to lower body ratio
more than 1 standard deviation below the mean, myopia, or an ectopic lens.

Patients with Marfan’s syndrome who have echocardiographic evidence of
aortic abnormalities should be placed on beta-blockers and monitored with
echocardiography every 6 months.
174. A 16-year-old male comes to your office after suffering
an eversion injury to his ankle while being tackled in a
football game 3 days ago. He was not able to bear weight
after the injury and now has tenderness at the distal
tibiofibular joint with no swelling. Compression of the fibula
against the tibia at the mid-calf elicits pain anterior to the
lateral malleolus and proximal to the ankle joint. Stabilizing
the leg and rotating the foot externally elicits pain at the
same location. Radiographs are negative. Which one of the
following would be most appropriate at this point?

A) Application of an elastic wrap to the ankle for 2 weeks
B) Therapeutic ultrasound
C) Stress radiographs
D) A CT scan
E) Long-term semirigid support

Syndesmotic (high ankle) sprains account for as many as 11% of ankle sprains. The
mechanism of injury is dorsiflexion and/or eversion of the ankle, most commonly in
contact sports. The syndesmotic structures include the anterior, posterior, and
transverse tibiofibular ligaments, as well as the interosseous membrane.
These injuries can cause chronic ankle instability, resulting in recurrent sprains and
hypertrophic ossification. The diagnosis can be made by several tests. The squeeze
test can be performed by compressing the fibula against the tibia at mid-calf. A
positive test occurs when this elicits pain in the region of the anterior tibiofibular
ligament. A positive external rotation stress test causes pain at the same site. It is
performed by stabilizing the leg and externally rotating the foot. The crossed-leg test
can also detect this injury. The patient places the involved ankle on the opposite
knee and pressure is applied to the medial side of the involved ankle, which causes
pain at the syndesmosis. While ankle support is often useful for less serious
sprains, a Cochrane review showed that semirigid supports are better than elastic
bandages. Therapeutic ultrasound has not been shown to have any value for ankle
sprains. The injury can be confirmed with an MRI. Indications for referral to an
orthopedic surgeon include fracture, dislocation or subluxation, syndesmotic injury,
tendon rupture, and uncertain diagnosis.
179. A 35-year-old male complains of 2 months of right shoulder
pain. He does not recall an injury, but says it is painful to lie on
his right side or to work with his right hand above his head. On
examination, the shoulder appears normal and there is no pain
with external rotation of the shoulder, bringing the arm across
the body (scarf test), or attempted external and internal rotation
of the shoulder against resistance. Lowering the arm from full
abduction (painful arc), attempted abduction above 45º against
resistance, and elevating the internally rotated arm above 90º
against resistance are all painful. The most likely diagnosis is

A) subdeltoid bursitis
B) adhesive capsulitis
C) impingement syndrome
D) glenohumeral osteoarthritis
E) acromioclavicular osteoarthritis

The combination of a painful arc and pain on use of the
supraspinatus muscle indicates impingement syndrome,
which is due to irritation of the rotator cuff under the
coracoacromial arch. It is by far the most common cause of
shoulder pain seen by family physicians. Subdeltoid bursitis
is a much more acute problem, and impairs shoulder mobility
in all directions. Adhesive capsulitis produces loss of external
rotation. Glenohumeral arthritis produces pain with external
rotation, and variable amounts of impaired mobility,
depending on progression of the problem over time.
Acromioclavicular joint arthritis produces a positive scarf
sign, and often a visible bump over the joint, since it lies so
close to the skin surface.
195. A 65-year-old female presents with a complaint of
slowly increasing discomfort in her knees of 3 years’
duration. An examination and radiograph are consistent
with noninflammatory osteoarthritis. She says that the pain
is well-controlled with acetaminophen, but she wants to
know what can be done to prevent further damage to the
joint. You recommend

A) referral to a rheumatologist for disease-modifying agents
such as methotrexate
B) hyaluranon injections to preserve cartilage
C) corticosteroid injections
D) symptomatic measures only

Osteoarthritis is a common finding in older people; some studies show that
25% of patients over age 65 have osteoarthritic changes. Unfortunately, no
pharmacologic treatments have been found to prevent the progression of
joint destruction. Maintaining ideal weight and avoiding excessive use of the
knees, including deep knee bends, running, and stair climbing, does lessen
destructive forces on the joint. A reasonable walking program can improve
both pain and joint function. Acetaminophen is the first choice for joint pain
in someone with noninflammatory osteoarthritis. NSAIDs provide better pain
relief but can cause renal damage, fluid retention, and GI bleeding, and are
therefore reserved as a second-line treatment. Narcotics usually are
reserved for short-term use during flares of arthritis. Studies show that
injections of corticosteroids or hyaluranons improve symptoms for some, but
have not been shown to lessen joint destruction. Disease-modifying agents,
such as methotrexate, can help inflammatory arthritic joints, as in psoriatic
arthritis and rheumatoid arthritis, but have not been shown to
be of benefit in osteoarthritis.
202. A positive Lachman test indicates injury to the

A) medial collateral ligament
B) posterior cruciate ligament
C) medial meniscus
D) anterior cruciate ligament
E) lateral collateral ligament

The Lachman test is performed with the knee flexed to 25º-
30º while the examiner grasps the distal femur in one hand
and the proximal tibia in the other. While the femur is held
stationary, the tibia is pulled anteriorly, using a “shucking”
action. If a distinct end point is reached, as if a piece of
loose rope suddenly becomes taut, the test is negative or
normal. A soft or indistinct end point, as if stretching an
elastic band, is a positive or abnormal test that indicates a
ruptured anterior cruciate ligament. In this case, the anterior
drawer test would also be positive, but it is not as specific as
the Lachman test. Injuries to the other structures listed are
diagnosed using other maneuvers, and are not associated
with a positive Lachman test.
207. A 16-year-old high-school basketball player is struck on the
end of her long finger by the ball. Her finger was fully extended
and the result was a forced flexion injury of the proximal
interphalangeal (PIP) joint. She is unable to actively extend the
PIP joint, although passive extension is possible. She is tender
over the dorsal aspect of the middle phalanx. Radiographs are
negative. Which one of the following is true regarding this injury?

A) Immediate referral to an orthopedist is indicated
B) Buddy taping to the adjacent ring finger is the only treatment
C) Any splint (fashioned aluminum splint, stack splint, ring splint)
would be adequate
D) Splinting should be continued for 2 weeks
E) A boutonniere deformity may result

An injury to the central extensor slip can occur when the
proximal interphalangeal (PIP) joint is forcibly flexed while the
digit is actively extended. The injury is evaluated by holding
the joint in a position of 15º–30º of flexion. The patient will
not be able to actively extend the joint, but passive extension
should be possible. There will be tenderness over the dorsal
aspect of the middle phalanx. Delay or improper treatment
may result in a boutonniere deformity, which usually develops
over several weeks but can occasionally develop acutely.
Treatment consists of splinting the PIP joint in full extension
for 6 weeks. The stack splint should only be used to treat
injuries of the distal interphalangeal joint.
   Mallet finger Tx - Stack splint for 6 weeks

Boutonnière deformity Tx: PIP joint splint for 6 weeks
229. A 25-year-old runner complains of non-focal
knee pain. She does not remember any specific
injury. You suspect patellofemoral pain syndrome.
Which one of the following would be most
consistent with this diagnosis?

A) Pain with prolonged sitting
B) Swelling
C) Locking
D) Giving way

Patellofemoral pain syndrome causes nonfocal or
anterior knee pain, and is often seen in runners.
Common symptoms include stiffness, pain with
prolonged sitting, and pain with climbing or
descending stairs. Rarely is there swelling, locking,
or giving way; these symptoms are more likely to be
associated with more profound problems such as a
ligament or cartilage tear.
233. A 53-year-old Hispanic male presents with a 3-day
history of right shoulder pain. The pain started shortly after
he caught himself when he fell coming down his front steps.
Radiographs of the shoulder are normal. Which one of the
following, if present, would be most suggestive of a rotator
cuff tear?

A) Inability to flex at the elbow against resistance
B) Signs of decreased arterial perfusion of the hand
C) Swelling of the acromioclavicular joint
D) Weakness in external rotation of the shoulder

Shoulder pain after a fall may result from a strained muscle
or ligament, an exacerbation of a smoldering subacromial
bursitis or tendinitis, or a tear of the rotator cuff. Often there
is a combination of two or three of these conditions. If the
rotator cuff tear is small, treatment is similar to that
recommended for the other conditions. However, if a
significant rupture has occurred, immobilization and/or
surgical consultation is appropriate. On physical
examination, a painful arc of abduction above 90º and
weakness in external rotation would be expected with a torn
rotator cuff. Of these two, weakness in external rotation is
much more specific.
238. A 32-year-old male comes to your office
for the second time for wrist pain following a
fall on the ice 10 days ago. At his first visit,
examination of the wrist showed no deformity
or swelling, but extension was decreased and
he had diffuse tenderness over the dorsum of
the wrist, particularly just distal and dorsal to
the radial styloid. A radiograph is shown.

Which one of the following do the radiographs

A) A dislocated lunate
B) A fracture of the scaphoid
C) A hamate fracture
D) A scapholunate dislocation
Metacarpal Anatomy

A dorsiflexion injury will typically cause a scaphoid fracture in
a young adult, resulting in tenderness to palpation over the
anatomic snuffbox. Often the plain posterior-anterior wrist
radiograph is normal. However, a special view with the wrist
prone in ulnar deviation elongates the scaphoid, often
demonstrating subtle navicular fractures. Hook of the
hamate fractures cause tenderness at the proximal
hypothenar area 1 cm distal to the flexion crease of the wrist.
When this fracture is suspected, carpal tunnel and supinated
oblique view radiographs should be obtained. A scapholunate
dislocation can be identified with a “clenched-fist” view and
the supinated view in ulnar deviation.
Scapholunate dislocation   Normal

   A knee xray series is indicated for any of these
     Age  55 years or older
     Tenderness at head of fibula

     Isolated tenderness of patella

     Inability to flex knee to 90 degrees

     Inability to walk four weight-bearing steps
      immediately after the injury and in the emergency

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