NMS Q&A Family Medicine

Sports Medicine 181Examination Answers1. The answer is E. Active external rotation of the armagainst resistance tests the infraspinatus. This will bepainful and possibly weak in response. The empty buckettest challenges the supraspinatus whereby the arms areheld 90 degrees in shoulder abduction with the thumbspointed downward. Inability to hold the position withmild downward pressure or gravity alone constitutes apositive test. The arm held passively horizontal (by theexaminer) with the elbow flexed 90 degrees as the forearmpoints directly upward, the shoulder is internally rotatedto bring the forearm into the horizontal position is theHawkins test and pain occurs with impingementsyndrome. (Failing) the drop arm test occurs in rotatorcuff tear, that is, involves more than just the suprspinatuscomponent. Inability to actively internally rotate theshoulder to where the hand in behind the back and thento push-off the examiner’s hand (push-off test) tests thesubscapularis.2. The answer is B, Tarsal tunnel syndrome. Causes oftarsal tunnel syndrome include entrapment of the posteriortibial nerve within the tarsal tunnel by varicosity ofthe posterior tibial vein; tenosynovitis of the flexor tendoncausing interstitial fluid accumulation within theentrapped area; and trauma causing interstitial bloodaccumulation or hematoma. Pronation of the foot causesthe symptoms. There is no specific area of tenderness topalpation. Plantar fasciitis causes plantar pain that remitsdaily after an hour or so walking. Stress fractures are tenderlocally (i.e., in this case over the second metatarsal).Radiculopathy such as the L5 example would not causepain with movements of the foot. Peripheral neuropathycauses symptoms in the distribution of an identifiedperipheral nerve without localization of tenderness commensuratewith the area of pain.3. The answer is D. An inhaled beta adrenergic drugadministered before an athletic session is the much preferredmethod. By definition the asthmatic attacks arequick in onset and remitting between bouts of physicalexercise with time periods analogous to those encounteredin rescue treatment. Choices A, B, and C are too longin onset and in their prolonged action. Oxygen has nodirect effect on reactive airway disease, though in acute,more severe dyspnea oxygen obviously is beneficial to theglobal well being of the patient.4. The answer is D. This patient has, of course, lateralepicondylitis, inflammation of the point of the supinatorapparatus at the condyle. It is also called “tennis elbow.”The latter term refers to the condition’s frequent causationby improper backhand motion, invoking wristextension and supination instead of the whole arm andshoulder in the tennis backhand. In the correct technique,the wrist is splinted in the neutral position and the elbowextension is minimized. The professional-style servingmotion puts a stress on the medial epicondyle. This inflammatorysyndrome is also referred to as “golfer’s elbow,” asmany players’ golf swings employ that medial elbow stressas well. The screwdriver, hand shaking, and doorknobmotions all invoke the supinator and wrist extensionapparatus.5. The answer is B. The absence of morning stiffness andafternoon gelling rules out rheumatoid arthritis in thispatient who has been training hard and whose onset ofpain has been gradual and precipitated by running. Theother conditions are each subtly different from oneanother but may all be lumped into the category of overusesyndromes involving the knee. And despite athletes’desires to the contrary, they all require, first and foremost,a period of rest. Iliotibial band syndrome and poplitealtendonitis both cause pain in the lateral aspect of the knee.Patellar tendonitis causes pain in the area of insertion ofthe quadriceps into the patella (i.e., the pain is located atthe superior aspect of the patella). Anserine bursitis resultsin pain at the location of the anserine bursa, in the inferiorand medial aspect of the knee.6. The answer is C. Hypertrophic cardiomyopathy resultsin a choking of the aortic outflow tract, more markedwhen venous return is diminished as when the subjectstands erect, and conversely alleviated when venous returnis enhanced as when squatting. The latter displaces bloodto the upper body, increasing right-sided return and subsequentleft-sided return. Patent ductus arteriosus is seldomdiscovered and corrected later than infancy, and itcauses a continuous “machinery type” murmur. The murmurof ventricular septal defect does not change withposition change. The murmur of PS would be expected toremain unchanged or perhaps increase with squatting. PSalso causes a left precordial click, and often the murmurobscures the P 2 sound. Congestive heart failure causesdyspnea on exertion, orthopnea, or peripheral edema.Hypertrophic cardiomyopathy (hypertrophic obstructivecardiomyopathy is an unusual, but not rare, cause of suddendeath during athletic exertion, accounting for half ofnontraumatic athletic deaths. Therefore, diagnosis at thetime of a preparticipation physical examination is crucial.The patient should be referred for echocardiogram orcardiac evaluation, and athletic activity should be forbiddenuntil the condition is ruled out. Risk factors for this