Assessment, evaluation and diagnosis

Six weeks after a humeral shaft fracture, a patient reports numbness over the dorsal web space between the thumb and index finger. Which nerve is MOST likely involved?

1. Musculocutaneous nerve
   The musculocutaneous nerve ends as the lateral cutaneous nerve of the forearm and does not reach the hand.
2. Ulnar nerve
   The ulnar nerve supplies the little finger and ulnar hand, not the dorsal web space between thumb and index finger.
3. Median nerve
   The median nerve supplies the palmar thumb side of the hand and is not at risk at the humeral shaft.
4. Radial nerve
   The radial nerve runs in the spiral groove of the humeral shaft and supplies sensation to the dorsal first web space.

A basketball player lands awkwardly, feels a pop, and has a large knee effusion within 2 hours. Which structure is MOST likely injured?

1. Anterior cruciate ligament
   A pop with a large effusion within about 2 hours is a hemarthrosis, and the ACL is the most common cause.
2. Patellar tendon
   A patellar tendon rupture leaves a palpable gap and an extension lag, not a rapid effusion after a landing pop.
3. Medial meniscus
   An isolated meniscal tear tends to swell slowly, over 12–24 hours, because the inner meniscus has little blood supply.
4. Medial collateral ligament
   The MCL is extra-articular, so an isolated MCL sprain does not fill the joint with blood quickly.

When measuring knee flexion with a standard goniometer, where should the athletic trainer place the axis (fulcrum)?

1. Medial tibial plateau
   The medial tibial plateau is on the wrong side and below the joint's axis.
2. Lateral femoral epicondyle
   For knee flexion, the goniometer axis sits over the lateral femoral epicondyle, with the arms toward the greater trochanter and lateral malleolus.
3. Center of the patella anteriorly
   The patella is anterior and moves during flexion, so it cannot serve as the axis.
4. Head of the fibula laterally
   The fibular head is a landmark below the joint line and is not the axis of knee motion.

A volleyball player has shoulder pain during active abduction only between about 60 and 120 degrees, with no pain above or below that range. Which condition is MOST likely?

1. Glenoid labral tear
   A labral tear gives deep pain, clicking or catching, often with overhead or rotation positions, not a mid-range arc.
2. Acromioclavicular joint sprain
   AC joint pain appears at the top of elevation, roughly 160–180°, not in the mid-range.
3. Subacromial impingement
   Pain only between about 60° and 120° of abduction is the classic painful arc of subacromial impingement.
4. Adhesive capsulitis
   Adhesive capsulitis limits motion in a capsular pattern rather than causing a pain-free range above and below an arc.

A valgus stress test at 30 degrees of knee flexion shows increased medial joint opening compared with the uninjured side, with a firm end point. What is the MOST likely impression?

1. Grade III MCL sprain
   A grade III sprain is a complete tear, with gross opening and no firm end point.
2. Grade II MCL sprain
   Increased opening with a firm end point means a partial tear, a grade II MCL sprain.
3. Medial meniscus tear
   A meniscal tear does not increase valgus opening at 30 degrees, so the laxity here comes from the ligament.
4. Grade I MCL sprain
   A grade I sprain causes pain without increased opening compared with the other knee.

With the patient supine and the shoulder at 90 degrees of abduction and full external rotation, the patient becomes apprehensive; a posterior force on the humeral head relieves it. Which condition is MOST likely?

1. Subacromial impingement
   Impingement pain is not relieved by a posterior force and does not produce apprehension.
2. Posterior glenohumeral instability
   Posterior instability is provoked in flexion, adduction and internal rotation, not by the apprehension position.
3. Superior labral (SLAP) tear
   A SLAP tear gives deep pain or clicking; the relief of apprehension with a posterior push points to instability.
4. Anterior glenohumeral instability
   Apprehension in abduction and external rotation that eases with a posterior force on the humeral head is the relocation sign of anterior instability.

A distance runner has plantar heel pain. Which finding MOST suggests plantar fasciitis rather than another cause of heel pain?

1. Burning and tingling along the medial heel
   Burning and tingling along the medial heel suggests nerve entrapment such as tarsal tunnel syndrome.
2. Pain at the Achilles insertion from shoe pressure
   Pain at the Achilles insertion from shoe pressure points to insertional Achilles problems or a retrocalcaneal bursitis.
3. Pain on first steps that eases with walking
   Pain with the first steps that eases as walking continues is the hallmark of plantar fasciitis.
4. Pain when the calcaneus is squeezed side to side
   Pain on squeezing the calcaneus side to side points to a calcaneal stress fracture.

A weightlifter felt a pop in the anterior elbow while lowering a heavy bar. Resisted isometric elbow flexion and supination are weak but painless. What does this finding MOST suggest?

1. A complete tendon rupture
   Weak but painless resisted testing means the contractile unit cannot transmit force, which indicates a complete rupture.
2. A joint capsule sprain
   A capsular sprain is not the source of weakness on an isometric test, which loads the muscle-tendon unit.
3. A partial muscle-tendon tear
   A partial tear is weak and painful, because some intact fibers are still loaded.
4. A minor muscle-tendon strain
   A minor strain is strong but painful on resisted testing.

During a neurological screen, the patient's patellar reflex is brisker than normal, and there is no clonus. How should the athletic trainer grade the reflex?

1. 2+
   2+ is a normal, average response, not a brisk one.
2. 3+
   A brisker-than-normal reflex without clonus is graded 3+.
3. 4+
   4+ is the top grade and does not fit a reflex described only as brisker than normal.
4. 1+
   1+ is a diminished reflex, the opposite finding.

A 15-year-old sprinter felt a sudden pop in the front of the hip while driving out of the starting blocks. There is point tenderness just below the iliac crest at the anterior superior iliac spine. Which injury is MOST likely?

1. Anterior superior iliac spine avulsion
   Point tenderness at the ASIS after a forceful sprint start fits an avulsion of the sartorius origin, an ASIS avulsion.
2. Femoral neck stress fracture
   A femoral neck stress fracture builds up gradually with groin pain, not with a sudden pop at the ASIS.
3. Anterior inferior iliac spine avulsion
   An AIIS avulsion pulls off the rectus femoris origin and is tender lower down, below the ASIS, typically after kicking.
4. Iliopsoas muscle strain
   An iliopsoas strain is tender deep in the groin near the lesser trochanter, not at the ASIS.

A gymnast fell on an outstretched hand and has tenderness in the anatomical snuffbox. Initial radiographs are negative. What is the MOST appropriate plan?

1. Return to practice with the wrist taped
   Taping and returning to practice risks displacement and nonunion of an occult scaphoid fracture.
2. Ice and compression, then reassess in 48 hours
   Ice and a 48-hour recheck leave the scaphoid unprotected and do not arrange follow-up imaging.
3. Thumb spica immobilization and follow-up imaging
   Snuffbox tenderness means a scaphoid fracture until proven otherwise, so the wrist goes in a thumb spica and is reimaged even with negative first films.
4. Treat as a sprain with early range of motion
   Treating it as a sprain with early motion assumes no fracture when negative early films do not rule one out.

A 13-year-old basketball player with Osgood-Schlatter disease and a parent ask about the long-term outlook. Which explanation is MOST accurate?

1. Jumping sports must be stopped permanently
   Jumping sports are modified around symptoms during flare-ups, not stopped permanently.
2. Surgery is usually needed to remove the bony bump
   Surgery is rarely needed; it is reserved for a painful ossicle that persists after skeletal maturity.
3. The bony bump will disappear within a few weeks
   The bony bump often remains after symptoms resolve and does not disappear within weeks.
4. Symptoms resolve as the growth plate closes
   Osgood-Schlatter symptoms settle as the tibial tuberosity growth plate closes, though the bump often remains.

A wrestler is taken down onto an outstretched, abducted arm and is unable to move the shoulder. Which finding is MOST consistent with an anterior glenohumeral dislocation?

1. Arm held in adduction and internal rotation
   An arm held in adduction and internal rotation is the position of a posterior dislocation.
2. Arm held in abduction and external rotation
   With an anterior dislocation the arm is held slightly abducted and externally rotated, and internal rotation is blocked.
3. Gap below the acromion only with traction
   A gap under the acromion seen only with traction is the sulcus sign of inferior laxity.
4. Step-off deformity at the distal clavicle
   A step-off at the distal clavicle points to an AC joint sprain, not a glenohumeral dislocation.

A 19-year-old distance runner has a second metatarsal stress fracture this season, has had no menses for 5 months, and says she is 'watching what she eats.' What is the MOST appropriate action?

1. Protect the foot and resume running when pain-free
   Protecting the foot treats only the fracture and returns the athlete to running with the cause untouched.
2. Refer to a registered dietitian for meal plans
   A dietitian belongs on the team, but referring only for meal plans leaves the amenorrhea and bone health without medical evaluation.
3. Start calcium and vitamin D and monitor
   Calcium and vitamin D alone do not correct low energy availability and skip the medical work-up.
4. Refer for physician-led team evaluation
   Amenorrhea, a recurrent bone stress injury and restrictive eating signal RED-S, which needs a physician-led team that includes dietary and mental-health care.

A basketball player has lateral foot pain after an inversion injury. Point tenderness at which site indicates the need for radiographs under the Ottawa foot rules?

1. Sinus tarsi
   Sinus tarsi tenderness is common after inversion sprains and is not part of the Ottawa rules.
2. Calcaneofibular ligament
   Calcaneofibular ligament tenderness reflects a ligament sprain, not a fracture criterion.
3. Base of the fifth metatarsal
   Under the Ottawa foot rules, tenderness at the base of the fifth metatarsal calls for radiographs.
4. Anterior talofibular ligament
   ATFL tenderness is the usual finding in a lateral ankle sprain and is not an Ottawa criterion.

A high school soccer player has signs of a concussion after a collision, but no preseason baseline testing was ever done. What is the MOST appropriate approach?

1. Use normative data with a full clinical exam
   Without a baseline, the athletic trainer compares results with normative data and relies on the full clinical exam and symptom evolution.
2. Order computerized neurocognitive testing first
   Computerized testing is not required first and should not replace the sideline clinical exam.
3. Rely on the symptom checklist alone
   A symptom checklist alone misses balance, cognitive and oculomotor deficits.
4. Postpone the assessment until baseline data exist
   Postponing the assessment delays removal and care of an athlete with signs of concussion.

A new special test is positive in 45 of 50 patients who have the condition and negative in 40 of 50 patients who do not. What is the test's sensitivity?

1. 85%
   85% is the overall accuracy, (45 + 40) ÷ 100, not the sensitivity.
2. 90%
   Sensitivity = true positives ÷ all with the condition = 45 ÷ 50 = 90%.
3. 80%
   80% is the specificity: 40 true negatives ÷ 50 without the condition.
4. 82%
   82% is the positive predictive value, 45 ÷ 55 positive tests.

A dancer has 3 weeks of focal pain over the second metatarsal shaft that worsens with activity. Initial radiographs are normal. What is the MOST appropriate next step?

1. Tape the arch and continue dancing
   Arch taping does not unload the second metatarsal shaft and keeps loading the injured bone.
2. Resume dancing on the normal films
   Early radiographs miss most stress fractures, so normal films do not clear the dancer.
3. Rest 3 days, then resume dancing
   Three days of rest is far too short for a suspected stress fracture.
4. Protect the foot and refer for an MRI
   Focal shaft pain with normal early films still suggests a stress fracture, so the foot is protected and MRI is used to confirm.

After a tackle, a football player reports burning pain down one arm that resolves within 1 minute. Neck range of motion is full and pain-free, and strength and sensation are normal. What is the MOST likely condition?

1. Cervical vertebral fracture
   A vertebral fracture causes neck pain and loss of motion, while this neck moves fully without pain.
2. C5–C6 disc herniation
   A C5–C6 disc herniation gives persistent radicular pain, often with neck motion pain and neurological deficits.
3. Brachial plexus stretch injury
   Burning pain down one arm that resolves within a minute, with normal strength and sensation, fits a brachial plexus stretch (burner).
4. Transient quadriplegia
   Transient quadriplegia involves more than one limb, with motor loss, not one arm with burning.

A 20-year-old hockey player has anterior hip and groin pain with clicking and catching during deep squats. Which special test would BEST help screen for an acetabular labral tear?

1. FADIR test
   The FADIR test (flexion, adduction, internal rotation) compresses the anterosuperior labrum and screens for a labral tear.
2. Ober test
   The Ober test checks iliotibial band and TFL tightness.
3. Trendelenburg test
   The Trendelenburg test checks hip abductor strength in single-leg stance.
4. Thomas test
   The Thomas test checks hip flexor length, not the labrum.