Therapeutic intervention, inside the plan of care

A basketball player is recovering from a grade II hamstring strain. Which criterion is MOST important before clearing the athlete for return to competition?

1. Absence of pain at rest and with walking
   Pain-free walking is an early milestone, far below the demands of competition.
2. Equal thigh girth on both sides
   Equal thigh girth does not measure strength or readiness to sprint.
3. Full passive hamstring range of motion
   Full passive range is needed but says nothing about tolerance to high-speed eccentric loading.
4. Sport-specific drills at full speed
   Completing sport-specific drills at full speed without pain shows the hamstring tolerates the sprinting loads of competition.

A 17-year-old runner has patellofemoral pain. Which exercise program has the BEST support in current evidence?

1. Isolated VMO strengthening
   Isolated VMO strengthening is not supported because the VMO cannot be selectively activated.
2. Hip and knee strengthening
   Combined hip and knee strengthening has the strongest evidence for reducing patellofemoral pain.
3. Modalities without exercise
   Modalities without exercise do not match exercise therapy for patellofemoral pain.
4. Knee-only open-chain exercises
   Knee-only open-chain work leaves out the hip strengthening that improves outcomes.

In which situation is continuous therapeutic ultrasound contraindicated over the treatment area?

1. Chronic patellar tendinopathy
   Chronic tendinopathy is a common indication for ultrasound, not a contraindication.
2. A healed hamstring strain
   A healed hamstring strain is an indication for heating before stretching, not a contraindication.
3. Low back pain in a pregnant patient
   Therapeutic ultrasound is contraindicated over the low back, abdomen or pelvis during pregnancy.
4. Ankle stiffness over a metal plate
   A metal plate does not rule out ultrasound, so ankle stiffness over a plate can still be treated with it.

A sprinter is in the middle stage of rehabilitation for a grade I hamstring strain and walks and jogs without pain. Which exercise BEST prepares the muscle for high-speed running?

1. Eccentric work at long lengths
   Eccentric work at long muscle lengths, such as Nordic curls, prepares the hamstring for the lengthening loads of high-speed running.
2. Isometric holds at mid-range only
   Mid-range isometrics do not load the hamstring at the long lengths where sprinting strains occur.
3. Static stretching into pain
   Stretching into pain risks reinjury and does not build eccentric strength.
4. Concentric seated leg curls only
   Concentric-only curls miss the eccentric demand of the late swing phase of sprinting.

A patient with a metal plate in the distal tibia from a healed fracture needs vigorous heating of the gastrocnemius-soleus before stretching. Which modality is contraindicated?

1. Warm whirlpool
   A warm whirlpool is safe over metal but heats only superficially.
2. Continuous ultrasound
   Continuous ultrasound can be used over metal implants and heats the calf deeply.
3. Moist heat pack
   A moist heat pack is safe over metal but heats only superficial tissue.
4. Shortwave diathermy
   Shortwave diathermy is contraindicated over metal, which concentrates the energy and can burn the tissue.

After immobilization for a first-time anterior glenohumeral dislocation, a patient has pain and muscle guarding that limit early range of motion. Which joint mobilization grade is MOST appropriate?

1. Grade III oscillations
   Grade III oscillations are large-amplitude movements that a painful, guarded shoulder will not tolerate this early.
2. Grade V thrust
   A grade V thrust at end range is far too aggressive for a painful, guarded shoulder that recently dislocated.
3. Grade I–II oscillations
   Grade I–II oscillations stay short of tissue resistance and are used for pain and muscle guarding.
4. Grade IV oscillations
   Grade IV oscillations are too forceful for a shoulder this painful and guarded so soon after a dislocation.

A patient with adhesive capsulitis has markedly limited glenohumeral abduction. Which joint mobilization should the athletic trainer use to improve abduction?

1. Inferior glide of the humeral head
   By the convex-concave rule, the convex humeral head glides inferiorly as the arm abducts, so inferior glide restores abduction.
2. Posterior glide of the humeral head
   Posterior glide improves flexion and internal rotation, not abduction.
3. Anterior glide of the humeral head
   Anterior glide improves extension and external rotation, not abduction.
4. Superior glide of the humeral head
   A superior glide drives the head toward the acromion and works against abduction.

A basketball player has forward head posture and rounded shoulders consistent with upper crossed syndrome. Which muscles should the athletic trainer include in a stretching program?

1. Rhomboids and deep cervical flexors
   The rhomboids and deep cervical flexors are weak muscles in this pattern, not tight ones.
2. Pectoralis minor and upper trapezius
   Upper crossed syndrome shortens the pectoralis minor and upper trapezius, so these are stretched.
3. Rhomboids and lower trapezius
   The rhomboids and lower trapezius are lengthened and weak in this pattern and are strengthened, not stretched.
4. Deep cervical flexors and serratus anterior
   The deep cervical flexors and serratus anterior are weak in upper crossed syndrome and are strengthened.

Two days after an acute knee injury, a patient has a moderate effusion and cannot produce a strong quadriceps contraction during quad sets. Which intervention should the athletic trainer apply before the exercise?

1. Rest until the effusion resolves
   Waiting for the effusion to resolve lets quadriceps strength fall further.
2. Ice to the knee before quad sets
   Cooling the knee before quad sets reduces arthrogenic muscle inhibition so the quadriceps can contract.
3. Continuous ultrasound to the joint line
   Continuous ultrasound heats an acutely inflamed joint, which is contraindicated at this stage.
4. Moist heat to the quadriceps first
   Heat on an acute knee with effusion can add swelling and does not reduce arthrogenic inhibition.

A 16-year-old gymnast with a stable grade I spondylolisthesis and signs of lumbar segmental instability begins rehabilitation. Which exercise should the athletic trainer start with?

1. Weighted Russian twists in sitting
   Weighted Russian twists add rotation under load, which an unstable segment does not tolerate early on.
2. Full sit-ups with feet anchored
   Anchored full sit-ups load the spine heavily in flexion and recruit hip flexors that pull on the lumbar spine.
3. Prone superman holds with arms overhead
   Prone superman holds load the spine in extension, which stresses the pars defect.
4. Abdominal drawing-in in hook-lying
   Abdominal drawing-in in hook-lying trains the deep stabilizers in a neutral, low-load position for segmental instability.

A pitcher has painful proximal biceps tendinopathy, with pain of 6 on a 10-point scale during resisted elbow flexion. Which exercise should the athletic trainer begin with?

1. Submaximal isometric elbow flexion
   Submaximal isometrics load the painful tendon and reduce pain, which makes them the starting point at a pain level of 6/10.
2. Heavy eccentric biceps curls
   Heavy eccentric curls are too provocative at this pain level.
3. Rest in a sling until pain-free
   Complete rest in a sling deconditions the tendon and does not help it adapt to load.
4. Full-range concentric curls with dumbbells
   Full-range dumbbell curls are a later progression once pain is controlled.

After neural slider exercises for sciatic symptoms, a patient reports tingling in the foot that lasts about 30 minutes after each session. What should the athletic trainer do?

1. Progress to neural tensioners
   Tensioners put more load on the nerve than sliders and would worsen symptoms.
2. Add sustained hamstring stretching
   Sustained hamstring stretching also tensions the sciatic nerve and adds to the irritation.
3. Reduce the amplitude of sliders
   Tingling that lasts 30 minutes means the neural dose is too high, so the slider amplitude is reduced.
4. Continue the same exercise dose
   Keeping the same dose repeats the irritation that caused the lasting tingling.

An athlete with a tibial stress fracture is returning to running on an anti-gravity treadmill. Which criterion should the athletic trainer use before increasing the percentage of body weight?

1. Pain no higher than 3 on a 10-point scale
   A pain allowance of 3/10 comes from tendon loading models and is not used for bone stress injuries.
2. No pain during or after the prior session
   With a bone stress injury, body weight is increased only when the previous session caused no pain during or after.
3. Two weeks completed at the current level
   Two weeks at a level is arbitrary; symptoms, not time, decide progression.
4. Heart rate under 70% of maximum
   Heart rate tracks cardiovascular effort, not how the bone tolerates load.

An athlete with a lower extremity stress fracture begins aquatic rehabilitation to increase bone loading gradually. Which order of water depth is MOST appropriate?

1. Deep water → waist depth → chest depth
   Going from waist to chest depth reduces load in the last step instead of increasing it.
2. Waist depth → chest depth → deep water
   Starting at waist depth applies the most load first and then reduces it.
3. Deep water → chest depth → waist depth
   Weight bearing rises as water gets shallower, so deep water, then chest depth, then waist depth increases bone loading step by step.
4. Chest depth → deep water → waist depth
   Going from chest depth to deep water reduces load, then jumps to waist depth, so loading is not progressive.

A patient has limited ankle dorsiflexion with the knee extended but normal dorsiflexion with the knee flexed. Which intervention should the athletic trainer select?

1. Calf stretch, knee straight
   Limited dorsiflexion only with the knee extended points to a short gastrocnemius, which a knee-straight calf stretch targets.
2. Posterior talar glide mobilization
   Dorsiflexion is normal with the knee bent, so the talocrural joint is not what limits this patient.
3. Plantar fascia stretching
   Plantar fascia stretching does not lengthen the gastrocnemius.
4. Calf stretch, knee bent
   A knee-bent stretch targets the soleus, which is not limited here.

The prescribed iontophoresis dose for a patient's localized tendon inflammation is 40 mA·min. At a current of 4.0 mA, how long should the treatment last?

1. 20 minutes
   20 minutes would deliver 80 mA·min, twice the prescription.
2. 4 minutes
   4 minutes would deliver only 16 mA·min.
3. 40 minutes
   40 minutes would deliver 160 mA·min, four times the prescription.
4. 10 minutes
   Time = dose ÷ current = 40 mA·min ÷ 4.0 mA = 10 minutes.

Six weeks after knee surgery, a patient has limited knee flexion and reduced patellar mobility. Which patellar mobilization MOST directly improves knee flexion?

1. Lateral glide
   Lateral glide addresses side-to-side mobility rather than flexion.
2. Inferior glide
   The patella glides inferiorly as the knee flexes, so inferior glide most directly restores flexion.
3. Medial glide
   Medial glide addresses side-to-side mobility, not the inferior travel that flexion needs.
4. Superior glide
   Superior patellar glide accompanies knee extension, not flexion.

An athletic trainer applies quadripolar interferential current to treat pain deep in the knee joint. How should the four electrodes be arranged?

1. Channels crossing over the target
   In quadripolar interferential, the two channels cross over the target so the interference field forms deep in the knee.
2. Channels parallel on one side
   Parallel channels on one side do not cross, so the field forms away from the target.
3. All four electrodes in a line
   Four electrodes in a line cannot form crossing channels.
4. One channel proximal, one distal
   One channel above and one below the knee does not cross the currents at the target.

A high school cross-country runner has diffuse pain along the posteromedial border of the distal tibia that began after a sudden increase in weekly mileage. Which initial management is MOST appropriate?

1. Complete non-weight bearing for 4 weeks
   Complete non-weight bearing is excessive for MTSS without a fracture.
2. Continue full mileage with a compression sleeve
   Keeping full mileage keeps the overload that caused the pain, and a sleeve does not change it.
3. Tibialis anterior strengthening alone
   Strengthening one muscle alone does not remove the load that caused MTSS.
4. Relative rest with reduced running load
   Medial tibial stress syndrome after a mileage jump is managed by relative rest and lower running load, then gradual return.

A patient is in a walking boot with heel wedges four weeks after an Achilles tendon repair. How should the athletic trainer progress the boot as healing allows?

1. Add heel wedges to raise the heel
   Adding wedges moves the ankle further into plantar flexion, the opposite of the progression.
2. Remove the boot and walk barefoot
   Walking barefoot at 4 weeks loads and stretches the repair abruptly.
3. Remove the heel wedges gradually
   Heel wedges protect the repair in plantar flexion and are removed step by step to bring the ankle toward neutral as the tendon heals.
4. Keep the boot unchanged for 6 months
   Six months unchanged in the boot leaves the ankle stiff and the calf weak.