volume 1 Flashcards
Which of the following statements is true?
a) exercise increases the neutrophils and lymphocytes in a patient
b) the ratio of CD4 to CD8 cells increases during exercise
c) salivary IgA increases during exercise
d) natural killer cell activity decreases during exercise
a) true quantitative changes include increases in neutrophils and lymphocytes because adrenaline levels rise during exercise. The neutrophil counts rise further but lymphocyte counts diminish because cortisol levels rise more steadily with continued
b) false - decreases, CD4 are helper Ts and CD8 are suppressor Ts, so a decrease in these increases vulnerability to infection
c) decreases - suppressed with short term and can be decreased more long term with long term high intensity exercise
d) false - it increases then back to baseline after recovery; diminished neutrophil chemotaxis and phagocytosis with high endurance training
also diminished neutrophil chemotaxis and phagocytosis with high intensity endurance training
Which of the following statements is false?
a) moderate exercise may protect against infection such as URTIs
b) elite athletes may be at greater risk of infection from URTIs
c) exercising during an infection does not have any significant risks
d) febrile illness puts athletes at greater risk of infection and febrile illness
c) false exercise during infection can prolong recovery time, exacerbate symptoms and increase the risk of compilations such as myocarditis
the rest After exercise, there is an “open window” where the immune defences appear to be down and people are more vulnerable to infection. Research indicates that marathon runners have more upper respiratory tract infections during periods when mileage is increased and in the two weeks following a marathon run.
see the j curve, sedentary people are at a average risk of infection
A 16 year old basketball player presents with approximately one week of fever, pharyngitis, lymphadenopathy and a positive monospot test, as well as atypical lymphocytosis on CBC. He wants to do when to exercise, what do you tell him? Spleen is enlarged on U/S
a) he can play sports as soon as he feels better
b) he can return to non-contact sports in 2 weeks as long as his symptoms have resolved
c) he can return to non-contact sports in 3 weeks as long as his symptoms have resolved
d) he can return to non contact sports in 3 weeks if his symptoms have resolved and labs have returned to normal and after repeat U/S to ensure his spleen has returned to normal size
d) is the answer
mono-risk of splenic rupture; U/S shows splenomegaly in ALL patients
risk of splenic rupture is 0.1-0.5% and highest risk in first 3 weeks (day 4-21); rupture after 28-35 days is very rare
exclude for minimum of 3 weeks from onset of illness or 3 weeks from diagnosis if the onset is not clear
after minimum 3 weeks off, can resume exercise at 50% of pre illness level, as long as following criteria are met:
- resolution of symptoms
- normal labs
- resolution of splenomegaly (ideally confirmed by U/S)
- resolution of complications (fatigue, airway obstruction, hepatitis)
if they continue to improve (no relapse of symptoms) in this 1st week of graded return, can progress to all sports including contact
if you can’t do an ultrasound, then should probably delay by another 1-2 weeks to avoid late splenic rupture
Which of the following patients is allowed to exercise?
a) 14 year old with diarrhea
b) 14 year old with a sore throat and runny nose
c) 14 year old with fever and elevated HR
d) 14 year old with myalgias
b) is allowed to exercise
can determine by “neck check” i.e. if symptoms are only above the neck and child feels okay after 10-15 minutes of moderate exercise are okay to go ahead
if they have systemic symptoms (fever, myalgia, diarrhea, elevated HR), they shouldn’t exercise for 7-14 days after resolution of symptoms because of risk of prolonging illness and subsequent complications, then ease in gradually (1-2 days for every day missed)
the other advice is to wash hands, etc.
also think about contagiousness
A 14 year old gymnast comes to your office complaining of lower back pain that has been going on for the last few months. On further questioning, she reveals that the pain is worse when she has been playing sports all day and better on her days off. The pain is worse with extension. She has not had any symptoms of bowel or bladder dysfunction, nor any numbness or tingling in her legs. Which of the following is not consistent with her most likely diagnosis, (which has been confirmed on X ray)?
a) mostly likely due to spondylolysis
b) physical exam likely shows hyperlordosis, paraspinal muscle spasm and hamstring tightness
c) oblique X rays should be routinely used to characterize the defect
d) treatment should include activity restriction for 4-8 weeks if wearing a brace or 3-6 months if not wearing a brace
c) oblique view IS the best to show the defect in the pars articulates (may show in 1/3 of cases), HOWEVER, NOTroutinely recommended because of radiation. AP/and Lateral are used to identify anatomical variants and developmental defects (i.e. spina bifida) **note, Zitelli says X ray lateral might show it
other investigations: bone scan will show lesion with increased turnover, CT can also confirm diagnosis and monitor healing
Treatment:
- avoid the stuff that makes it worse: i.e. avoid extension, abdominal strengthening, hip flexor and hamstring stretches, and antilordotic exercises should be initiated, preferably by a physio, some suggest braces to limit extension
once pain free without a brace, then gradually return to full activity, most patients get there within 6 months
athlete who has resumed pain free activities without a brace is considered healed
can have neurological symptoms if nerve root is affected
definitions (Zitelli pg 844)
spondylolistehsis - forward displacement of one vertebral body over another (i.e. L5 on S1), most commonly at the lumbosacral articulation; may be because of insufficiency or fatigue fractures of the pars intraarticularis (also known as spondylolysis aka isthmic spondylolisthesis, most common) , congenitaldysplasia o fate posterior spinal elements or degenerative changes, or secondary to pathological fractures
insidious onset
A 14 year old gymnast comes to your office complaining of lower back pain that has been going on for the last few months. On further questioning, she reveals that the pain is worse when she has been playing sports all day and better on her days off. The pain is worse with extension. She has not had any symptoms of bowel or bladder dysfunction, nor any numbness or tingling in her legs. Investigations including X ray, bone scan and CT are normal. Which of the following is her most likely diagnosis?
a) spondylolysis
b) posterior element overuse syndrome
c) disk herniation
d) vertebral avulsion fracture
b) is the answer
worse with extension and insidious, it’s either spondylolysis or posterior element overuse syndrome; since investigations are normal, it is posterior element overuse syndrome - aka hyperlordotic or muscular back pain
may involve muscle tendon units, ligaments and facet joints
focal tenderness of lumbar spine and paraspinal muscles may be tender
investigations are usually negative
Treatment: physio (same exercises as above), NSAIDS, bracing might help
usually can resume full activity by 4-8 weeks
A teenage weight lifter presents with acute lower back pain after a lift. He does not have any numbness, tingling or weakness, no bowel/bladder symptoms, and straight leg test is negative. What is his most likely diagnosis?
a) spondylolysis
b) posterior element overuse syndrome
c) disk herniation
d) vertebral avulsion fracture
d) vertebral avulsion fracture is the answer
Repetitive spinal flexion and extension can injure the ring apophysis, resulting in fractures that may posteriorly displace into the spinal canal, along with the intervertebral disc
acute flexion on onset
NO neurological symptoms (difference with disk herniation)
on exam - may have limit in extension and flexion and paraspinal muscle spasm
diagnosis: lateral lumbar spine X ray - ossified fragment in canal
CT is the best to identify displaced apophyseal fracture (MRI might miss it)
management: rest, heat and NSAIDS
may need to rest for 3-6 months
if have neuro symptoms then may need surgery
A 16 year old volleyball player presents with acute lower back pain after bending quickly to get a ball. Straight leg test is positive and he has diminished lower leg reflexes and lower leg weakness. There is no bowel or bladder dysfunction. Which is the most likely diagnosis?
a) spondylolysis
b) posterior element overuse syndrome
c) disk herniation
d) vertebral avulsion fracture
c) disk herniation
only 11% of young athletes get disc herniation
usually acute (can be chronic) flexion related
results also in back muscle spasm, hamstring tightness and buttock pain
radicular symptoms (muscle weakness and paraasthesias) are rare
O/E: decreased flexion, positive leg raise test, occasional decreased reflexes/strength of the lower extremities
diagnosis: lumbar X ray - to rule out fractures, tumours
MRI for progressive/refractory cases, can reveal extent of herniation and neural compression, but can be overly sensitive so clinical correlation is important
Most patients improve with conservative management, including NSAIDs and physical therapy, within three to six months. Surgical indications include cauda equina syndrome (loss of bowel/bladder function and leg paralysis resulting from nerve compression), progressive neurological deficit or refractory pain
back pain - always consider constitutional symptoms and causes
return to play - can return to sports when feeling better (pain free ROM and normal strength)
prevention - improve on muscle balances/technique/flexibility, core strengthening
reduce training during rapid growth
Which of the following statements is false?
a) competitive sports should be started as early as 4-5 years old
b) body fat reduces between age 2-5
c) vision is not fully mature until age 6-7
d) children should be encouraged to participate in a broad range of activities when they start sports (entry level in age 6-9 group)
e) 75% of kids no longer play organized sports by age 15
a) false, competition should be avoided, should focus on development of basic skills
by about age 6, kids have the required skills and coordination to participate in organized spots
Which of the following is the recommended caloric intake for a 12 year old boy?
a) 1800 calories
b) 2200 calories
c) 2500 calories
d) 3000 calories
c) 2500 calories is the answer
before puberty, boys and girls same, after puberty it’s different
also need to adjust for extra energy intake
age 4-6 year old 1800 calories for males and females
age 7-10 2000 calories for males and females
age 11-14 2500 males 2200 females
age 15-18 3000 males 2200 females
Which of the following is false?
a) proteins should be 10-30% of intake for 4-18 year olds
b) carbohydrates should be 30% of diet for 4-18 year olds
c) fats should be 25-35% of intake for 4-18 year olds
d) the recommended daily calcium intake for a 7 year old is 1000 mg/day
e) children age 4-18 year old should get 600 IU/day of vitamin D
b) false - stored as glycogen, can be used during exercise for energy, should be 45-65% of intake in this age group
1 gram of carbs contains 4 kcal of energy
the rest are true- for prolonged exercise, not primary source, but for prolonged exercise help the liver make glucose by gluconeogenesis
1 gram of protein makes 4 kcal of energy
fats 25-35%, only 10% should be saturated
absorb fat-soluble vitamins (A, D, E, K), to provide essential fatty acids, protect vital organs and provide insulation
calcium for 4-8 year old should be 1000 mg/day , 1300 mg/day for 9-18 year old
How much iron should a 15 year old girl be eating?
a) 5mg/day
b) 8 mg/day
c) 11mg/day
d) 15 mg/day
d) 15 mg/day for girl age 14-18, 11 mg/day for boy age 14-18
8mg/day for 9-13 year old boy or girl
athletes, particularly female athletes, vegetarians and distance runners should be screened periodically for iron status (can lose iron in sweat)
eggs have iron
A 13 year old who weighs 40 kg long distance runner wants to know how to stay well hydrated for her track meet this weekend. Which of the following is the appropriate advice to give her?
a) 400-600 ml of cold water 2-3 hours before the event, 150-300 ml every 15 to 20 minutes while exercising, for longer events should drink sports drinks, and following activity should drink enough sodium containing fluid and snacks to replace sweat losses
b) 400-600 ml of cold water 2-3 hours before the event, 150-300 ml of water every 15 to 20 minutes while exercising,including for longer events and following activity should drink enough water to replace sweat losses
c) 400-600 ml of sports drinks 2-3 hours before the event, 150-300 ml of water every 15 to 20 minutes while exercising,including for longer events and following activity should drink enough water to replace sweat losses
a) is the answer
the advice is 400-600 ml of cold water 2-3 hours before the event, 150-300 ml every 15 to 20 minutes while exercising, for longer events should drink sports drinks, and following activity should drink enough sodium containing fluid and snacks to replace sweat losses
amount to replace losses is approx 1.5 L /kg of body weight lost
table in statement about this based on 13 ml/kg during exercise and 4 ml/kg after exercise
sports drinks should contain 6% carbs and 20-30 meq/L of Na Cl
events
How long before exercise should athletes (at a minimum) have a meal and consume their last snack prior to activity?
a) 6 hours and 2 hours
b) 4 hours and 3 hours
c) 3 hours and half and hour
d) 3 hours and 1-2 hours respectively
d) is the answer
this allows proper digestion and minimizes the chance of an upset stomach
carbs/protein and fat
fibre should be limited
avoid high fat meals (can delay gastric emptying)
early morning - snack or liquid meal 1-2 hour before, then full breakfast after the even, help ensure sufficient energy
Which ligament is the most commonly injured ankle ligament in an ankle sprain?
a) anterior talofibular ligament (ATFL)
b) calcaneofibular ligament
c) posterior talofibular ligament
d) syndesmotic ligament
e) deltoid ligament
a)is the most commonly injured, then calcaneofibular then posterior talofibular (progressively more severe)
syndesmotic ligament is “high ankle sprain” ligament between tibia and fibula; deltoid ligament is found medially and emanates from the distal tibia
ankle injuries most common (20%) of the sports related MSK injuries
sports injuries are 8% of paediatric ER visits
41% of ER visits are sports related, sprains (34%) contusions (30%) and fractures (25%)
