A 30-year-old man presents to his primary care physician for pain in his left ankle. The patient states that he was at karate practice when he suddenly felt severe pain in his ankle forcing him to stop. The patient has a past medical history notable for type I diabetes and is currently being treated for an episode of acute bacterial sinusitis with moxifloxacin. The patient recently had to have his insulin dose increased secondary to poorly controlled blood glucose levels. Otherwise, the patient takes ibuprofen for headaches and loratadine for seasonal allergies. Physical exam reveals a young healthy man in no acute distress. Pain is elicited over the Achilles tendon with dorsiflexion of the left foot. Pain is also elicited with plantar flexion of the left foot against resistance. Which of the following is the best next step in management?

Change antibiotics and refrain from athletic activities

Refrain from athletic activities for 1 to 2 weeks

Rehabilitation exercises and activity as tolerated

A 22-year-old man presents to the emergency department after being tackled in a game of football. The patient was hit from behind and fell to the ground. After the event, he complained of severe pain in his knee. The patient has a past medical history of anabolic steroid use. His current medications include whey protein supplements, multivitamins, and fish oil. His temperature is 99.5°F (37.5°C), blood pressure is 137/68 mmHg, pulse is 100/min, respirations are 17/min, and oxygen saturation is 98% on room air. On physical exam, you see a muscular young man clutching his knee in pain. The knee is inflamed and erythematous. When valgus stress is applied to the leg, there is some laxity when compared to the contralateral leg. The patient is requesting surgery for his injury. Arthrocentesis is performed and demonstrates no abnormalities of the synovial fluid. Which of the following physical exam findings is most likely to be seen in this patient?

A palpable click with passive motion of the knee

Anterior displacement of the femur relative to the tibia

Severe pain with compression of the patella

Anterior displacement of the tibia relative to the femur

A 25-year-old man presents with pain and a limited range of motion in his right shoulder. He is a collegiate baseball player and says he has not been playing for approx. 1 week because his shoulder hurts when he throws. He also noticed trouble raising his arm over his head. He describes the pain as moderate, dull, and aching in character and worse when he moves his arm above his shoulder or when he lays in bed on his side. He denies any recent acute trauma to the shoulder or other joint pain. The medical history is significant for asthma, which is managed medically. The current medications include albuterol inhaled and fluticasone. He reports a 5-year history of chewing tobacco but denies smoking, alcohol, or drug use. The temperature is 37.0°C (98.6°F); blood pressure is 110/85 mm Hg; pulse is 97/min; respiratory rate is 15/min, and oxygen saturation is 99% on room air. The physical examination is significant for tenderness to palpation on the anterolateral aspect of the right shoulder. The active range of motion on abduction of the right shoulder is decreased. The passive range of motion is intact. No swelling, warmth, or erythema is noted. The sensation is intact. The deep tendon reflexes are 2+ bilaterally. The peripheral pulses are 2+. The laboratory results are all within normal limits. A plain radiograph of the right shoulder shows no evidence of fracture or bone deformities. An MRI of the right shoulder shows increased T1 and T2 signals in the rotator cuff tendon. Which of the following is the best initial course of treatment for this patient?

NSAIDs and conservative measures

Intra-articular corticosteroid injection

Conservative measures (rest and ice)

A 23-year-old woman presents to her primary care physician for knee pain. The pain started yesterday and has not improved since then. The patient is generally in good health. She attends college and plays soccer for her school's team. Three days ago, she was slide tackled during a game and her leg was struck from the inside. She fell to the ground and sat out for the rest of the game. It was not until yesterday that she noticed swelling in her knee. She also feels as if her knee is unstable and does not feel confident bearing weight on her leg during athletic activities. Her past medical history is notable for asthma, which is currently treated with an albuterol inhaler. On physical exam, you note bruising over her leg, knee, and medial thigh, and edema of her knee. Passive range of motion of the knee is notable only for minor clicking and catching of the joint. The patient's gait appears normal, though the patient states that her injured knee does not feel stable. Further physical exam is performed and imaging is ordered. Which of the following is the most likely diagnosis?

Medial collateral ligament tear

Anterior cruciate ligament tear

Posterior cruciate ligament tear

A 20-year-old woman college volleyball player presents with left shoulder pain and difficulty elevating her left arm. The patient began to experience dull pain in her left shoulder 5 days ago after a volleyball game. The pain is worse when she sleeps with her arm under the pillow or elevates or abducts her left arm. Her temperature is 37.0℃ (98.6℉), the blood pressure is 110/75 mm Hg, the pulse is 66/min, the respiratory rate is 13/min, and the oxygen saturation is 99% on room air. On physical examination, she is alert and cooperative. The left shoulder is normal on the inspection with no swelling or bony deformities. There is point tenderness to palpation of the anterolateral aspect of the left shoulder. Active range of motion of abduction of the left arm is restricted to 70°. Passive range of motion of abduction of the left arm is normal but elicits pain. Strength in the left shoulder is 4/5 and strength in the right shoulder is 5/5. Deep tendon reflexes are 2+ bilaterally. The sensation is intact. Which of the following is the most likely cause of this patient’s condition?

Tear of the supraspinatus muscle

Intra-articular humeral fracture

Entrapment of the axillary nerve

Intervertebral disk protrusion at the C4-5 level

Sports medicine injuries for USMLE Step 3: High-Yield Surgery Lessons

🏃‍♂️ Weekend Warrior Woes

Deconditioned individuals (often male, 30-50 y/o) sustaining acute injuries during sporadic, intense activity (e.g., basketball, soccer). Caused by forces exceeding the tissue's tensile strength.

Achilles Tendon Rupture:
- Mechanism: Sudden eccentric load or forceful push-off.
- Hx: Audible "pop," sharp pain, feeling of being kicked in the calf.
- Exam: Palpable gap, positive Thompson test. 💡 Risk ↑ with fluoroquinolone use.
Rotator Cuff Tear (Supraspinatus):
- Mechanism: Forceful abduction or fall on an outstretched arm.
- Exam: Weakness in abduction initiation, positive drop arm/empty can tests.

⭐ The Achilles tendon typically ruptures in a "watershed" area, 2-6 cm proximal to the calcaneal insertion, due to its relatively poor blood supply.

Positive Thompson Test for Achilles Tendon Rupture

Diagnosis - Provocative Positions

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🛠️ Management - Fix-It Strategies

Conservative First (Most Cases):
- 📌 PRICE Principle: Protect, Rest, Ice (15-20 min), Compression, Elevation.
- Analgesia: NSAIDs (e.g., ibuprofen) for inflammation; acetaminophen for pain.
- Physical Therapy (PT): Key for restoring range of motion (ROM), strength, and proprioception.
Interventional Options:
- Corticosteroid Injections: For bursitis, tendinopathies. ⚠️ Risk of tendon rupture (e.g., Achilles, patellar).
- Surgical Intervention:
  - Indications: Complete tears (ACL, Achilles), significant instability, displaced fractures, failure of >6 months conservative therapy.

⭐ For young, active patients with ACL tears, surgical reconstruction (e.g., patellar/hamstring tendon autograft) is often preferred to prevent chronic instability and subsequent meniscal/cartilage damage.

💪 Shoulder & Elbow Strains

Shoulder Pain: Often from overuse, common in throwing/overhead athletes.

Rotator Cuff (SITS muscles):

Muscle	Action	Provocative Test
Supraspinatus	Abduction (initial 15°)	Empty Can / Jobe's
Infraspinatus	External Rotation	Resisted Ext. Rotation
Teres Minor	External Rotation	Resisted Ext. Rotation
Subscapularis	Internal Rotation	Lift-off Test

Rotator Cuff Muscles: Posterior and Anterior Views

⭐ The supraspinatus is the most commonly injured rotator cuff muscle, often due to impingement in the subacromial space.

Biceps Tendinopathy: Anterior shoulder pain, worse with lifting. Positive Speed's or Yergason's test.

Elbow Pain:
- Lateral Epicondylitis (Tennis Elbow): Pain at lateral epicondyle, worse with resisted wrist extension. Affects extensor carpi radialis brevis.
- Medial Epicondylitis (Golfer's Elbow): Pain at medial epicondyle, worse with resisted wrist flexion. Affects pronator teres, flexor carpi radialis.

⚡ High-Yield Points - Biggest Takeaways

ACL tears typically result from non-contact pivoting; the Lachman test is most sensitive.

The "unhappy triad" is a combined injury of the ACL, MCL, and medial meniscus.

Meniscal tears present with joint line tenderness, locking, and a positive McMurray test.

Rotator cuff injuries (supraspinatus) cause pain with overhead activity; test with empty/full can tests.

Ankle sprains most commonly involve the anterior talofibular ligament (ATFL) from an inversion injury.

Achilles tendon rupture presents with a sudden "pop" and a positive Thompson test.

Stress fractures often have normal initial X-rays; MRI is the most sensitive imaging.

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