Return to Play Criteria — MCQs
An RTA patient presented to the emergency department with severe pain in the ankle. An X-ray was performed, given below. What is the best next step in management?
Which of the following tests is used to test anterior instability of shoulder?
What is the condition commonly known as jumper's knee?
A pole vaulter had a fall during pole vaulting and had paralysis of the arm . Which of the following investigations gives the best recovery prognosis -
What is the age of tendon transfer in post polio residual paralysis
A football player experienced a twist in the ankle and knee. Clinically, no bone injury was appreciated. The examiner is performing the test shown in the image. Which test is this?
Which of the following is NOT typically associated with the recovery phase after a disaster?
Painful arc syndrome is characterized by pain during which movement?
What is the primary pathology in Athletic Pubalgia?
Pain and tenderness over the lateral condyle of the humerus with painful dorsiflexion of the wrist is indicative of which of the following conditions?
Return to Play Criteria Indian Medical PG Practice Questions and MCQs
Question 1: An RTA patient presented to the emergency department with severe pain in the ankle. An X-ray was performed, given below. What is the best next step in management?
- A. Neurovascular Assessment and Closed reduction with slab application (Correct Answer)
- B. Neurovascular Assessment and Closed reduction with cast application
- C. Neurovascular Assessment and Immediate surgery
- D. Neurovascular Assessment and Immediate open reduction
Explanation: ***Neurovascular Assessment and Closed reduction with slab application*** - The X-ray shows an **ankle dislocation without an obvious fracture**, making **closed reduction** the appropriate initial treatment. - A **slab (splint)** is preferred over a full cast initially for acute injuries to accommodate for swelling, reducing the risk of compartment syndrome, and allowing for serial neurovascular checks. *Neurovascular Assessment and Closed reduction with cast application* - While closed reduction is correct, applying a **full cast** immediately after an acute injury carries a risk of **compartment syndrome** due to potential swelling that cannot be accommodated by a rigid cast. - A cast would typically be applied after the initial swelling has subsided, usually a few days to a week after initial reduction and splinting. *Neurovascular Assessment and Immediate surgery* - **Immediate surgery** is generally reserved for **open fractures/dislocations**, dislocations that cannot be reduced closed (irreducible dislocations), or those with significant associated fractures that require surgical fixation to stabilize the joint. - In this case, the dislocation appears to be isolated and amenable to closed reduction, making surgery not the immediate next step. *Neurovascular Assessment and Immediate open reduction* - **Open reduction** is performed when closed reduction fails or is contraindicated, for example, due to soft tissue interposition or highly unstable fracture patterns. - Since closed reduction has not yet been attempted, immediate open reduction is premature and unnecessary for an apparently simple dislocation.
Question 2: Which of the following tests is used to test anterior instability of shoulder?
- A. Push-pull test
- B. Apprehension Test (crank test) (Correct Answer)
- C. Posterior drawer test
- D. Jerk test
Explanation: ***Apprehension Test (crank test)*** - The **apprehension test** assesses for anterior shoulder instability by passively abducting and externally rotating the arm, which is the position of potential anterior dislocation. - A positive test is indicated by the patient's **apprehension** or fear of dislocation, often accompanied by muscle guarding, as the head of the humerus is forced anteriorly. *Push-pull test* - The push-pull test is used to assess for **posterior shoulder stability**, specifically for **posterior labral tears** or instability. - It involves applying axial compression while simultaneously pulling the humerus posteriorly, looking for pain or a clunk. *Posterior drawer test* - The posterior drawer test is primarily used to evaluate **posterior glenohumeral instability**. - It involves stabilizing the scapula and applying a posterior force to the humerus while the arm is flexed, abducted, and internally rotated. *Jerk test* - The jerk test is used to identify **posterior-inferior glenohumeral instability** or a **posterior labral tear**, particularly a reverse Bankart lesion. - It involves axially loading the arm while moving it from an abducted and externally rotated position to an adducted and internally rotated position, looking for a sudden "jerk" or clunk.
Question 3: What is the condition commonly known as jumper's knee?
- A. Inflammation of the patellar tendon at its insertion on the patella.
- B. Tendinopathy of the quadriceps tendon.
- C. Injury to the hamstring tendon.
- D. Patellar tendonitis due to overuse of the patellar tendon. (Correct Answer)
Explanation: ***Patellar tendonitis due to overuse of the patellar tendon.*** - **Jumper's knee** is the common term for **patellar tendonitis**, which specifically refers to inflammation of the patellar tendon. - This condition is frequently caused by **overuse**, especially in activities involving repetitive jumping and landing. *Inflammation of the patellar tendon at its insertion on the patella.* - While jumper's knee does involve inflammation of the patellar tendon, it is more commonly at its insertion on the **tibial tubercle** or specifically its origin at the **inferior pole of the patella**, not necessarily at the patella itself. - This option is less precise as it describes only one aspect of the condition without mentioning the critical role of overuse. *Tendinopathy of the quadriceps tendon.* - **Tendinopathy of the quadriceps tendon** is a distinct condition affecting the tendon above the patella, known as **quadriceps tendinopathy**. - It presents with pain proximal to the patella, differentiating it from jumper's knee, which involves the tendon distal to the patella. *Injury to the hamstring tendon.* - An **injury to the hamstring tendon** would cause pain and symptoms on the posterior aspect of the knee or thigh. - This is completely unrelated to jumper's knee, which is characterized by anterior knee pain.
Question 4: A pole vaulter had a fall during pole vaulting and had paralysis of the arm . Which of the following investigations gives the best recovery prognosis -
- A. Electromyography (Correct Answer)
- B. Strength Duration Curve
- C. Creatine phosphokinase levels
- D. Muscle biopsy
Explanation: Electromyography - **Electromyography (EMG)** can help assess the extent of nerve damage and reinnervation, providing insights into the potential for recovery [1]. - The presence of **spontaneous activity** (fibrillations, positive sharp waves) indicates denervation, while the appearance of **motor unit action potentials (MUAPs)** suggests reinnervation [1]. *Creatine phosphokinase levels* - **Creatine phosphokinase (CPK)** levels primarily indicate **muscle damage**, not the extent of nerve injury or recovery potential. - While muscle damage can occur with nerve injury, CPK does not provide specific prognostic information for nerve regeneration. *Strength Duration Curve* - The **strength duration curve** assesses the excitability of a nerve or muscle to electrical stimulation. - While it can differentiate between **nerve and muscle damage**, it provides less comprehensive prognostic information compared to EMG regarding the status of nerve regeneration. *Muscle biopsy* - A **muscle biopsy** would directly evaluate muscle pathology, such as atrophy or regeneration. - However, it is an **invasive procedure** and provides less direct information about nerve recovery compared to EMG, which directly assesses nerve and muscle electrical activity.
Question 5: What is the age of tendon transfer in post polio residual paralysis
- A. 1 year
- B. 2 years
- C. >5 years (Correct Answer)
- D. <6 months
Explanation: ***>5 years*** - Tendon transfer surgery is typically delayed until the child is **at least five years old** to ensure maximal spontaneous recovery has occurred and definitive muscle weakness patterns are established. - This age allows for better patient cooperation with **post-operative rehabilitation** and provides sufficient size for effective tendon grafting and fixation. *1 year* - This age is generally too early for tendon transfer, as it does not allow enough time for the **natural recovery process** from polio to conclude. - Performing surgery at this age risks unnecessary intervention if motor function might still spontaneously improve. *2 years* - While some recovery may have occurred, **two years** is still often considered premature for definitive tendon transfer in post-polio paralysis. - The child's growth and neuromuscular maturation are not yet complete, which could impact surgical outcomes and the ability to gauge permanent deficits. *<6 months* - This age is far too early for tendon transfer surgery in post-polio residual paralysis. - Infants require time for initial muscle recovery post-infection and for their skeletal and muscular systems to develop sufficiently for such a procedure.
Question 6: A football player experienced a twist in the ankle and knee. Clinically, no bone injury was appreciated. The examiner is performing the test shown in the image. Which test is this?
- A. Posterior drawer for PCL
- B. McMurray
- C. Lachman (Correct Answer)
- D. Anterior drawer for ACL
Explanation: ***Lachman*** - The image shows the examiner holding the distal thigh and proximal tibia, with the knee flexed at a **20-30 degree angle**, applying an **anterior translational force** to the tibia. This specific maneuver is characteristic of the Lachman test. - The Lachman test is highly sensitive for detecting **anterior cruciate ligament (ACL) tears**, particularly in acute injuries, due to the reduced hamstring spasm compared to the anterior drawer test. *Posterior drawer for PCL* - The posterior drawer test involves flexing the knee to **90 degrees** and applying a **posterior force** to the tibia to assess the integrity of the **posterior cruciate ligament (PCL)**. - The position of the knee in the image (flexed at a shallower angle) and the direction of the applied force (anteriorly towards the femur) do not match the technique for a posterior drawer test. *McMurray* - The McMurray test is performed to evaluate **meniscal tears** by flexing, extending, and rotating the knee while applying a varus or valgus stress. - The maneuver in the image, involving direct anterior translation of the tibia with the knee in slight flexion, is not consistent with the McMurray test. *Anterior drawer for ACL* - While also testing the **ACL**, the anterior drawer test typically involves flexing the knee to **90 degrees** and sitting on the foot, then pulling the tibia anteriorly. - The knee flexion angle in the image is much shallower than 90 degrees, making it inconsistent with the standard anterior drawer test.
Question 7: Which of the following is NOT typically associated with the recovery phase after a disaster?
- A. Rehabilitation
- B. Reconstruction
- C. Response (Correct Answer)
- D. Mitigation
Explanation: ***Response (Correct Answer)*** - **Response** activities occur during or immediately after the disaster event, NOT in the recovery phase - Includes immediate search and rescue, medical triage, emergency shelter provision, and acute crisis management - The goal is to **save lives, protect property**, and meet basic human needs during the acute crisis (typically 0-72 hours) - This is distinct from the recovery phase, which begins after the immediate emergency is controlled *Rehabilitation* - **Rehabilitation** is a key component of the **recovery phase** - Focuses on restoring services and infrastructure to acceptable levels after the initial emergency - Includes both physical recovery of individuals and return to functionality of critical systems like utilities and healthcare *Reconstruction* - **Reconstruction** is a major part of the **recovery phase** - Involves rebuilding infrastructure, homes, and communities, often to a better, more resilient standard than before - This is often a lengthy process aiming for long-term stability and development *Mitigation* - While **mitigation** can be incorporated into recovery planning, it is primarily focused on **future disaster prevention** - Measures taken to reduce the **loss of life and property** from future disasters - Can be implemented before a disaster strikes or planned during recovery, but the emphasis is on **risk reduction for future events** rather than immediate restoration from the current event
Question 8: Painful arc syndrome is characterized by pain during which movement?
- A. Initial abduction
- B. Terminal abduction
- C. Mid-range abduction (Correct Answer)
- D. Full range of abduction
Explanation: **Explanation:** **Painful Arc Syndrome** is a clinical sign typically associated with **Subacromial Impingement Syndrome**. It occurs when the structures within the subacromial space (most commonly the Supraspinatus tendon or the subacromial bursa) become compressed between the greater tuberosity of the humerus and the acromion process. 1. **Why Mid-range Abduction is Correct:** During abduction, the subacromial space is at its narrowest between **60° and 120°**. In this range, the inflamed or degenerated tendon is pinched against the acromial arch, eliciting sharp pain. This is the "mid-range" of motion. 2. **Analysis of Incorrect Options:** * **Initial Abduction (0°–15°):** Pain here usually indicates a complete Supraspinatus tear (inability to initiate) or severe tendonitis, but the subacromial space is not yet maximally compromised. * **Terminal Abduction (120°–180°):** Pain at the very end of abduction is characteristic of **Acromioclavicular (AC) joint arthritis**, not impingement. * **Full Range:** Pain throughout the entire range is more suggestive of adhesive capsulitis (Frozen Shoulder) or acute calcific tendonitis rather than a classic "arc." **Clinical Pearls for NEET-PG:** * **Neer’s Test and Hawkins-Kennedy Test:** These are the specific clinical provocative tests used to confirm subacromial impingement. * **The "Critical Zone":** The area of the Supraspinatus tendon roughly 1 cm proximal to its insertion is relatively avascular and is the most common site for pathology in this syndrome. * **Management:** Initial treatment is conservative (NSAIDs, PT, subacromial steroid injection). Surgical decompression (Acromioplasty) is reserved for refractory cases.
Question 9: What is the primary pathology in Athletic Pubalgia?
- A. Abdominal muscle strain (Correct Answer)
- B. Rectus femoris strain
- C. Gluteus medius strain
- D. Hamstring strain
Explanation: **Athletic Pubalgia**, commonly referred to as a "Sports Hernia," is a clinical syndrome characterized by chronic groin pain in athletes. Despite the name, there is no true clinical hernia present. ### **Explanation of the Correct Answer** The primary pathology involves a **strain or weakening of the posterior inguinal wall** and the **rectus abdominis insertion** onto the pubis. * **The Mechanism:** The rectus abdominis and the adductor longus act as antagonists. In high-intensity sports involving sudden changes in direction (soccer, hockey), the strong pull of the adductor muscles against a relatively weaker abdominal wall leads to micro-tears in the **rectus abdominis fascia** or the **external oblique aponeurosis**. This imbalance causes instability at the pubic symphysis. ### **Why Other Options are Incorrect** * **B. Rectus femoris strain:** This typically presents with anterior thigh pain and tenderness at the Anterior Inferior Iliac Spine (AIIS), often following explosive kicking or sprinting. * **C. Gluteus medius strain:** This causes lateral hip pain and weakness in abduction (Trendelenburg gait), not groin pain. * **D. Hamstring strain:** This involves the posterior compartment of the thigh, usually presenting with pain at the ischial tuberosity or the mid-muscle belly. ### **High-Yield Clinical Pearls for NEET-PG** * **Clinical Presentation:** Insidious onset of exercise-induced groin pain that radiates to the adductor region or testicles; pain is aggravated by Valsalva maneuvers or resisted sit-ups. * **Investigation of Choice:** **MRI** is the gold standard to visualize "cleft signs" or edema at the rectus abdominis-adductor longus attachment. * **Management:** Initial treatment is conservative (rest and PT). Surgery (pelvic floor repair or adductor tenotomy) is reserved for refractory cases. * **Differential Diagnosis:** Must be distinguished from **Osteitis Pubis**, which shows characteristic bony erosions and sclerosis on X-ray.
Question 10: Pain and tenderness over the lateral condyle of the humerus with painful dorsiflexion of the wrist is indicative of which of the following conditions?
- A. Golfer's Elbow
- B. Tennis Elbow (Correct Answer)
- C. Pitcher's Elbow
- D. Cricket Elbow
Explanation: **Explanation:** The clinical presentation described is a classic case of **Tennis Elbow**, also known as **Lateral Epicondylitis**. **1. Why Tennis Elbow is Correct:** Tennis elbow is a clinical condition characterized by pain and tenderness over the **lateral epicondyle** of the humerus. It is caused by repetitive strain and microtrauma at the common extensor origin, primarily involving the **Extensor Carpi Radialis Brevis (ECRB)** muscle. Since the ECRB is a primary wrist extensor, **resisted dorsiflexion (extension)** of the wrist exacerbates the pain, as it puts tension on the inflamed tendon origin. **2. Why Other Options are Incorrect:** * **Golfer’s Elbow (Medial Epicondylitis):** This involves the common flexor origin. Pain and tenderness are located over the **medial epicondyle**, and symptoms are aggravated by resisted **palmar flexion** of the wrist. * **Pitcher’s Elbow:** This refers to medial epicondyle apophysitis or ulnar collateral ligament (UCL) injury, typically seen in adolescent baseball players due to extreme valgus stress during throwing. * **Cricket Elbow:** This is a non-specific term but often refers to injuries like olecranon bursitis or posterior impingement due to repetitive bowling actions. **3. NEET-PG High-Yield Pearls:** * **Most common muscle involved:** Extensor Carpi Radialis Brevis (ECRB). * **Cozen’s Test:** Pain on resisted wrist extension with the elbow flexed (Diagnostic for Tennis Elbow). * **Mill’s Test:** Pain on passive wrist flexion and forearm pronation with the elbow extended. * **Maudsley’s Test:** Pain on resisted extension of the middle finger (due to ECRB tension). * **Treatment:** Conservative management (Rest, NSAIDs, bracing) is the first line. Refractory cases may require corticosteroid or PRP injections, or surgical release (Nirschl procedure).
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