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Musculoskeletal

Which of the following is a benign condition and does not require further workup if history and physical are otherwise normal?

A. Murmur that gets louder when athlete moves from squatting to standing position

B. History of syncope during exertion

C. Chest pain during exertion

D. History of syncope after exertion

Answer: D

Post-exertional syncope is a benign, common condition and is due to lower extremity vasodilation secondary to decreased vascular tone after exertion. If the history is consistent with post-exertional syncope, and the family history and physical exam are normal, no further workup is required. A history of syncope or chest pain during exertion is concerning for primary cardiac abnormalities, such as prolonged QT syndrome, hypertrophic obstructive cardiomyopathy (HOCM), or other cardiac abnormalities, and requires further evaluation with electrocardiogram and echocardiogram. A murmur that increases when the patient moves from squatting to standing is concerning for HOCM and requires evaluation with echocardiogram. When a patient moves from the squatting to the standing position, there is a transient pooling of blood in the legs, resulting in decreased venous return to the heart and decreased left ventricular (LV) filling. In patients with HOCM, this decrease in LV filling results in increased obstruction below the aortic valve and resulting in the systolic murmur getting louder when the patient moves from squatting to sitting (or while performing the Valsalva maneuver).

Reference: Peterson AR, Bernhardt DT. The preparticipation sports evaluation. Pediatr Rev. 2011;32(5):e53-e65. Pubmed ID: 21536775.

Which of the following is a part of the female athlete triad?

A. Dysmenorrhea

B. Joint hypermobility

C. Disordered eating

D. Depression

Answer: C

The three endpoint elements of the female athlete triad include oligomenorrhea, low bone mineral density, and disordered eating. Screening for these elements should be included in the preparticipation exam, and the presence of one element should prompt evaluation of the other elements. Joint hypermobility may be benign or associated with heritable disorders of connective tissue (HDCTs), such as Ehlers-Danlos and Marfan syndrome. While there may be some overlap, neither dysmenorrhea nor depression are a part of the classically defined female athlete triad.

References: Peterson AR, Bernhardt DT. The preparticipation sports evaluation. Pediatr Rev. 2011;32(5):e53-e65. Pubmed ID: 21536775.

Weiss Kelly AK, Hecht S; Council on Sports Medicine and Fitness. The Female Athlete Triad. Pediatrics. 2016;138(2). pii: e20160922. Pubmed ID: 27432852.

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