NATA-BOC Upper Extremity Injury Assessment 2 — Questions and Answers

Question 1: An athlete presents with lateral elbow pain that worsens with gripping and wrist extension. Which special test would best confirm the diagnosis?

Phalen test
Cozen test (Correct answer)
Speed test
Yergason test

Correct answer: Cozen test

The Cozen test (resisted wrist extension with the elbow extended and forearm pronated) is specific for lateral epicondylitis. Pain at the lateral epicondyle during this test confirms involvement of the wrist extensor muscles, primarily the extensor carpi radialis brevis.

Lateral epicondylitis (tennis elbow) affects the common extensor tendon origin at the lateral epicondyle, most commonly the extensor carpi radialis brevis (ECRB). The Cozen test is performed by stabilizing the patient's elbow in extension with the forearm pronated and asking the patient to extend the wrist against resistance. Pain at the lateral epicondyle is a positive result. The Mill test (passive wrist flexion with the elbow extended and forearm pronated) stretches the extensor origin and reproduces pain. Maudsley test (resisted middle finger extension) specifically targets the ECRB. The Phalen test assesses carpal tunnel syndrome. Speed test and Yergason test evaluate the biceps tendon and labrum. Risk factors for lateral epicondylitis include repetitive wrist extension activities, poor grip strength, and age 35-55.

Question 2: A volleyball player complains of shoulder pain and weakness with overhead serving. The Speed test is positive. Which structure is most likely involved?

Supraspinatus tendon
Long head of the biceps tendon (Correct answer)
Infraspinatus tendon
Subscapularis tendon

Correct answer: Long head of the biceps tendon

A positive Speed test indicates pathology of the long head of the biceps tendon. The test is performed with the shoulder flexed to 90 degrees, elbow extended, and forearm supinated while the patient resists a downward force.

The Speed test (also called the Speed-Palm Up test) evaluates the long head of the biceps tendon. It is performed with the patient's shoulder flexed to 60-90 degrees, elbow extended, and forearm fully supinated. The examiner applies a downward force while the patient resists. Pain in the bicipital groove is positive for biceps tendinopathy or a SLAP lesion. The long head of the biceps tendon originates from the superior glenoid labrum and the supraglenoid tubercle, courses through the bicipital groove, and is vulnerable to impingement and repetitive overhead activities. The supraspinatus is tested with the empty can test (Jobe test). The infraspinatus is tested with resisted external rotation. The subscapularis is tested with the lift-off test (Gerber test) or belly press test. In volleyball players, biceps tendinopathy often coexists with impingement syndrome.

Question 3: During a sideline evaluation, an athletic trainer suspects an athlete has dislocated their acromioclavicular (AC) joint. Which finding is most consistent with a Grade III AC separation?

Tenderness at the AC joint without deformity
Slight elevation of the distal clavicle with pain on cross-body adduction
Complete displacement of the clavicle above the acromion with obvious deformity (Correct answer)
Pain only with extreme overhead reaching

Correct answer: Complete displacement of the clavicle above the acromion with obvious deformity

A Grade III AC separation involves complete disruption of both the AC ligaments and coracoclavicular ligaments, resulting in complete displacement of the clavicle superiorly with an obvious step deformity or 'piano key sign.'

AC joint injuries are classified by the Rockwood system (Grades I-VI): Grade I — AC ligament sprain, no displacement, tender but stable; Grade II — AC ligament disrupted, CC ligaments sprained but intact, slight clavicle elevation (less than 25% displacement); Grade III — both AC and CC ligaments disrupted, complete displacement (25-100%), obvious deformity, positive piano key sign; Grade IV — clavicle displaced posteriorly into the trapezius; Grade V — 100-300% displacement with fascial disruption; Grade VI — clavicle displaced inferiorly (very rare). The 'piano key sign' refers to the ability to push the elevated clavicle down (like a piano key) only to have it spring back up. Grades I-II are typically treated conservatively. Grade III management is debated (conservative vs. surgical). Grades IV-VI usually require surgical intervention.

Question 4: An athletic trainer suspects a scaphoid fracture in an athlete who fell on an outstretched hand. Anatomical snuffbox tenderness is present. Initial radiographs are negative. What is the most appropriate next step?

Clear the athlete for return to play since X-rays are negative
Immobilize the wrist in a thumb spica splint and re-evaluate in 10-14 days (Correct answer)
Apply a compression wrap and follow up in 3-4 weeks
Order an immediate MRI

Correct answer: Immobilize the wrist in a thumb spica splint and re-evaluate in 10-14 days

Scaphoid fractures are notoriously difficult to detect on initial radiographs (up to 20% are missed). When clinical suspicion is high (snuffbox tenderness, mechanism of injury), the standard of care is to immobilize in a thumb spica and obtain follow-up X-rays at 10-14 days.

The scaphoid bone has a retrograde blood supply (enters distally), making proximal pole fractures particularly vulnerable to avascular necrosis (AVN) and nonunion. Up to 20% of scaphoid fractures are radiographically occult on initial X-rays because the fracture line may not be visible until bone resorption occurs at the fracture site (takes 10-14 days). Clinical indicators of scaphoid fracture include: anatomical snuffbox tenderness, pain with axial compression of the thumb (scaphoid compression test), tenderness over the scaphoid tubercle, pain with wrist radial deviation, and mechanism of fall on outstretched hand (FOOSH) with wrist extension. The standard protocol is: suspect the fracture based on clinical findings, immobilize in a thumb spica splint or cast, repeat X-rays at 10-14 days, and if still negative but clinically suspicious, obtain MRI or bone scan. This conservative approach prevents the devastating complication of AVN.

Question 5: Which special test specifically assesses for a SLAP (Superior Labrum Anterior to Posterior) lesion of the shoulder?

Hawkins-Kennedy test
O'Brien test (Active Compression test) (Correct answer)
Sulcus sign
Drop arm test

Correct answer: O'Brien test (Active Compression test)

The O'Brien test (Active Compression test) is specifically designed to assess for SLAP lesions. It involves two positions: arm forward flexed 90 degrees and adducted 15 degrees with the thumb down (pain), then repeated with the palm up (pain decreases or resolves).

The O'Brien test is performed in two steps: Position 1 — shoulder flexed to 90 degrees, adducted 15 degrees across midline, and fully internally rotated (thumb pointing down). The examiner applies a downward force while the patient resists. Pain deep in the shoulder suggests a labral lesion. Position 2 — same position but with the forearm fully supinated (palm up). The examiner again applies a downward force. If the deep pain decreases or resolves in position 2, it is suggestive of a SLAP lesion. If pain is on top of the shoulder (AC joint) and not affected by forearm rotation, it suggests AC joint pathology instead. Sensitivity is approximately 63-100% depending on the study. The Hawkins-Kennedy test assesses subacromial impingement. The sulcus sign tests inferior glenohumeral instability. The drop arm test evaluates rotator cuff integrity (specifically large supraspinatus tears).

Question 6: An athlete sustains a mallet finger injury during a basketball game. Which deformity is characteristic of this injury?

Hyperextension of the DIP joint
Flexion deformity of the DIP joint with inability to actively extend it (Correct answer)
Lateral deviation of the PIP joint
Flexion contracture of the MCP joint

Correct answer: Flexion deformity of the DIP joint with inability to actively extend it

Mallet finger results from disruption of the terminal extensor tendon at its insertion on the distal phalanx. This causes a characteristic flexion droop of the DIP joint with inability to actively extend it, though passive extension remains intact.

Mallet finger (baseball finger) occurs when the extensor tendon is avulsed from the distal phalanx, either as a tendon-only injury or with a bony fragment (avulsion fracture). The mechanism is typically forced flexion of an extended DIP joint (catching a ball on the fingertip). The presentation is characteristic: the DIP joint rests in approximately 40-45 degrees of flexion, the patient cannot actively extend the DIP joint, passive extension is full, and the injury is usually not particularly painful, which can lead to delayed presentation. Treatment for tendon-only injuries is continuous extension splinting of the DIP joint (in slight hyperextension) for 6-8 weeks, 24 hours a day. If the splint is removed and the DIP flexes even once during this period, the 6-week clock restarts. Bony avulsions involving more than 30% of the articular surface or with volar subluxation may require surgical fixation.

NATA-BOC Upper Extremity Injury Assessment 2

An athlete presents with lateral elbow pain that worsens with gripping and wrist extension.
Which special test would best confirm the diagnosis?