Emergency Assessment and On-Field Management
The Emergency Assessment and On-Field Management domain tests whether you can recognize and act on time-critical events before a diagnosis is settled: catastrophic bleeding, airway loss, spinal instability, heat stroke, exertional sickling, and cardiac arrest. Sideline items reward a fixed sequence and punish improvisation.
Primary survey
Run the sequence in order and do not let the obvious injury pull you off it: catastrophic hemorrhage control, airway with the cervical spine held neutral, breathing, circulation with distal pulse and perfusion checks, disability (AVPU, pupils, gross motor), exposure while protecting the athlete from the environment. Any athlete who is unresponsive, has altered mental status, or has midline cervical tenderness after an axial load stays in spinal motion restriction until cleared.
Equipment-laden athletes
With helmet and shoulder pads both in place, the head sits near neutral; removing one without the other lets the cervical spine extend. The facemask is removed (cutters, quick-release hardware) to gain the airway rather than taking off the helmet. Log-roll the athlete as a unit with a designated leader calling the roll, then transfer with a coordinated lift.
Environmental emergencies
Exertional heat stroke is a rectal temperature above roughly 40.5 °C with central nervous system dysfunction - confusion, aggression, collapse. Treatment is immediate cold-water immersion, cooling first and transporting second, stopping cooling near 38.5 °C. Oral and tympanic readings are not acceptable for the decision. Exertional sickling presents with cramping, weakness, and collapse out of proportion to workload in a sickle cell trait athlete; stop activity, give oxygen, and hydrate aggressively.
Worked example
A cross-country runner collapses late in a warm race, is combative and confused, skin hot, rectal probe 41.3 °C. Reasoning: hot skin plus CNS dysfunction equals heat stroke until disproven, so rectal temperature is repeated, cold-water immersion starts on the field, vitals and mental status are rechecked continuously, and transport is arranged with cooling continued en route. Antipyretics and ice packs at the neck and groin are not substitutes for immersion.
Traps that cost marks
Treating a seizure as a concussion, skipping the secondary survey because the primary survey was normal, removing a helmet while shoulder pads stay on, calling heat illness "mild" from an oral temperature, and forgetting the automated external defibrillator in a collapsed athlete with no pulse.
Head Injury and Concussion
The Head Injury and Concussion domain tests recognition, the removal decision, the return-to-learn and return-to-sport sequence, and the separation of concussion from cervical, vestibular, and oculomotor mimics.
Recognition principles
Concussion is a functional, not structural, injury; CT and MRI are normal by definition. Imaging is ordered to exclude hemorrhage in athletes with red flags, not to diagnose or clear concussion. Red flags: declining Glasgow Coma Scale, focal neurologic deficit, worsening headache, repeated vomiting, seizure, increasing drowsiness, unequal pupils, or suspected cervical injury.
Assessment tools
Use the consensus sport concussion tools for the acute setting and the office version for follow-up; the child versions apply to ages 8–12. A symptom checklist alone is insufficient - combine symptom report with balance testing, an oculomotor/vestibular screen (smooth pursuits, saccades, convergence, vestibulo-ocular reflex), and a full neurologic and cervical examination.
Management sequence
Remove from play the same day - no same-day return at any level of competition. Follow 24–48 hours of relative rest (light daily walking, limited screen load), then sub-symptom threshold aerobic exercise, adding cervical and vestibular rehabilitation for persistent symptoms. Return to school precedes return to sport. The graded exertion progression uses a minimum of 24 hours per step: symptom-limited activity, aerobic exercise, individual sport-specific drills, non-contact training drills, full-contact practice, return to competition.
Worked example
A 16-year-old hockey player takes a shoulder to the jaw, has no loss of consciousness, but reports headache, dizziness, and blurred vision, and scores abnormally on convergence and tandem gait. Reasoning: absence of loss of consciousness is irrelevant; the multidomain abnormality confirms removal. She is pulled immediately, given written follow-up instructions, and begins relative rest. Two days later she tolerates 20 minutes of sub-symptom aerobic work, then advances through school return before starting the six-step progression.
Traps that cost marks
"No loss of consciousness, so it is not a concussion." Clearing an athlete by CT. Prescribing weeks of dark-room rest. Advancing two steps in one day. Letting an athlete return to contact before completing return to learn.
Cervical and Thoracic Spine in Sport
The Cervical and Thoracic Spine domain tests on-field spinal decision-making, the differentiation of burner from cord injury, myelopathy screening, and sport-specific return criteria.
On-field cervical spine
Mechanism (axial load, hyperflexion, hyperextension) drives suspicion more than symptoms alone. Midline tenderness, painful active range of motion, bilateral symptoms, or any transient neurologic complaint means immobilization and transport. Transient quadriparesis is bilateral burning and weakness after axial load, often with cervical canal stenosis; it resolves in minutes to hours but is not a burner.
Burners and stingers
Unilateral burning, dysesthesia, and weakness in a C5–C6 distribution after shoulder depression with neck extension or lateral flexion. Symptoms typically resolve within minutes. Recurrent burners require imaging and technique review; bilateral symptoms are cord until proven otherwise.
Myelopathy red flags
Hoffmann sign, inverted brachial plexus reflex, clonus, Babinski sign, gait disturbance, and clumsy hands. Myelopathic athletes are not cleared for collision sport without specialty evaluation.
Structural contraindications
Spear tackler's spine - cervical stenosis with loss of normal lordosis and spear-tackling technique - is an absolute bar to return in collision sport. Congenital Klippel-Feil fusion of multiple segments, atlantoaxial instability, and odontoid abnormalities also restrict return.
Thoracic considerations
Rib stress injury in rowers and swimmers presents as focal, progressive pain worse with deep breathing and loading; plain films are often initially negative, so bone scan or MRI is used. Costochondritis and intercostal strain are diagnoses of exclusion.
Worked example
A linebacker reports burning down one arm after a tackle; symptoms resolve in four minutes, Spurling is positive, reflexes are symmetric, and Hoffmann is absent. Reasoning: unilateral, brief, no cord signs - this is a stinger. He may return if strength and sensation are fully normal, asymptomatic on provocation testing, and no recurrence in the same game; recurrent episodes prompt imaging and tackling technique review.
Traps that cost marks
Clearing bilateral symptoms as a "stinger," missing myelopathy signs, ignoring loss of cervical lordosis on films, and returning an athlete the same day after a second burner in one season without evaluation.
Upper Extremity Injury and Return Decisions
The Upper Extremity domain tests acute management of shoulder, elbow, wrist, and hand injuries common in contact and overhead sport, and the criteria used to decide same-day return versus removal.
Shoulder
Anterior dislocation presents with squaring of the shoulder, palpable anterior mass, and inability to abduct. If the neurovascular examination is intact and no fracture is suspected, prompt reduction by an experienced provider shortens disability; post-reduction films and axillary nerve assessment are mandatory before return. Acromioclavicular sprains are graded by displacement and tenderness; grade I–II typically return with padding, grade III and above require imaging and a longer course. Clavicle fracture is a relative removal for collision sport.
Elbow and throwing arm
Valgus extension overload in throwers produces posteromedial pain, loose bodies, and ulnar collateral ligament insufficiency; the moving valgus stress test and magnetic resonance arthrography are used. Medial epicondyle avulsion in adolescents requires removal from throwing.
Wrist and hand
Snuffbox tenderness after a fall on the outstretched hand means occult scaphoid fracture until proven: immobilize, splint, and image, with repeat imaging or MRI if initial films are negative. Mallet finger (extensor avulsion) is splinted in extension; jersey finger (flexor digitorum profundus avulsion) is a surgical referral. Gamekeeper's thumb is an ulnar collateral ligament injury at the metacarpophalangeal joint.
Worked example
A wrestler falls on an outstretched hand and has dorsal wrist pain with snuffbox tenderness but normal radiographs. Reasoning: a normal film does not exclude scaphoid fracture. He is splinted in a thumb spica, held from contact, and advanced imaging is arranged; return is deferred pending imaging and clinical union.
Traps that cost marks
Clearing a shoulder before documenting axillary nerve function, treating a negative radiograph as exclusion of scaphoid fracture, allowing a throwing athlete to "play through" medial elbow pain, and missing a jersey finger because the finger is splinted for "a sprain."
Lower Extremity Injury and Return Decisions
The Lower Extremity domain tests acute knee, ankle, hip, and foot injury decisions, the use of validated decision rules, and recognition of injuries that must not be played through.
Knee
Anterior cruciate ligament rupture presents with a pop, rapid hemarthrosis, and instability; Lachman is the most sensitive test and pivot shift the most specific. Any acute hemarthrosis in a young athlete is an anterior cruciate ligament injury or osteochondral fracture until proven. Meniscal tears cause joint-line tenderness and mechanical symptoms; locked knees require prompt referral.
Ankle
Ottawa ankle rules indicate imaging with malleolar tenderness at the posterior edge or tip within 6 cm, or inability to bear weight for four steps immediately and in the clinic, plus navicular and base of fifth metatarsal tenderness. Syndesmotic (high) ankle injury shows squeeze-test and external rotation pain above the joint line and takes longer than a lateral sprain. Achilles rupture is confirmed by a positive Thompson test.
Hip and groin
Femoral neck stress fracture in distance runners presents with anterior groin pain, pain at end range of hip rotation, and inability to hop; it is a surgical emergency if displaced and requires crutch offloading and imaging. Femoroacetabular impingement and adductor strain are common in cutting sports.
Foot
Jones fracture (zone 2, 1.5–3 cm distal to the tuberosity) has a watershed blood supply and a higher nonunion rate, so it is treated more conservatively than an avulsion. Navicular stress fracture in jumping athletes often has negative early films. Chronic exertional compartment syndrome causes exercise-induced pain relieved by rest, with normal resting pressures; diagnosis requires post-exertion compartment pressure testing.
Worked example
A basketball player rolls his ankle, has lateral tenderness, but takes four unaided steps and has no malleolar or fifth metatarsal tenderness. Reasoning: Ottawa rules negative, so no radiograph. He is managed as a lateral sprain with early weight bearing and proprioceptive rehabilitation; a squeeze test is performed because syndesmotic injury changes the timeline.
Traps that cost marks
Missing femoral neck stress fracture in a runner, treating a Jones fracture as a simple sprain, and diagnosing chronic exertional compartment syndrome from resting compartment pressures.
Rehabilitation, Exercise Physiology, and Return to Sport
The Rehabilitation, Exercise Physiology, and Return to Sport domain tests whether you can design and justify loading programs, apply training principles, and defend a return decision with objective criteria rather than the calendar.
Core principles
Specific adaptation to imposed demands means the training stimulus must match the target tissue and sport demand. The general adaptation syndrome explains why overload without recovery produces maladaptation. Progressive overload, individuality, and periodization (macrocycle, mesocycle, microcycle) organize return timelines around competition.
Tissue-specific loading
Tendinopathy responds to progressive eccentric and heavy slow resistance loading - the classic Achilles program uses straight-knee and bent-knee heel raises at high volume, twice daily, for roughly 12 weeks, accepting some soreness. Bone stress injury requires relative rest with load redistribution and correction of energy availability and biomechanics. Muscle strains progress from isometric to lengthened eccentric loading before high-velocity work.
Modalities and taping
Cryotherapy, compression, and elevation manage symptoms without accelerating tissue healing. Ultrasound and laser have weak evidence for musculoskeletal healing. Rigid taping and bracing provide mechanical restriction and proprioceptive input; kinesiotape evidence is modest, and neither substitutes for strength work.
Return criteria
Use pain-free sport-specific movement, full range of motion, strength at least 90% of the contralateral limb, hop-test limb symmetry above 90%, and psychological readiness alongside clinical healing. Anticipate recurrence risk in the first weeks of return.
Worked example
A soccer player eight months after anterior cruciate ligament reconstruction has full extension, quadriceps symmetry of 82%, and a 78% limb symmetry index on the single-leg hop. Reasoning: strength and hop symmetry fall short, so return is deferred despite the elapsed time. A four-week block of heavy quadriceps loading and plyometric progression is prescribed, with retesting before contact training.
Traps that cost marks
Clearing on time elapsed rather than criteria, prescribing complete rest for tendinopathy, and using passive modalities instead of loading.
Nutrition, Ergogenic Aids, and Pharmacology
The Nutrition, Ergogenic Aids, and Pharmacology domain tests fueling and hydration decisions for training and competition, recognition of low energy availability, and anti-doping rules relevant to prescribing in athletes.
Fueling and hydration
Athletes in moderate training need roughly 6–10 g/kg carbohydrate daily, with 30–60 g per hour during sessions lasting more than 1–2.5 hours. Protein targets about 1.2–2.0 g/kg daily distributed as 0.25–0.3 g/kg per meal. Body mass loss above 2% degrades performance; prescribe fluid and sodium replacement based on individual sweat rate rather than a universal rule.
Low energy availability
Relative energy deficiency in sport spans menstrual dysfunction, low bone density, impaired immunity, and endocrine suppression. Screen for it in athletes with recurrent stress fractures, unexplained fatigue, or disordered eating patterns; referral is part of management.
Anti-doping essentials
The prohibited list is grouped by classes such as anabolic agents, peptide hormones, beta-2 agonists, diuretics, and hormone modulators. Substances are prohibited at all times, in competition only, or in specified sports. Caffeine is not prohibited. Pseudoephedrine is prohibited in competition above a urinary threshold. Intravenous infusions are prohibited in competition except for small medically justified volumes. Glucocorticoids are prohibited in competition by systemic routes, while local injection routes are permitted; a therapeutic use exemption applies only when no permitted alternative exists. Athletes should verify any supplement through a third-party certification program.
Worked example
A college cyclist asks about a decongestant containing pseudoephedrine two days before a race. Reasoning: pseudoephedrine is prohibited in competition above the urinary threshold, so the product is withdrawn, a permitted alternative is selected, and if the prescription were unavoidable a therapeutic use exemption would need to be filed before competition.
Traps that cost marks
Treating all anti-doping rules as applying only in competition, assuming supplementation is harmless without contamination checks, and diagnosing low energy availability purely from low body weight.