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General Sports & Tendon MCQs

Practice Set 1 of 2

This practice set contains high-yield board review questions covering key concepts in General Sports & Tendon. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 1

Topic: General Sports & Tendon

A 45-year-old runner presents with chronic posterior heel pain. MRI reveals severe insertional Achilles tendinopathy. The surgeon plans an aggressive debridement of the tendon insertion. If surgical debridement requires excision of greater than 50% of the tendon insertion, which of the following is the most appropriate next step?

. V-Y tendinous advancement of the gastrocnemius
. Flexor hallucis longus (FHL) tendon transfer
. Flexor digitorum longus (FDL) tendon transfer
. Peroneus brevis tendon transfer
. Primary repair with heavy nonabsorbable suture only

Correct Answer & Explanation

. Flexor hallucis longus (FHL) tendon transfer

Explanation

When surgical debridement of insertional Achilles tendinopathy compromises more than 50% of the tendon insertion, augmentation is required to prevent rupture. The flexor hallucis longus (FHL) is the preferred transfer due to its strength, axis of pull, and proximity.

Question 2

Topic: General Sports & Tendon
A 55-year-old male presents with non-insertional Achilles tendinopathy. He is prescribed an eccentric training program (Alfredson protocol). Which of the following best describes the physiologic rationale for this specific physical therapy regimen?
. It increases type III collagen synthesis
. It selectively decreases paratenon vascularity through ischemia
. It stimulates mechanotransduction leading to type I collagen synthesis and remodeling
. It lengthens the gastrocnemius-soleus complex by rupturing microadhesions
. It alters the footprint of the tendon on the calcaneal tuberosity

Correct Answer & Explanation

. It stimulates mechanotransduction leading to type I collagen synthesis and remodeling

Explanation

Eccentric training (such as the Alfredson protocol) promotes tendon healing via mechanotransduction. This leads to increased type I collagen synthesis, improved collagen alignment, and a decrease in pathological neovascularization within the tendinopathic tissue.

Question 3

Topic: General Sports & Tendon

Which of the following biologic factors is most highly upregulated in the pathophysiology of chronic non-insertional Achilles tendinopathy, contributing directly to neovascularization?

. Tumor necrosis factor-alpha (TNF-a)
. Vascular endothelial growth factor (VEGF)
. Interleukin-1 (IL-1)
. Matrix metalloproteinase-1 (MMP-1)
. Transforming growth factor-beta (TGF-b)

Correct Answer & Explanation

. Vascular endothelial growth factor (VEGF)

Explanation

Chronic tendinopathy is characterized by angiofibroblastic dysplasia and neovascularization, driven predominantly by VEGF. Notably, there is an absence of acute inflammatory cells in chronic tendinosis.

Question 4

Topic: General Sports & Tendon

Reported hamstring strength deficit by isokinetic testing after complete proximal rupture is approximately:

. 10%
. 20%
. 60%
. 90%
. No deficit

Correct Answer & Explanation

. 60%

Explanation

In a series of 12 patients with complete or near complete proximal hamstring ruptures, the mean strength deficit measured 61% for the hamstring and 23% for the quadriceps musculature.

Question 5

Topic: General Sports & Tendon

Which of the following activities is associated with proximal hamstring ruptures:

. High jumping
. Skating
. Water skiing
. Swimming
. Basketball

Correct Answer & Explanation

. Water skiing

Explanation

Water skiing is associated with proximal hamstring ruptures in both novice and experienced skiers. The mechanisms, however, are reported to be different depending on the level of skier. The novice skier typically sustains the injury while trying to get up on one or two skis from a submerged position, whereas the injury is typically the result of a fall in an experienced skier.

Question 6

Topic: General Sports & Tendon

Patients with symptomatic chronic proximal hamstring ruptures typically complain of:

. Anterior thigh cramping with running
. Difficulty decelerating the leg during running
. Difficulty ascending stairs
. Difficulty descending stairs
. Difficulty accelerating the leg during running

Correct Answer & Explanation

. Difficulty decelerating the leg during running

Explanation

Patients typically complain of a pulling sensation or cramping in the posterior thigh with vigorous activity. In addition, they may describe difficulty controlling the leg, which has been attributed to the impaired deceleration of the thigh as a result of the complete rupture.

Question 7

Topic: General Sports & Tendon

The recommended treatment of a complete proximal hamstring rupture with 4-cm retraction in a young athletic adult is:

. Nonoperative rehabilitation
. Nonoperative rehabilitation followed by surgical repair if there is continued disability
. Surgical reattachment of the proximal hamstrings
. No rehabilitation or surgery is indicated
. C omplete proximal hamstring ruptures have not been reported

Correct Answer & Explanation

. Surgical reattachment of the proximal hamstrings

Explanation

Patients with disability secondary to chronic complete proximal hamstring ruptures have been increasingly identified. Because of the reports of continued weakness and poor leg control, more authors are recommending acute repair of these injuries. Chronic repairs are reported to be much more difficult although good results are reported.

Question 8

Topic: General Sports & Tendon

Which of the following is the most consistent histological finding in chronic non-insertional Achilles tendinopathy?

. Abundant acute inflammatory cells (neutrophils)
. Mucoid degeneration and neovascularization
. Calcium hydroxyapatite crystal deposition
. Extensive fibrinoid necrosis
. Amyloid deposition

Correct Answer & Explanation

. Mucoid degeneration and neovascularization

Explanation

Chronic Achilles tendinopathy is an angiofibroblastic process characterized by collagen disorientation, mucoid (myxoid) degeneration, and neovascularization. Acute inflammatory cells are typically absent, which is why the condition is accurately termed "tendinosis."

Question 9

Topic: General Sports & Tendon

The following figure is the magnetic resonance image (MRI) of a 40-year- old avid female water-skier who felt a pop in her left hip as she was pulled over the front of her ski. Recommended treatment includes:

. Percutaneous pinning
. Nonweight bearing crutch ambulation
. Physical therapy
. Operative repair of the injured structures
. Reassurance and symptomatic treatment

Correct Answer & Explanation

. Operative repair of the injured structures

Explanation

The MRI shows a complete avulsion of the hamstring tendons off the ischial tuberosity. In active individuals, operative repair is recommended for complete avulsions. Nonoperative treatment of complete hamstring avulsion injury yields a low rate of return to sport at preinjury activity level.

Question 10

Topic: General Sports & Tendon

A 35-year-old female runner presents with deep posterior gluteal pain radiating down the posterior thigh. MRI reveals edema in the quadratus femoris muscle. What is the most likely diagnosis?

. Piriformis syndrome
. Proximal hamstring avulsion
. Ischiofemoral impingement
. Pudendal nerve entrapment
. Gluteus medius tendinopathy

Correct Answer & Explanation

. Ischiofemoral impingement

Explanation

Ischiofemoral impingement results from a narrowed space between the lesser trochanter and the ischium. This leads to compression and characteristic MRI edema or atrophy of the quadratus femoris muscle.

Question 11

Topic: General Sports & Tendon

Which of the following is the most widely accepted indication for acute surgical repair of a proximal hamstring avulsion injury?

. Single tendon avulsion with 1 cm of retraction
. Conjoined tendon avulsion with 1 cm retraction in a recreational runner
. Semimembranosus avulsion with no retraction
. Avulsion of all three tendons with >2 cm of retraction
. Intramuscular tear of the biceps femoris at the musculotendinous junction

Correct Answer & Explanation

. Avulsion of all three tendons with >2 cm of retraction

Explanation

Acute surgical repair of proximal hamstring avulsions is strongly recommended for tears involving all three tendons (complete avulsion) with greater than 2 cm of retraction. This prevents significant loss of power, deformity, and chronic pain.

Question 12

Topic: General Sports & Tendon

When performing an open repair of a proximal hamstring avulsion, the surgeon identifies the conjoined tendon. Which muscles form this specific anatomical structure at the ischial tuberosity?

. Semimembranosus and semitendinosus
. Long head of biceps femoris and semitendinosus
. Short head of biceps femoris and semimembranosus
. Adductor magnus and semitendinosus
. Long head of biceps femoris and semimembranosus

Correct Answer & Explanation

. Long head of biceps femoris and semitendinosus

Explanation

The proximal hamstring origin at the ischial tuberosity consists of the conjoined tendon (long head of the biceps femoris and the semitendinosus) and the distinct, more lateral and anterior origin of the semimembranosus.

Question 13

Topic: General Sports & Tendon

A 35-year-old distance runner presents with deep posterior gluteal pain. MRI reveals narrowing of the space between the lesser trochanter and the ischium with edema in the quadratus femoris muscle. What is the diagnosis?

. Piriformis syndrome
. Ischiofemoral impingement
. Proximal hamstring avulsion
. Gluteus medius tear
. Pudendal nerve entrapment

Correct Answer & Explanation

. Ischiofemoral impingement

Explanation

Ischiofemoral impingement is characterized by the narrowing of the ischiofemoral space. It typically presents with deep buttock pain and edema or tears in the quadratus femoris muscle on MRI.

Question 14

Topic: General Sports & Tendon

Which of the following is the most dreaded and functionally limiting complication of surgical repair of a chronic proximal hamstring avulsion?

. Deep vein thrombosis
. Ischiadic (sciatic) nerve palsy
. Heterotopic ossification
. Superficial wound infection
. Recurrent rupture

Correct Answer & Explanation

. Ischiadic (sciatic) nerve palsy

Explanation

The sciatic nerve is in close proximity to the proximal hamstring origin (approximately 1.2 cm away). In chronic repairs, scar tissue often tethers the nerve, making iatrogenic sciatic nerve injury a high risk.

Question 15

Topic: General Sports & Tendon

A 35-year-old water skier falls and sustains a forced hyperflexion injury of the hip with the knee extended. MRI demonstrates a complete 3-tendon proximal hamstring avulsion retracted 3.5 cm. What is the most appropriate management?

. Non-weight bearing with crutches for 6 weeks
. Corticosteroid injection to the ischial tuberosity
. Open surgical repair with suture anchors
. Platelet-rich plasma injection
. Endoscopic debridement of the ischial bursa

Correct Answer & Explanation

. Open surgical repair with suture anchors

Explanation

Complete 3-tendon proximal hamstring avulsions retracted greater than 2 cm in active individuals are a strong indication for acute surgical repair. Non-operative management in this setting results in significant residual weakness, pain, and cramping.

Question 16

Topic: General Sports & Tendon

A 40-year-old marathon runner complains of chronic, localized pain over the ischial tuberosity that worsens during prolonged sitting and uphill running. Which clinical test is most specific for diagnosing proximal hamstring tendinopathy?

. FADIR test
. Thomas test
. Modified bent-knee stretch test
. Ober test
. Ely test

Correct Answer & Explanation

. Modified bent-knee stretch test

Explanation

The modified bent-knee stretch test and the Puranen-Orava test place maximal tension on the proximal hamstring origins. They are highly sensitive and specific clinical maneuvers for diagnosing proximal hamstring tendinopathy.

Question 17

Topic: General Sports & Tendon
Which of the following cellular changes is considered the histologic hallmark of chronic tendinopathy (e.g., tennis elbow or Achilles tendinopathy) rather than an acute inflammatory process?
. Dense infiltration of polymorphonuclear leukocytes
. Abundant type I collagen proliferation with highly organized fibril alignment
. Angiofibroblastic hyperplasia with disorganized type III collagen
. Presence of widespread ischemic necrosis and lipid pooling
. Hypertrophy of the synovial sheath with fibrinoid exudate

Correct Answer & Explanation

. Angiofibroblastic hyperplasia with disorganized type III collagen

Explanation

Chronic tendinopathy is characterized by angiofibroblastic hyperplasia (tendinosis), marked by disorganized collagen (primarily type III), hypercellularity of fibroblasts, and neovascularization, without a significant acute inflammatory infiltrate.

Question 18

Topic: General Sports & Tendon

During open surgical repair of a chronic proximal hamstring avulsion, careful retractor placement is required to protect the sciatic nerve. Anatomically, what is the normal relationship of the sciatic nerve to the ischial tuberosity?

. Medial and deep to the ischial tuberosity
. Approximately 1.2 cm lateral to the ischial tuberosity
. Directly posterior and superficial to the hamstring origin
. Anterior to the adductor magnus origin
. Inferior to the lesser trochanter

Correct Answer & Explanation

. Medial and deep to the ischial tuberosity

Explanation

The sciatic nerve typically exits the greater sciatic foramen and descends approximately 1.2 cm lateral to the lateral border of the ischial tuberosity. Retractors must be placed carefully on the lateral aspect of the tuberosity to avoid injury.

Question 19

Topic: General Sports & Tendon

When performing a surgical repair of a complete proximal hamstring rupture, understanding the anatomy of the ischial tuberosity origin is essential. Which muscle's tendon originates most laterally and anteriorly on the tuberosity?

. Long head of the biceps femoris
. Short head of the biceps femoris
. Semimembranosus
. Semitendinosus
. Adductor magnus

Correct Answer & Explanation

. Semimembranosus

Explanation

At the ischial tuberosity footprint, the semimembranosus tendon has a distinct lateral and anterior origin. The long head of the biceps femoris and semitendinosus form a conjoined tendon that originates more medially and posteriorly.

Question 20

Topic: General Sports & Tendon

A 38-year-old runner presents with deep buttock pain radiating down the posterior thigh, exacerbated by prolonged sitting and running. Physical examination reveals tenderness over the piriformis muscle, pain with passive internal rotation of the hip in flexion, and normal straight leg raise. Electromyography (EMG) and nerve conduction studies (NCS) are unremarkable. What is the MOST likely diagnosis?

. Lumbar disc herniation at L5-S1.
. Sacroiliac joint dysfunction.
. Proximal hamstring tendinopathy.
. Piriformis syndrome.
. Sciatic nerve tumor.

Correct Answer & Explanation

. Piriformis syndrome.

Explanation

The clinical presentation of deep buttock pain radiating down the posterior thigh, exacerbated by prolonged sitting and running, tenderness over the piriformis, and pain with passive internal rotation of the hip in flexion, with a normal straight leg raise and unremarkable EMG/NCS, is highly suggestive of piriformis syndrome. Piriformis syndrome is a diagnosis of exclusion, where the sciatic nerve is compressed or irritated by the piriformis muscle. Lumbar disc herniation would typically present with a positive straight leg raise and often abnormal EMG/NCS. Sacroiliac joint dysfunction usually has pain localized to the SI joint, possibly radiating, but not typically sciatic distribution and piriformis tenderness. Proximal hamstring tendinopathy would have tenderness more inferior and specific to hamstring origin, without the rotational findings. Sciatic nerve tumor is less likely given the normal EMG/NCS and typical mechanical pain.

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