This practice set contains high-yield board review questions covering key concepts in Knee Sports. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.
Question 1441
Topic: Knee Sports
The semimembranosus tendon has a complex insertion at the posteromedial corner of the knee, providing dynamic stabilization. Which of the following is NOT a recognized major insertion arm of the semimembranosus tendon?
Correct Answer & Explanation
. Arcuate ligament
Explanation
The semimembranosus tendon has five primary insertions: (1) direct insertion into the posteromedial tibia, (2) an anterior arm extending deep to the superficial MCL, (3) the oblique popliteal ligament extending laterally across the posterior joint capsule, (4) an inferior arm inserting down the popliteal fascia, and (5) a capsular arm. The arcuate ligament is a key structure of the posterolateral corner (PLC) of the knee and is not an extension of the semimembranosus.
Question 1442
Topic: Knee Sports
A 30-year-old male undergoes surgical reconstruction of the posterolateral corner (PLC) of the knee following a multiligamentous knee injury. To achieve anatomic reconstruction, the surgeon must identify the exact femoral footprint of the popliteus tendon. Which of the following describes the correct location of the popliteus tendon insertion relative to the lateral collateral ligament (LCL) femoral attachment?
Correct Answer & Explanation
. Distal and anterior
Explanation
On the lateral femoral condyle, the popliteus tendon inserts into the anterior portion of the popliteal sulcus. Anatomical studies consistently demonstrate that the femoral footprint of the popliteus tendon is situated distal and anterior (typically 18.5 mm anterior and distal) to the femoral origin of the lateral collateral ligament (LCL).
Question 1443
Topic: Knee Sports
Anatomic reconstruction of the posterolateral corner (PLC) of the knee requires precise placement of tunnels. What is the correct anatomical attachment of the fibular collateral ligament (LCL) on the lateral femoral condyle?
Correct Answer & Explanation
. Proximal and posterior to the lateral epicondyle
Explanation
The fibular collateral ligament (LCL) originates slightly proximal and posterior to the lateral femoral epicondyle. The popliteus tendon inserts into the popliteal sulcus, which is located anterior and distal to the LCL attachment. Recognizing this anatomy is critical to avoid non-anatomic graft placement during PLC reconstruction, which can lead to early failure.
Question 1444
Topic: Knee Sports
A 19-year-old female presents with recurrent patellar dislocations. Imaging shows a tibial tubercle-trochlear groove (TT-TG) distance of 14 mm and a normal Insall-Salvati ratio. An isolated medial patellofemoral ligament (MPFL) reconstruction is planned. What is the primary biomechanical consequence of placing the femoral tunnel for the MPFL graft significantly proximal to Schöttle's point?
Correct Answer & Explanation
. Increased graft tension in flexion, resulting in medial patellar overload and restriction of knee flexion
Explanation
The MPFL is the primary restraint to lateral patellar translation from 0 to 30 degrees of flexion. Proper femoral tunnel placement (Schöttle's point) is critical for graft isometry. If the femoral tunnel is placed too proximal, the distance between the patellar and femoral attachments increases as the knee flexes. This non-isometric placement causes the graft to become excessively tight in flexion, leading to medial patellofemoral cartilage overload, restricted range of motion (loss of flexion), and potentially iatrogenic medial patellar subluxation or increased risk of early osteoarthritis.
Question 1445
Topic: Knee Sports
A 55-year-old female presents with acute medial knee pain following a squatting maneuver. MRI reveals a complete radial tear directly adjacent to the posterior root attachment of the medial meniscus, with associated meniscal extrusion of 4 mm.
Which of the following best describes the biomechanical consequence of leaving this specific root injury unaddressed?
Correct Answer & Explanation
. It is biomechanically equivalent to a total medial meniscectomy, leading to substantially increased peak contact pressures
Explanation
The posterior roots of the menisci are critical for anchoring the meniscus and allowing it to convert axial joint loads into hoop stresses. A posterior medial meniscal root tear disrupts this structural continuity, resulting in meniscal extrusion and complete loss of hoop stress generation. Biomechanical studies have demonstrated that an unaddressed posterior medial meniscal root tear results in contact areas and peak contact pressures that are virtually indistinguishable from a total medial meniscectomy, rapidly leading to accelerated articular cartilage degeneration.
Question 1446
Topic: Knee Sports
A 14-year-old male gymnast with open physes presents with chronic right knee pain. MRI reveals a 2 x 2 cm osteochondritis dissecans (OCD) lesion on the lateral aspect of the medial femoral condyle.
The articular cartilage is intact, and there is no high T2 signal fluid behind the fragment, indicating a stable lesion. He has failed 6 months of strict non-operative management including restricted weight-bearing. What is the most appropriate next step in management?
Correct Answer & Explanation
. Arthroscopic transarticular extra-cartilaginous or trans-cartilaginous drilling
Explanation
For a stable juvenile osteochondritis dissecans (JOCD) lesion (intact articular cartilage, no fluid behind the fragment on MRI) that has failed a prolonged course (typically 3-6 months) of non-operative management, arthroscopic drilling is the treatment of choice. Drilling penetrates the sclerotic margin of the lesion to promote vascular ingrowth and healing of the osteochondral fragment. Restorative procedures like OATS or ACI are reserved for unstable lesions, unsalvageable fragments, or large full-thickness defects.
Question 1447
Topic: Knee Sports
A 26-year-old man sustains a dashboard injury resulting in an isolated posterior cruciate ligament (PCL) tear. Following failure of non-operative management, a single-bundle PCL reconstruction is planned. To accurately reproduce the biomechanics of the primary restraint to posterior tibial translation at 90 degrees of flexion, the graft should be placed to reconstruct which specific bundle, and where is its native femoral footprint located?
Correct Answer & Explanation
. Anterolateral bundle; located shallow (anterior) and superior (proximal) on the lateral aspect of the medial femoral condyle
Explanation
The PCL consists of two main bundles: the larger anterolateral (AL) bundle and the smaller posteromedial (PM) bundle. The AL bundle is tight in flexion (the primary restraint to posterior translation at 90 degrees) and is the bundle reconstructed in a single-bundle PCL reconstruction. Its native femoral footprint is located on the lateral aspect of the medial femoral condyle. Specifically, it is positioned shallow (anterior in the notch) and superior (proximal, near the notch roof) relative to the articular margin.
Question 1448
Topic: Knee Sports
During an anatomic single-bundle anterior cruciate ligament (ACL) reconstruction, the femoral tunnel is drilled through the accessory anteromedial portal. Compared to traditional drilling through a transtibial portal, what is the primary biomechanical advantage of this technique?
Correct Answer & Explanation
. Better restoration of rotational stability (pivot shift)
Explanation
Anatomic ACL femoral tunnel placement (drilled lower on the lateral notch wall into the native footprint) better restores rotational stability and resists the pivot shift compared to the traditional high, vertical placement often achieved with the transtibial technique. The more horizontal graft orientation obtained via the anteromedial portal significantly improves rotational control.
Question 1449
Topic: Knee Sports
A 25-year-old male sustains a multiligament knee injury. Examination reveals a grade 3 posterior sag and grade 3 varus opening in full extension and at 30 degrees of flexion. The dial test shows increased external rotation at 30 degrees but is symmetric at 90 degrees. He is planned for PCL and posterolateral corner (PLC) reconstruction.
What anatomic structure of the PLC is the primary restraint to varus gapping at 30 degrees of knee flexion?
Correct Answer & Explanation
. Fibular collateral ligament (LCL)
Explanation
The fibular collateral ligament (LCL) is the primary restraint to varus stress at 30 degrees of knee flexion. The popliteus tendon and the popliteofibular ligament act as the primary restraints to external rotation. In a complete PLC reconstruction, restoring the LCL is critical for coronal plane (varus) stability.
Question 1450
Topic: Knee Sports
A 19-year-old female is undergoing a medial patellofemoral ligament (MPFL) reconstruction for recurrent lateral patellar instability. Correct placement of the femoral tunnel is essential to avoid over-constraining the joint. Which of the following landmarks accurately describes the anatomic femoral footprint of the native MPFL?
Correct Answer & Explanation
. In the saddle-shaped depression between the medial epicondyle and the adductor tubercle
Explanation
The anatomic femoral footprint of the MPFL is located in the saddle-shaped depression between the adductor tubercle (proximal) and the medial epicondyle (distal). Non-anatomic placement, particularly too proximal and anterior, increases graft tension in flexion, leading to stiffness, graft failure, or elevated patellofemoral contact pressures.
Question 1451
Topic: Knee Sports
A 50-year-old female presents with acute-onset medial joint line pain and an effusion after squatting deeply. An MRI shows an extrusion of the medial meniscus on coronal views and an 'empty meniscus' or 'ghost sign' on a single sagittal cut. Figure 1
illustrates a similar pathology. Biomechanically, what is the direct consequence of this specific injury pattern if left untreated?
Correct Answer & Explanation
. Loss of meniscal hoop stresses equivalent to a total meniscectomy
Explanation
The scenario describes a posterior medial meniscal root tear. The 'ghost sign' on sagittal MRI is classic for this injury. The meniscal roots are critical for anchoring the meniscus and converting axial loads into circumferential 'hoop stresses.' A complete root tear abolishes these hoop stresses, leading to meniscal extrusion. Biomechanical studies have shown that a posterior medial meniscal root tear results in a loss of contact area and an increase in peak contact pressures equivalent to a total medial meniscectomy, predisposing the patient to rapid-onset osteoarthritis.
Question 1452
Topic: Knee Sports
A 24-year-old rugby player sustains a blow to the anteromedial aspect of his fully extended right knee. He complains of posterolateral knee pain, giving way, and difficulty descending stairs. On examination, the dial test reveals 20 degrees of increased external rotation compared to the contralateral normal knee at 30 degrees of flexion, but symmetrical external rotation at 90 degrees of flexion. Based on these physical examination findings, which of the following injury patterns is most likely present?
Correct Answer & Explanation
. Isolated posterolateral corner (PLC) injury
Explanation
The dial test (tibial external rotation test) evaluates the integrity of the posterolateral corner (PLC) and the posterior cruciate ligament (PCL). Increased external rotation of greater than 10 degrees (compared with the normal side) at 30 degrees of knee flexion, but NOT at 90 degrees of flexion, is indicative of an isolated posterolateral corner (PLC) injury. Increased external rotation at both 30 and 90 degrees of flexion indicates a combined PCL and PLC injury.
Question 1453
Topic: Knee Sports
A 16-year-old female gymnast presents with a history of recurrent lateral patellar dislocations. She is indicated for a medial patellofemoral ligament (MPFL) reconstruction. To ensure proper isometry of the graft, the femoral tunnel must be placed at 'Schöttle's point'. Which of the following best describes the anatomic location of the MPFL origin on the femur?
Correct Answer & Explanation
. Between the medial epicondyle and adductor tubercle
Explanation
The medial patellofemoral ligament (MPFL) provides 50-60% of the restraining force against lateral patellar displacement from 0 to 30 degrees of knee flexion. Its anatomic femoral origin is located in a 'saddle' region situated between the medial epicondyle and the adductor tubercle. Non-anatomic placement of the femoral tunnel during reconstruction (most commonly placed too anterior or too proximal) leads to anisometry, causing increased patellofemoral pressures, graft stretching, or a block to flexion.
Question 1454
Topic: Knee Sports
A 23-year-old male underwent an anterior cruciate ligament (ACL) reconstruction using a bone-patellar tendon-bone autograft 6 months ago. He has aggressively participated in physical therapy but continues to complain of a painful mechanical block to terminal extension, lacking 10 degrees compared to the uninjured side. Figure 11
displays a sagittal MRI of his knee. What is the most likely diagnosis?
The clinical presentation of a mechanical block to extension along with pain at terminal extension following ACL reconstruction is highly suspicious for a Cyclops lesion. This is a focal, nodular area of anterior arthrofibrosis that forms anterior to the ACL graft, physically blocking extension. It occurs in 1-10% of ACL reconstructions. Although an excessively anterior tibial tunnel can cause roof impingement and a block to extension, the discrete nodule visualized on MRI (often hyperintense on T2 anterior to the graft) defines a Cyclops lesion. Treatment consists of arthroscopic excision.
Question 1455
Topic: Knee Sports
A 52-year-old female undergoes an MRI of the knee for posterior knee pain after a deep squat. The MRI demonstrates a complete radial tear at the posterior root attachment of the medial meniscus. If left untreated, this specific injury pattern alters the joint biomechanics most similarly to which of the following scenarios?
Correct Answer & Explanation
. Total medial meniscectomy
Explanation
A medial meniscus posterior root tear results in a complete loss of circumferential hoop stresses, often leading to meniscal extrusion. Biomechanically, this loss of function decreases the tibiofemoral contact area and significantly increases peak contact pressures to levels that are equivalent to a total medial meniscectomy, leading to rapid development of osteoarthritis.
Question 1456
Topic: Knee Sports
A 16-year-old gymnast requires medial patellofemoral ligament (MPFL) reconstruction for recurrent instability. Intraoperative fluoroscopy is used to identify Schöttle's point for the femoral tunnel. Which of the following describes the correct fluoroscopic location of this point on a strictly lateral radiograph?
Correct Answer & Explanation
. 1 mm anterior to the posterior femoral cortical line and just proximal to the posterior extension of Blumensaat's line
Explanation
Schöttle's point is a reliable radiographic landmark used to identify the anatomic femoral origin of the MPFL. On a true lateral radiograph, it is located 1 mm anterior to the posterior cortical extension line, 2.5 mm distal to the posterior border of the medial femoral condyle articular surface, and strictly proximal to the level of the posterior aspect of Blumensaat's line.
Question 1457
Topic: Knee Sports
A 13-year-old male presents with vague anterior knee pain and occasional catching. Radiographs reveal a lesion consistent with osteochondritis dissecans (OCD) in the most classic location within the knee. Which of the following best describes this anatomical location?
Correct Answer & Explanation
. Lateral aspect of the medial femoral condyle
Explanation
The classic and most common location for an osteochondritis dissecans (OCD) lesion in the knee is the lateral aspect of the medial femoral condyle, which accounts for approximately 70% to 80% of all cases. This is best visualized on a notch (tunnel) view radiograph.
Question 1458
Topic: Knee Sports
A 22-year-old collegiate soccer player sustains a twisting knee injury. MRI demonstrates a complete anterior cruciate ligament (ACL) tear and a medial meniscus posterior root tear.
Biomechanically, an unrepaired medial meniscus posterior root tear alters knee joint kinematics in a manner most similar to which of the following?
Correct Answer & Explanation
. A total medial meniscectomy
Explanation
Medial meniscus posterior root tears result in the loss of hoop stresses, leading to medial compartment contact pressures and kinematics that are biomechanically equivalent to a total medial meniscectomy. Repair of the root (e.g., via a trans-tibial pull-out technique) is critical during ACL reconstruction to restore hoop stresses, prevent rapid progression of osteoarthritis, and protect the ACL graft from excessive anterior translation forces.
Question 1459
Topic: Knee Sports
A 28-year-old athlete presents with a hyperextension injury to the knee. On physical examination, the dial test is performed. There is 15 degrees of increased external rotation of the tibia relative to the uninjured contralateral side at 30 degrees of knee flexion. At 90 degrees of knee flexion, the external rotation is symmetric bilaterally. Which structure is most likely injured?
Correct Answer & Explanation
. Isolated posterolateral corner (PLC)
Explanation
The dial test assesses the integrity of the posterolateral corner (PLC) and the posterior cruciate ligament (PCL). Increased external rotation (>10 degrees compared to the normal side) at 30 degrees of flexion but symmetric rotation at 90 degrees indicates an isolated PLC injury. If external rotation is increased at both 30 and 90 degrees, it indicates a combined PCL and PLC injury.
Question 1460
Topic: Knee Sports
A 19-year-old female undergoes medial patellofemoral ligament (MPFL) reconstruction for recurrent patellar instability. To avoid non-anatomic graft placement that could result in excessive tension during knee flexion, the surgeon identifies the femoral footprint utilizing Schöttle's point. Anatomically, this footprint is located in relation to which of the following osseous landmarks?
Correct Answer & Explanation
. Distal to the adductor tubercle, proximal and posterior to the medial epicondyle
Explanation
The anatomic femoral origin of the MPFL lies in a saddle-like sulcus that is distal to the adductor tubercle, proximal and posterior to the medial epicondyle, and anterior to the gastrocnemius tubercle. Radiographically, Schöttle's point is 1 mm anterior to the posterior cortical line, 2.5 mm distal to the posterior articular border, and proximal to Blumensaat's line. Proper placement is essential; a graft placed too proximal or anterior will overtighten in flexion.
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