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Shoulder & Hip Sports MCQs

Practice Set 133 of 142

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

Question 2641

Topic: Shoulder & Hip Sports

A 25-year-old minor league pitcher is evaluated for a decline in throwing velocity and vague shoulder pain. Range of motion testing reveals 30 degrees of internal rotation and 120 degrees of external rotation in his throwing shoulder, compared to 60 degrees of internal rotation and 90 degrees of external rotation in his non-throwing shoulder. What is the most appropriate initial management for this condition?

. Arthroscopic SLAP repair
. Diagnostic arthroscopy with posterior capsular release
. Physical therapy focusing on posterior capsular 'sleeper' stretches
. Anterior capsulorrhaphy
. Subacromial corticosteroid injection

Correct Answer & Explanation

. Physical therapy focusing on posterior capsular 'sleeper' stretches

Explanation

The patient demonstrates Glenohumeral Internal Rotation Deficit (GIRD). The definition of pathologic GIRD is a loss of internal rotation (IR) that exceeds the gain in external rotation (ER), leading to an overall loss of total arc of motion compared to the contralateral side. In this case, the throwing shoulder has a total arc of 150 (30+120) compared to the normal 150 (60+90), which represents a symmetric shift in the arc of motion (adaptive GIRD), rather than pathologic. However, regardless of whether it is adaptive or early pathologic GIRD, the initial treatment is always conservative, centered on a posterior capsular stretching program ('sleeper stretches') to address the acquired posterior capsular contracture.

Question 2642

Topic: Shoulder & Hip Sports

A 55-year-old patient presents with acute anterior shoulder pain and weakness after a fall on an outstretched hand. On examination, the patient has a positive belly-press test and a positive bear-hug test. The 'lift-off' test cannot be performed due to restricted internal rotation. These examination findings indicate a tear of which structure?

. Supraspinatus tendon
. Infraspinatus tendon
. Subscapularis tendon
. Long head of the biceps tendon
. Teres minor tendon

Correct Answer & Explanation

. Subscapularis tendon

Explanation

The belly-press, bear-hug, and lift-off tests are all specific physical examination maneuvers designed to evaluate the integrity of the subscapularis tendon. The subscapularis is the primary internal rotator of the shoulder. The belly-press and bear-hug tests are particularly useful when the lift-off test cannot be performed because the patient lacks the necessary passive internal rotation to place their hand behind their lower back.

Question 2643

Topic: Shoulder & Hip Sports

A 45-year-old male presents with a 2-week history of severe, unremitting, burning right shoulder pain that woke him from sleep. The pain has recently subsided, but he now has profound weakness in overhead elevation and external rotation. He reports no preceding trauma. An MRI of the shoulder is unremarkable without evidence of rotator cuff tearing. EMG performed 4 weeks later shows acute denervation potentials isolated to the supraspinatus and infraspinatus muscles. What is the most likely diagnosis?

. Cervical spondylotic myelopathy
. Parsonage-Turner syndrome (Neuralgic amyotrophy)
. Suprascapular nerve entrapment at the spinoglenoid notch
. Quadrilateral space syndrome
. Thoracic outlet syndrome

Correct Answer & Explanation

. Parsonage-Turner syndrome (Neuralgic amyotrophy)

Explanation

Parsonage-Turner syndrome (acute brachial neuritis or neuralgic amyotrophy) is characterized by the sudden onset of severe, unremitting pain about the shoulder girdle (often waking the patient at night), followed by patchy muscle weakness and atrophy as the pain begins to subside. The suprascapular nerve (innervating the supraspinatus and infraspinatus) is commonly involved, mimicking a massive rotator cuff tear. The absence of trauma, normal shoulder MRI, and EMG findings confirm a neurogenic etiology. Suprascapular nerve entrapment at the spinoglenoid notch would typically present with isolated infraspinatus involvement without the antecedent severe, acute pain phase.

Question 2644

Topic: Shoulder & Hip Sports

A 28-year-old professional volleyball player presents with insidious onset of right shoulder weakness. Examination reveals isolated atrophy of the infraspinatus with preserved supraspinatus bulk. External rotation strength is 3/5. Which of the following is the most likely etiology?

. Suprascapular nerve entrapment at the suprascapular notch
. Quadrilateral space syndrome
. Paralabral cyst at the spinoglenoid notch
. Parsonage-Turner syndrome
. Subcoracoid impingement

Correct Answer & Explanation

. Paralabral cyst at the spinoglenoid notch

Explanation

Isolated infraspinatus atrophy implies compression of the suprascapular nerve distal to its innervation of the supraspinatus. This typically occurs at the spinoglenoid notch. In overhead athletes, this is frequently associated with posterior superior labral tears that act as a one-way valve, leading to a paralabral cyst that compresses the nerve in the spinoglenoid notch.

Question 2645

Topic: Shoulder & Hip Sports

A 30-year-old recreational weightlifter complains of vague posterior shoulder pain and weakness. An MRI reveals an isolated paralabral cyst in the quadrilateral space. Which muscle is most likely to demonstrate denervation changes on electromyography (EMG)?

. Infraspinatus
. Teres major
. Teres minor
. Supraspinatus
. Subscapularis

Correct Answer & Explanation

. Teres minor

Explanation

The quadrilateral space contains the axillary nerve and the posterior humeral circumflex artery. Compression here (Quadrilateral Space Syndrome) predominantly affects the axillary nerve branches, notably causing denervation and atrophy of the teres minor muscle, and sometimes the deltoid.

Question 2646

Topic: Shoulder & Hip Sports

A 35-year-old male suffers a seizure and presents with his shoulder locked in internal rotation. A CT scan confirms an irreducible posterior shoulder dislocation with a reverse Hill-Sachs lesion (anteromedial humeral head impaction) involving 35% of the articular surface. What is the most appropriate surgical management for this humeral head defect to prevent recurrent instability?

. Arthroscopic posterior Bankart repair
. Open reduction and transfer of the lesser tuberosity into the defect (modified McLaughlin procedure)
. Latarjet procedure
. Hemiarthroplasty
. Derotational proximal humeral osteotomy

Correct Answer & Explanation

. Open reduction and transfer of the lesser tuberosity into the defect (modified McLaughlin procedure)

Explanation

For a reverse Hill-Sachs lesion involving 20-40% of the articular surface, filling the defect is required to prevent it from engaging the posterior glenoid rim. The modified McLaughlin procedure (transfer of the lesser tuberosity with the attached subscapularis tendon into the defect) is the standard of care for defects of this size.

Question 2647

Topic: Shoulder & Hip Sports

A 30-year-old volleyball player presents with isolated weakness in external rotation of the shoulder. MRI reveals a paralabral cyst. Compression of the suprascapular nerve at the spinoglenoid notch will typically result in denervation of which of the following muscles?

. Supraspinatus only
. Supraspinatus and infraspinatus
. Teres minor only
. Infraspinatus only
. Deltoid and teres minor

Correct Answer & Explanation

. Infraspinatus only

Explanation

The suprascapular nerve innervates the supraspinatus before passing through the spinoglenoid notch. Therefore, a cyst at the spinoglenoid notch selectively compresses the distal nerve branch, causing isolated infraspinatus denervation.

Question 2648

Topic: Shoulder & Hip Sports

A 25-year-old male undergoes a Latarjet procedure for recurrent anterior shoulder instability. Postoperatively, he has profound weakness in elbow flexion and decreased sensation over the lateral forearm. Which nerve was most likely injured during coracoid retraction?

. Axillary nerve
. Radial nerve
. Musculocutaneous nerve
. Median nerve
. Suprascapular nerve

Correct Answer & Explanation

. Musculocutaneous nerve

Explanation

The musculocutaneous nerve typically enters the coracobrachialis 5 to 8 cm distal to the coracoid process. Vigorous medial retraction of the conjoined tendon during a Latarjet procedure places this nerve at high risk for neuropraxia.

Question 2649

Topic: Shoulder & Hip Sports

A 22-year-old rugby player has recurrent anterior shoulder instability. CT evaluation reveals anterior glenoid bone loss. The glenoid width measures 30 mm, and the anterior defect measures 6 mm. According to the glenoid track concept, what is the calculated width of this patient's glenoid track?

. 18.9 mm
. 24.9 mm
. 24.0 mm
. 30.0 mm
. 14.1 mm

Correct Answer & Explanation

. 18.9 mm

Explanation

The width of the glenoid track is calculated as 83% of the inferior glenoid diameter (D), minus the width of the anterior bone defect (d). Formula: Glenoid track = (0.83 * D) - d. Given D = 30 mm and d = 6 mm. First, 0.83 * 30 = 24.9 mm. Then, 24.9 - 6 = 18.9 mm. The glenoid track width is 18.9 mm.

Question 2650

Topic: Shoulder & Hip Sports

During a Latarjet procedure for anterior shoulder instability, the coracoid process is osteotomized and transferred to the anterior glenoid rim. Which nerve is at greatest risk of injury during the medial retraction of the conjoined tendon?

. Axillary nerve
. Suprascapular nerve
. Musculocutaneous nerve
. Median nerve
. Radial nerve

Correct Answer & Explanation

. Musculocutaneous nerve

Explanation

The musculocutaneous nerve typically enters the coracobrachialis muscle approximately 5 to 8 cm distal to the tip of the coracoid process (though this can be variable). Medial and aggressive retraction of the conjoined tendon during the Latarjet procedure places significant traction on this nerve, making it the most vulnerable structure during this specific step of the operation.

Question 2651

Topic: Shoulder & Hip Sports

A 31-year-old elite volleyball player presents with insidious onset of posterior shoulder pain and weakness. Physical examination demonstrates normal external rotation strength in adduction, but profound weakness in external rotation with the arm abducted. Muscle atrophy is noted exclusively in the infraspinatus fossa. Where is the most likely location of a paralabral cyst in this patient?

. Suprascapular notch
. Quadrilateral space
. Triangular interval
. Spinoglenoid notch
. Rotator interval

Correct Answer & Explanation

. Spinoglenoid notch

Explanation

Isolated atrophy and weakness of the infraspinatus indicate compression of the suprascapular nerve at the spinoglenoid notch. At this level, the nerve has already given off its motor branches to the supraspinatus (which occurs more proximally at the suprascapular notch). Spinoglenoid cysts are highly associated with posterior SLAP tears.

Question 2652

Topic: Shoulder & Hip Sports

A 65-year-old man presents with pseudoparalysis of the shoulder, an inability to actively externally rotate, and a positive hornblower's sign. Imaging reveals a massive, retracted, irreducible tear of the supraspinatus, infraspinatus, and teres minor. The subscapularis is fully intact. He wishes to undergo a tendon transfer. Which of the following tendon transfers is most appropriate for restoring his external rotation and forward elevation?

. Latissimus dorsi transfer
. Pectoralis major transfer
. Pectoralis minor transfer
. Conjoined tendon transfer
. Biceps rerouting

Correct Answer & Explanation

. Latissimus dorsi transfer

Explanation

Latissimus dorsi or lower trapezius tendon transfers are the preferred surgical options for younger, active patients with massive, irreparable posterosuperior rotator cuff tears (supraspinatus and infraspinatus/teres minor) who have an intact subscapularis. An intact subscapularis is a vital prerequisite for a successful latissimus dorsi transfer to provide an anterior counterforce (force couple) for overhead function. Pectoralis major transfers are used for irreparable subscapularis tears.

Question 2653

Topic: Shoulder & Hip Sports

During the physical examination of a patient with a suspected rotator cuff tear, you wish to isolate the function of the inferior (lower) portion of the subscapularis muscle. Which of the following provocative tests is most specific for assessing the lower subscapularis?

. Belly-press test
. Bear-hug test
. Lift-off test
. Jobe's empty can test
. Neer impingement sign

Correct Answer & Explanation

. Lift-off test

Explanation

The subscapularis has distinct functional zones. The superior portion is primarily tested by the belly-press and bear-hug tests. The lift-off test (Gerber's test) requires internal rotation behind the back, which biomechanically isolates the inferior (lower) portion of the subscapularis. An inability to lift the hand off the lumbar spine indicates a tear involving the lower subscapularis.

Question 2654

Topic: Shoulder & Hip Sports

A 24-year-old professional baseball pitcher complains of right shoulder pain during the late cocking phase of throwing. He exhibits a significant Glenohumeral Internal Rotation Deficit (GIRD). If diagnostic arthroscopy is performed for suspected internal impingement, what is the most characteristic pattern of pathology observed?

. Anterosuperior labral tear with subscapularis articular-sided fraying.
. Posterior Bankart lesion with a reverse Hill-Sachs defect.
. Posterosuperior labral fraying/tear and articular-sided tearing at the supraspinatus-infraspinatus junction.
. Anterior labral tear with bursal-sided supraspinatus tearing.
. Isolated superior labral tear anterior to posterior (SLAP) with a normal rotator cuff.

Correct Answer & Explanation

. Posterosuperior labral fraying/tear and articular-sided tearing at the supraspinatus-infraspinatus junction.

Explanation

Internal impingement in overhead throwing athletes occurs during the late cocking phase (abduction and maximum external rotation). In this position, the articular surface of the posterosuperior rotator cuff (supraspinatus/infraspinatus interval) abuts against the posterosuperior glenoid labrum. This pathologic contact leads to 'kissing lesions': articular-sided cuff tears and posterosuperior labral tears.

Question 2655

Topic: Shoulder & Hip Sports

In the surgical evaluation for a Superior Capsular Reconstruction (SCR) in a patient with a massive, irreparable posterosuperior rotator cuff tear, which of the following preoperative findings is considered an absolute contraindication to the procedure?

. An intact subscapularis tendon
. Hamada grade 4 glenohumeral osteoarthritis
. Goutallier grade 2 fatty infiltration of the infraspinatus
. Patient age greater than 60 years
. A combined tear involving the supraspinatus and entire infraspinatus

Correct Answer & Explanation

. Hamada grade 4 glenohumeral osteoarthritis

Explanation

Superior Capsular Reconstruction (SCR) is indicated for massive, irreparable posterosuperior rotator cuff tears in patients without advanced arthritis. Advanced glenohumeral osteoarthritis (Hamada grade 4 or 5) is an absolute contraindication to SCR; these patients are better served with a reverse total shoulder arthroplasty (rTSA). An intact subscapularis is actually preferred for SCR success.

Question 2656

Topic: Shoulder & Hip Sports

During a Latarjet procedure, the coracoid bone block is secured to the anterior glenoid neck with two screws. If the screws are directed too far medially (e.g., greater than 15 degrees medial to the glenoid articular surface), which neurologic structure is at the greatest risk of iatrogenic injury from the prominent screw tips posteriorly?

. Axillary nerve
. Musculocutaneous nerve
. Suprascapular nerve
. Subscapular nerve
. Radial nerve

Correct Answer & Explanation

. Suprascapular nerve

Explanation

Screws directed excessively medial during a Latarjet procedure can breach the posterior glenoid neck and enter the spinoglenoid notch. The suprascapular nerve courses through this notch to innervate the infraspinatus and is at high risk of injury from prominent or misdirected hardware.

Question 2657

Topic: Shoulder & Hip Sports

A 45-year-old male presents with severe, unremitting right shoulder pain that awoke him from sleep. The acute pain subsided after two weeks, but he now has profound weakness in forward elevation and external rotation. If an MRI is obtained, what is the most likely finding?

. Massive full-thickness tear of the supraspinatus and infraspinatus with acute retraction
. Increased T2 signal (denervation edema) in the supraspinatus and infraspinatus muscle bellies without tendon disruption
. An isolated paralabral cyst in the spinoglenoid notch causing nerve compression
. Severe fatty infiltration (Goutallier Grade 4) of the subscapularis
. Thickening and hyperintensity of the coracohumeral ligament characteristic of adhesive capsulitis

Correct Answer & Explanation

. Increased T2 signal (denervation edema) in the supraspinatus and infraspinatus muscle bellies without tendon disruption

Explanation

The clinical presentation is classic for Parsonage-Turner Syndrome (neuralgic amyotrophy / acute brachial neuritis). Following the acute painful phase, patients develop profound weakness. MRI typically reveals denervation edema (increased T2 signal) in the affected muscles (commonly supraspinatus, infraspinatus, or deltoid) with structurally intact rotator cuff tendons.

Question 2658

Topic: Shoulder & Hip Sports

In the surgical management of anterior shoulder instability, a 'remplissage' procedure involves tenodesis of the infraspinatus tendon and posterior capsule into a humeral head defect. Which of the following is the most appropriate indication for performing a remplissage in conjunction with an arthroscopic Bankart repair?

. Subcritical glenoid bone loss (<15%) with an off-track (engaging) Hill-Sachs lesion
. Critical glenoid bone loss (>25%) regardless of the Hill-Sachs lesion size
. An on-track Hill-Sachs lesion with an intact anterior capsule
. Concomitant HAGL (humeral avulsion of the glenohumeral ligament) lesion
. Revision setting after a failed open Latarjet procedure

Correct Answer & Explanation

. Subcritical glenoid bone loss (<15%) with an off-track (engaging) Hill-Sachs lesion

Explanation

A remplissage is indicated to address an 'off-track' (engaging) Hill-Sachs lesion in the setting of subcritical glenoid bone loss. If critical glenoid bone loss (>20-25%) is present, a bony augmentation procedure (e.g., Latarjet) is required regardless of the Hill-Sachs lesion.

Question 2659

Topic: Shoulder & Hip Sports

A 24-year-old rugby player undergoes a Latarjet procedure. Postoperatively, he has weakness in elbow flexion and decreased sensation over the lateral forearm. Improper retractor placement under which of the following structures is the most likely cause of this complication?

. Coracoacromial ligament
. Conjoint tendon
. Pectoralis minor
. Subscapularis
. Long head of the biceps

Correct Answer & Explanation

. Conjoint tendon

Explanation

The musculocutaneous nerve typically enters the conjoint tendon (coracobrachialis) 3-8 cm distal to the coracoid tip. Retractors placed too medially, deeply, or forcefully under the conjoint tendon during the Latarjet procedure can cause neuropraxia of the musculocutaneous nerve, leading to biceps weakness and lateral antebrachial cutaneous nerve sensory deficits.

Question 2660

Topic: Shoulder & Hip Sports

A 62-year-old male laborer presents with profound weakness in shoulder external rotation and a positive Hornblower's sign. MRI reveals a massive, retracted, and irreparable tear of the supraspinatus, infraspinatus, and teres minor. The subscapularis is intact. Which of the following tendon transfers provides the most biomechanically advantageous line of pull to restore external rotation?

. Pectoralis major transfer
. Latissimus dorsi transfer
. Lower trapezius transfer
. Rhomboid major transfer
. Pectoralis minor transfer

Correct Answer & Explanation

. Lower trapezius transfer

Explanation

For irreparable posterosuperior rotator cuff tears with profound external rotation weakness (infraspinatus/teres minor deficit), the lower trapezius transfer (often augmented with an Achilles tendon allograft) closely matches the physiological line of pull of the infraspinatus. This makes it biomechanically superior to the latissimus dorsi transfer, which has an inferior-to-superior vector.

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