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Shoulder & Hip Sports MCQs

Practice Set 20 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 381

Topic: Shoulder & Hip Sports

.A patient is unable to actively externally rotate the shoulder when the arm is placed into 90 degrees of abduction and neutral rotation. This finding is most consistent with a tear of the

. biceps tendon.
. isolated subscapularis.
. isolated supraspinatus.
. superior and anterior labrum.
. infraspinatus and teres minor.

Correct Answer & Explanation

. biceps tendon.

Explanation

Question 382

Topic: Shoulder & Hip Sports

Figure 1 is the T2 axial MRI scan of a 21-year-old man who was injured while playing for his college football team. His pain was aggravated with blocking maneuvers and alleviated with rest, and he had to stop playing because of the pain. What examination maneuver most likely will reproduce his pain?

. Forward elevation in the scapular plane
. External rotation and abduction
. Flexion, adduction, and internal rotation
. Flexion and abduction

Correct Answer & Explanation

. Forward elevation in the scapular plane

Explanation

This patient has a mechanism of injury and MRI scan consistent with a posterior labral tear and posterior instability. Flexion, adduction, and internal rotation produce a net posterior vector on the glenohumeral joint and should reproduce this patient's symptoms. Pain or instability with the arm elevated in the scapular plane describes an impingement sign. Pain or instability with the arm in external rotation and abduction describes the apprehension sign. Pain or instability with the arm in flexion and abduction is anonspecific finding.

Question 383

Topic: Shoulder & Hip Sports

A 41-year-old male truck driver fell off his truck and tried to break his fall by holding on to the side of the door with his left arm. His MRI is depicted in Figures A. Which of the following special tests would most likely be positive on physical examination? Review Topic

. Empty can test
. Hornblower's test
. Belly press test
. External rotation lag sign
. Relocation test

Correct Answer & Explanation

. Empty can test

Explanation

Based on this patient's MRI he has sustained a full-thickness tear of his subscapularis tendon. As a result, he will likely have a positive belly press test on physical exam.While the subscapularis is the largest of the rotator cuff muscles, the relativeprevalence of injuries to the subscapularis tendon has only recently been recognized. The primary function of the subscapularis is to internally rotate the humerus. Patients with such injury often present with anterior shoulder pain, and increased external rotation compared to the contralateral limb. It is often associated with medial subluxation of the long head of biceps. A number of special tests have been developed to help aid in the clinical diagnosis of this injury including the belly press, lift off and bear hug tests.Gerber et al. demonstrated the efficacy of a simple clinical maneuver called the โ€˜lift-off testโ€™ to reliably diagnose or exclude clinically relevant rupture of the subscapularis tendon in 16 patients.Barth et al. evaluated the diagnostic value of three clinical tests commonly used to diagnose subscapularis tendon tears; the lift-off test, belly-press test, and bear-hug test. They found that the lift-off test was the most difficult for patients to perform. However, when it was performed and found to be positive, it was 74% sensitive of very severe tears. They also found that the bear hug test was the most sensitive of all tests (82%).Figures A shows an axial MRI arthrogram showing a subscapularis tear with dislocation of the biceps tendon. Illustration A demonstrates how to perform the bear hug test.Incorrect Answers:

Question 384

Topic: Shoulder & Hip Sports

An active 68-year-old woman undergoes an uncomplicated rotator cuff repair with a double-row construct using biocomposite knotless anchors. At her two month follow up, she is noted to have increased shoulder pain, weakness and limited motion. Imaging reveals failure of the rotator cuff repair. What is the most likely mechanism of failure? Review Topic

. Anchor fatigue and breakage
. Anchor pull out from bone
. Suture rupture secondary to anchor eyelet abrasion
. Suture pull out from the repaired tissue
. Infection

Correct Answer & Explanation

. Anchor fatigue and breakage

Explanation

Rotator cuff repair (RCR) failure most commonly occurs from a failure of the repaired tissue to heal with suture anchor pull out from the repaired tissue.The overall complication rate of arthroscopic RCR is roughly 10%. Failed RCR most commonly results from failure to heal (19-94%) secondary to poor rotator cuff tissue, insufficient vascularity or poor bone quality. Other causes of RCR failure include surgical complications (deltoid disruption, infection, foreign body reaction, stiffness, neurologic injury), diagnostic errors (missed lesions of the rotator interval, long head of biceps or subscapularis tear), and technical errors (excessive tension due to lack of proper tissue mobilization, anchor pull out secondary to improper anchor placement).George et al evaluated the causes of failed RCR and results of revision RCR. While results of revision RCR are inferior to primary RCR, arthroscopic repair yields > 60% good or excellent results. Risk factors for poor results following revision RCR include poor tissue quality, detachment of the deltoid origin and multiple previous surgeries.Diduch et al reviewed the design and composition of various anchors used in arthroscopic shoulder surgery. Current advancements in the field include high-strength polyethylene sutures, new biocompatible anchor materials (PEEK, biocomposite) and modified designs including knotless systems. With improved strength of the current anchors and repair constructs, the most common mode of arthroscopic RCR failure is now related to tissue failure occurring at the tissue-anchor interface.Cole et al discussed the different primary rotator cuff repair constructs, including single row, double row, transosseous and transosseous equivalent. The authors concluded that construct selection depends on tear acuity, size and tissue quality. For acute tears < 12mm in anteroposterior length, single-row configuration likely has sufficient strength to maintain the repair and promote healing. For more chronic tears, poor tissue quality, or tears > 12-15mm in the anteroposterior dimension, the authors recommend double-row or transosseous-equivalent repair to better restore the anatomic footprint and provide optimal mechanical stability to achieve healing.Illustration A is an algorithm from George et al detailing the decision-making process when considering revision RCR for a symptomatic failed RCR.Incorrect Responses

Question 385

Topic: Shoulder & Hip Sports
A 15-year-old wrestler sustains an abduction, hyperextension, and external rotation injury to his right shoulder. The MRI scan findings shown in Figures 27a and 27b are most consistent with
. an avulsion of the lesser tuberosity.
. a midsubstance tear of the capsule.
. a tear of the anterior inferior labrum.
. a tear of the subscapularis.
. a tear of the humeral insertion of the inferior glenohumeral ligament.

Correct Answer & Explanation

. a tear of the humeral insertion of the inferior glenohumeral ligament.

Explanation

DISCUSSION: An isolated avulsion of the lesser tuberosity occurs very rarely and usually is found in 12- and 13-year-old adolescents. The MRI scans reveal a tear of the humeral attachment of the inferior glenohumeral ligament, a so-called HAGL lesion. This injury to the inferior glenohumeral ligament occurs much less commonly than the classic Bankart lesion (anterior inferior labral tear). A tear of the subscapularis occurs with a similar mechanism of injury but generally occurs in older individuals. REFERENCES: Bokor DJ, Conboy VB, Olson C: Anterior instability of the glenohumeral joint with humeral avulsion of the glenohumeral ligament: A review of 41 cases. J Bone Joint Surg Br 1999;81:93-96. Wolf EM, Cheng JC, Dickson K: Humeral avulsion of the inferior glenohumeral ligaments as a cause of anterior shoulder instability. Arthroscopy 1995;11:600-607.

Question 386

Topic: Shoulder & Hip Sports
Figures 26a through 26c show the MRI scans of a 47-year-old man who underwent arthroscopic shoulder surgery 6 months ago and continues to have pain despite a prolonged course of rehabilitation. Management should now consist of
. rotator cuff repair.
. revision acromioplasty.
. fragment excision.
. open reduction and internal fixation.
. continued rehabilitation.

Correct Answer & Explanation

. open reduction and internal fixation.

Explanation

The MRI scans show an os acromiale of the mesoacromion type. This represents an unfused acromial apophysis. Pain is thought to be caused by either motion at the site or downward displacement of the anterior aspect of the acromion onto the rotator cuff, causing impingement. Most patients can be treated nonsurgically as they are usually asymptomatic. In those patients with persistent symptoms of pain and tenderness over the acromion, surgery consisting of rigid internal fixation and bone grafting has yielded satisfactory results. Excision may be a viable treatment option for the preacromion type.

Question 387

Topic: Shoulder & Hip Sports
Based on the injury shown on the axial MRI scan of the shoulder in Figure 1, what other pathology should be closely examined for during surgery?
. Subscapularis tear
. Supraspinatus tear
. Superior labral anterior-posterior (SLAP) tear
. Bankart tear

Correct Answer & Explanation

. Subscapularis tear

Explanation

The axial MRI scan reveals a subluxated biceps tendon. In the study by Koh and associates, 85% of patients with a biceps subluxation on MRI were found to have a subscapularis tear at the time of arthroscopy. These are not always obvious on the MRI, and close inspection of the leading edge/upper border of the subscapularis tendon at the time of arthroscopy is necessary.

Question 388

Topic: Shoulder & Hip Sports
A 52-year-old man has had right shoulder pain in the deltoid region that increases at night for the past 2 months. He denies any history of trauma. Examination reveals mild tenderness over the greater tuberosity, and the Neer and Hawkins impingement signs are positive. AP and outlet lateral radiographs are shown in Figures 24a and 24b. Initial management should consist of
. a program of stretching exercises and rotator cuff strengthening exercises.
. a series of six cortisone injections.
. arthroscopic acromioplasty.
. arthroscopic acromioplasty and laser capsulorrhaphy.
. open acromioplasty.

Correct Answer & Explanation

. a program of stretching exercises and rotator cuff strengthening exercises.

Explanation

The patient has the findings of classic subacromial impingement. Initial management should consist of stretching exercises directed at the posterior capsule and a program of rotator cuff and deltoid strengthening exercises performed below the horizontal in a โ€œsafeโ€ plane. The judicious use of subacromial cortisone injections (one or two) may be helpful. Anterior acromioplasty is reserved for patients who have failed to respond to nonsurgical management.

Question 389

Topic: Shoulder & Hip Sports

Which of the following patients has the highest risk of developing recurrent instability after an arthroscopic Bankart procedure for anterior shoulder instability? Review Topic

. year old female, recreational soccer player with ligamentous laxity and an x-ray showing a Hill-Sachs lesion and loss of glenoid contour
. year old male, who plays hockey recreationally with no laxity and an x-ray showing a loss of glenoid contour
. year old female, competitive tennis player with no laxity and x-ray findings of a Hill-Sachs lesion and loss of glenoid contour
. year old male, recreational basketball player with ligamentous laxity and x-ray findings of a Hill-Sachs lesion
. year old male, competitive football player with no laxity and no abnormal x-ray findings.

Correct Answer & Explanation

. year old female, recreational soccer player with ligamentous laxity and an x-ray showing a Hill-Sachs lesion and loss of glenoid contour

Explanation

The 18-year old competitive tennis player with no ligamentous laxity and x-ray findings consistent with a Hill-Sachs lesion and loss of glenoid contour has an instability severity index score (ISIS) of 9, which is associated with a >70% chance of recurrent instability after a arthroscopic Bankart procedure.The surgical management of anterior shoulder instability consists of both arthroscopic and open approaches. The guiding principles for treatment are the restoration of the normal glenoid labrum anatomy and retensioning of the inferior glenohumeral ligament which is achieved via soft-tissue reconstructions (repair of any labral detachment +/- capsular shift) or bony procedures (such as transfer of the coracoid process).Ahmed et al. reviewed 302 patients who had undergone arthroscopic Bankart repair and capsular shift for the treatment of recurrent anterior glenohumeral instability. The prevalence of patient and injury-related risk factors for recurrence was assessed. The rate of recurrent glenohumeral instability after arthroscopic Bankart repair and capsular shift was 13.2%. The risk of recurrence was independently predicted by the patientโ€™s age at surgery, the severity of glenoid bone loss, and the presence of an engaging Hill-Sachs lesion.Balg et al. identified risk factors for recurrent instability after arthroscopic Bankart procedure in 131 consecutive patients. Age under 20 years at the time of surgery; involvement in competitive or contact sports or those involving forced overhead activity; shoulder hyperlaxity; a Hill-Sachs lesion present on an AP radiograph of the shoulder in external rotation and/or loss of the sclerotic inferior glenoid contour were all identified as risk factors. These factors were integrated into a 10-point preoperative instability severity index score (ISIS). Patients with a score over 6 points had an unacceptable recurrence risk of 70%.Illustration A summarizes the components of the ISIS as developed by Balg and Boileau.Incorrect Answers:

Question 390

Topic: Shoulder & Hip Sports
A 21-year-old patient has had pain and a marked decrease in active and passive shoulder motion after having had a seizure 2 months ago as the result of alcohol abuse. Current AP and axillary radiographs and a CT scan are shown in Figures 26a through 26c. Management should consist of:
. closed reduction under sedation.
. total shoulder arthroplasty.
. open reduction and subscapularis and lesser tuberosity transfer.
. open reduction and disimpaction with bone grafting.
. hemiarthroplasty with the humeral component placed in less than 20 degrees of retroversion.

Correct Answer & Explanation

. open reduction and subscapularis and lesser tuberosity transfer.

Explanation

Open reduction and subscapularis and lesser tuberosity transfer into the defect is the treatment of choice in young individuals who have defects that involve between 20% to 45% of the head. Disimpaction and bone grafting is an option in injuries that are less than 3 weeks old. Closed reduction 2 to 3 months after injury usually is unsuccessful and increases the risk of fracture or neurovascular injury. Total shoulder arthroplasty is reserved for defects of greater than 50% or with associated glenoid surface damage. Hemiarthroplasty should be avoided in young individuals unless 50% or more of the head is involved.

Question 391

Topic: Shoulder & Hip Sports

What procedure can eliminate a sulcus sign? Review Topic

. Rotator interval closure
. SLAP repair
. Bankart repair
. Supraspinatus repair
. Subacromial decompression

Correct Answer & Explanation

. Rotator interval closure

Explanation

A sulcus sign represents inferior subluxation of the shoulder. The elimination of this sign and correction of the inferior subluxation is best achieved through either an open or arthroscopic rotator interval closure. A SLAP repair stabilizes the biceps anchor but does not affect the sulcus sign. A Bankart repair, which corrects anterior-inferior laxity, is not sufficient to eliminate a sulcus sign. Subacromial decompression and supraspinatus repairs have no effect on inferior subluxation.

Question 392

Topic: Shoulder & Hip Sports

Figure 1 is the radiograph of a 21-year-old college lacrosse player who has a 2-year history of progressive left groin pain that is exacerbated by activity. Pain is preventing him from participating with his team. Examination reveals a fit man without tenderness to palpation around the hip. No clicking or popping occurs with hip range of motion. Strength of all muscles about the hip is normal, but there is some mild pain with resisted hip flexion and hip adduction. While lying supine, progressive hip flexion with internal rotation and adduction reproduces his groin pain. The patient participates in physical therapy for 8 weeks with his team's trainer but notes little improvement. What is the most appropriate next diagnostic step to determine the cause of his pain?

. Diagnostic arthroscopy of the hip
. Hip bone scan
. Hip MRI arthrogram
. Hip ultrasonography

Correct Answer & Explanation

. Hip MRI arthrogram

Explanation

This clinical scenario describes a patient with FAI attributable to pincer (acetabular) deformity. This form of FAI, which involves prominence of the anterosuperior acetabular lip, may be more common among women. Decreased range of motion and pain occur secondary to the abutment of the femoral head against the acetabular labrum and rim. Hip flexion, combined with adduction and internal rotation, recreates this contact and causes pain, but CAM or pincer etiology remains unknown. The differential diagnosis of hip pain in a young athlete includes femoral neck stress reaction/fracture, sacroiliac arthritis, intra-articular loose body, trochanteric bursitis, osteitis pubis, and hernia. No information presented in this scenario suggests any of these causes. Diagnosis of FAI is best performed via MR imaging, with an arthrogram increasing the sensitivity and specificity for labral pathology. Ultrasonography may be useful in the diagnosis of dysplasia or for dynamic assessment of a snapping hip, but ultrasonography is not commonlyused to diagnose labral pathology. Although concomitant chondral lesions of the femoral head are uncommon, the forced leverage of the anterosuperior femoral neck upon the anterior acetabulum may result in a โ€œcontra-coupโ€ chondral injury on the posteroinferior acetabulum. This is the most common location of chondral lesions in this scenario. Without bony resection to prevent further impingement, this patient will continue to experience symptoms. Because there is no evidence of femoral neck prominence (CAM lesion), there is no indication for osteoplasty of the femoral neck; resection of the pincer lesion is necessary. This will often require take-down of the labrum in this location. If possible, iatrogenic or traumatic labral tears should subsequently be repaired after pincer debridement because the labrum hasimportant functions for hip stability and maintenance of the suction seal of the joint.

Question 393

Topic: Shoulder & Hip Sports
A 23-year-old man reports a 6-year history of recurrent instability in the right dominant shoulder. He has not undergone surgery and has essentially stopped all of his sporting activities. On examination, he has instability and apprehension in the midrange of motion (abduction of 45 to 60 degrees with external rotation) and a palpable clunk representing a transient dislocation over the anterior glenoid rim. A three-dimensional CT scan is shown in Figure 31. What is the most appropriate surgical intervention to provide him with reliable stability postoperatively?
. Arthroscopic Bankart surgery
. Bony glenoid augmentation procedure
. Subscapularis advancement
. Open capsular shift
. Hemiarthroplasty

Correct Answer & Explanation

. Bony glenoid augmentation procedure

Explanation

DISCUSSION: In the setting of significant anteroinferior glenoid bone deficiency (greater than 20% to 25%), both open and arthroscopic Bankart repairs have demonstrated higher rates of failure. Bony glenoid augmentation procedures such as the Bristow-Latarjet, which describe coracoid transfers to reconstruct the deficient glenoid, have led to decreased rates of recurrent shoulder instability. In this scenario, the patient has a significant loss of glenoid bone. There are also several clues in the history to suspect bone deficiency: multiple recurrences, a long history of recurrence, and instability in the midranges of motion. A bony augmentation procedure such as the Latarjet has been well-described to provide a well functioning and stable shoulder joint.

Question 394

Topic: Shoulder & Hip Sports

In evaluating a patient for femoroacetabular impingement (FAI), a true AP pelvis radiograph demonstrates the projection of the anterior acetabular wall crossing the posterior acetabular wall. This 'crossover sign' is most strongly indicative of which of the following pathomorphologies?

. Cam impingement
. Focal cranial acetabular retroversion
. Global acetabular retroversion
. Coxa profunda
. Protrusio acetabuli

Correct Answer & Explanation

. Focal cranial acetabular retroversion

Explanation

The 'crossover sign' is a key radiographic marker seen on an AP pelvis radiograph where the line of the anterior acetabular rim crosses the line of the posterior acetabular rim. It specifically indicates focal cranial (or anterior) acetabular retroversion, which is a common cause of pincer-type femoroacetabular impingement. Global retroversion would also typically show an abnormal prominent ischial spine sign.

Question 395

Topic: Shoulder & Hip Sports

In the evaluation of a 22-year-old athlete with suspected femoroacetabular impingement (FAI), a cross-table lateral radiograph of the hip demonstrates an alpha angle of 65 degrees. Where is the cam morphology most likely located based on this specific view?

. Anterosuperior head-neck junction
. Posteroinferior head-neck junction
. Direct superior head-neck junction
. Anteroinferior head-neck junction
. Fovea capitis

Correct Answer & Explanation

. Anterosuperior head-neck junction

Explanation

The cross-table lateral radiograph best profiles the anterosuperior aspect of the femoral head-neck junction, which is the most common location for cam lesions in FAI.

Question 396

Topic: Shoulder & Hip Sports

A 25-year-old professional hockey player presents with groin pain exacerbated by hip flexion and internal rotation. Imaging reveals a prominent osseous bump at the anterolateral femoral head-neck junction with an alpha angle of 68 degrees. This morphology primarily leads to which type of labral and chondral damage?

. Contrecoup cartilage injury of the posteroinferior acetabulum
. Avulsion of the ligamentum teres
. Delamination of the anterosuperior acetabular cartilage with relative labral sparing initially
. Primary labral tearing with secondary central cartilage wear
. Global uniform loss of articular cartilage space

Correct Answer & Explanation

. Contrecoup cartilage injury of the posteroinferior acetabulum

Explanation

Cam morphology (alpha angle >55 degrees) produces shear forces during hip flexion/internal rotation, causing 'outside-in' delamination of the anterosuperior acetabular cartilage. The labrum is often pushed outward and spared initially, unlike pincer impingement where labral failure is primary.

Question 397

Topic: Shoulder & Hip Sports

In the pathomorphology of femoroacetabular impingement (FAI), what specific pattern of articular cartilage damage is most characteristic of a classic Cam-type lesion?

. Circumferential global acetabular chondromalacia
. Posterior labral tearing with contrecoup anterior cartilage injury
. Anterosuperior labral detachment with adjacent deep acetabular cartilage delamination
. Hypertrophy and ossification of the transverse acetabular ligament
. Avulsion of the ligamentum teres with foveal cartilage erosion

Correct Answer & Explanation

. Circumferential global acetabular chondromalacia

Explanation

Cam impingement occurs when a non-spherical femoral head engages the acetabulum during flexion. This creates severe shear forces that typically result in anterosuperior labral tears and classic 'delamination' of the adjacent acetabular articular cartilage.

Question 398

Topic: Shoulder & Hip Sports

In femoroacetabular impingement (FAI), cam morphology leads to specific patterns of intra-articular damage. Which biomechanical mechanism primarily drives the characteristic chondral injury associated with a cam lesion during repetitive hip flexion?

. Pincer-like crushing of the labrum against the femoral neck
. Shear forces causing outside-in chondrolabral delamination at the anterosuperior transition zone
. Global articular cartilage thinning due to upregulation of inflammatory cytokines
. Posterior rim impaction resulting in contrecoup cartilage loss
. Ischemic necrosis of the anterolateral femoral head

Correct Answer & Explanation

. Pincer-like crushing of the labrum against the femoral neck

Explanation

Cam impingement occurs when an aspherical femoral head-neck junction forcefully enters the acetabulum during flexion. This generates significant shear forces at the chondrolabral junction, characteristically causing delamination of the anterosuperior acetabular cartilage from the subchondral bone.

Question 399

Topic: Shoulder & Hip Sports
A 48-year-old ski instructor dislocates his nondominant shoulder in a fall. Management consisting of application of a sling for 1 week results in improvement in his pain. Follow-up examination 6 weeks after the injury reveals that the patient continues to have difficulty with shoulder elevation. Management should now include
. use of the sling for an additional 3 weeks.
. physical therapy.
. a corticosteroid injection.
. an MRI scan of the rotator cuff.
. arthroscopic labral repair.

Correct Answer & Explanation

. an MRI scan of the rotator cuff.

Explanation

DISCUSSION: Patients who are older than age 45 years and have initial dislocations are at greater risk for tearing the rotator cuff. Patients who are unable to lift the upper extremity or who have continued pain should undergo further evaluation for potential rotator cuff tears; early diagnosis is preferred. Physical therapy or continued use of a sling will be of little benefit. A corticosteroid injection might delay the diagnosis and compromise subsequent rotator cuff repair. Repairing the labrum generally is not necessary in a patient of this age who has an initial dislocation. REFERENCES: Hawkins RJ, Bell RH, Hawkins RH, Koppert GJ: Anterior dislocation of the shoulder in the older patient. Clin Orthop 1986;206:192-195. Matsen FA III, Thomas SC, Rockwood CA: Anterior glenohumeral instability, in Rockwood CA, Matsen FA III (eds): The Shoulder. Philadelphia, PA, WB Saunders, 1990, pp 526-622.

Question 400

Topic: Shoulder & Hip Sports
The MRI scan of the shoulder shown in Figure 2 was performed with the arm in abduction and external rotation. The image reveals what condition?
. Contact between the rotator cuff and the posterior-superior labrum
. Anterior instability
. A ganglion cyst of the spinoglenoid notch
. Osteonecrosis of the humeral head
. Posterior subluxation

Correct Answer & Explanation

. Contact between the rotator cuff and the posterior-superior labrum

Explanation

DISCUSSION: Internal impingement of the shoulder is now a well-recognized cause of shoulder pain in the throwing athlete. First described by Walch and associates, it involves contact of the rotator cuff and labrum in the maximally externally rotated and abducted shoulder, such as in the late cocking phase of the throwing motion. Schickendantz and associates have shown this contact to be physiologic in most patients and becoming pathologic with repetitive overhead activity.

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