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 661
Topic: Shoulder & Hip Sports
A 21-year-old male rugby player has a history of recurrent anterior shoulder dislocations. Imaging demonstrates a 25% anterior glenoid bone loss and an engaging Hill-Sachs lesion. He is scheduled for a Latarjet procedure. Which of the following structures is transferred along with the coracoid process to the anterior glenoid?
Correct Answer & Explanation
. Pectoralis minor
Explanation
The Latarjet procedure involves the transfer of the coracoid process, along with the attached conjoint tendon (short head of the biceps and coracobrachialis), to the anterior defect of the glenoid. This provides both a bony block and a dynamic 'sling' effect from the conjoint tendon over the subscapularis when the arm is abducted and externally rotated.
Question 662
Topic: Shoulder & Hip Sports
A 42-year-old male sustains a severe blunt trauma to his left shoulder in a motor vehicle accident. Radiographs and CT scans reveal a multi-part fracture of the scapular body extending into the glenoid neck. In evaluating the glenoid neck fracture, the glenopolar angle (GPA) is measured. Which of the following statements regarding the glenopolar angle is most accurate?
Correct Answer & Explanation
. The normal GPA is between 10 and 20 degrees.
Explanation
The glenopolar angle (GPA) assesses the rotational malalignment of the glenoid. It is measured on a true AP (Grashey) view or 3D CT. The angle is formed by a line drawn from the highest point of the glenoid cavity to the lowest point, and a second line drawn from the highest point of the glenoid cavity to the most inferior angle of the scapular body. The normal range is 30 to 45 degrees. A decreased GPA (<20-22 degrees) is associated with poor functional outcomes due to altered rotator cuff mechanics and is generally an indication for open reduction and internal fixation.
Question 663
Topic: Shoulder & Hip Sports
A 32-year-old professional volleyball player presents with insidious onset of vague posterior shoulder pain and profound weakness in external rotation. He has full, painless passive range of motion. Examination reveals isolated atrophy of the infraspinatus with a normal-appearing supraspinatus. MRI is most likely to show a cyst in which of the following locations?
Correct Answer & Explanation
. Spinoglenoid notch
Explanation
Isolated atrophy and weakness of the infraspinatus indicate compression of the suprascapular nerve at the spinoglenoid notch (after it has already given off its motor branches to the supraspinatus). This is commonly caused by a paralabral cyst associated with a posterior or SLAP labral tear. Compression at the suprascapular notch would affect both the supraspinatus and infraspinatus muscles.
Question 664
Topic: Shoulder & Hip Sports
A 55-year-old male presents with shoulder pain and weakness following a fall on an extended arm. On examination, he is able to passively rotate his arm internally behind his back. When the examiner pulls the patient's hand away from the back and asks the patient to maintain this position, the patient's hand falls back against his lumbar spine. What is this test called and what muscle is it testing?
Correct Answer & Explanation
. Internal rotation lag sign; Subscapularis
Explanation
The test described is the Internal Rotation Lag Sign (IRLS). The examiner passively brings the patient's hand away from the back (maximal internal rotation) and asks the patient to hold it there. An inability to maintain the hand away from the back (a 'lag') indicates a subscapularis tear. The lift-off test requires the patient to actively push the hand away from the back against resistance, which tests the same muscle but is a different maneuver.
Question 665
Topic: Shoulder & Hip Sports
A 25-year-old male with recurrent anterior shoulder instability and 25% glenoid bone loss undergoes a Latarjet procedure. Which of the following nerves is at greatest risk of injury during the coracoid osteotomy and transfer?
Correct Answer & Explanation
. Musculocutaneous nerve
Explanation
The Latarjet procedure involves the transfer of the coracoid process and its attached conjoint tendon (short head of the biceps and coracobrachialis) to the anterior glenoid neck. The musculocutaneous nerve enters the coracobrachialis muscle typically 3-5 cm distal to the coracoid tip. Retraction of the conjoint tendon or careless dissection medial/distal to the coracoid places this nerve at significant risk during the initial exposure and osteotomy.
Question 666
Topic: Shoulder & Hip Sports
A 55-year-old manual laborer has a massive, irreparable posterosuperior rotator cuff tear (supraspinatus and infraspinatus). He has preserved forward elevation but severe weakness in external rotation (Hornblower's sign positive). He has no glenohumeral arthritis. Which of the following is the classic tendon transfer utilized to restore active external rotation in this specific scenario?
Correct Answer & Explanation
. Pectoralis major transfer
Explanation
For massive irreparable posterosuperior cuff tears with isolated loss of active external rotation and an intact subscapularis, the latissimus dorsi transfer (LDT) has historically been the workhorse to restore active external rotation and depress the humeral head. The latissimus (normally an internal rotator) is redirected to the greater tuberosity to function as an external rotator.
Question 667
Topic: Shoulder & Hip Sports
A 13-year-old elite baseball pitcher presents with anterior shoulder pain worsening with throwing. Examination shows proximal humerus tenderness but normal ROM. Radiographs reveal widening of the proximal humeral physis. What is the most appropriate initial management?
Correct Answer & Explanation
. Immediate surgical pinning
Explanation
'Little Leaguer's shoulder' is a stress fracture (epiphysiolysis) of the proximal humeral physis due to repetitive rotational torque. Treatment is strictly non-operative, requiring complete rest from throwing (usually 3 months) until clinical and radiographic resolution, followed by a structured return-to-throwing protocol.
Question 668
Topic: Shoulder & Hip Sports
A 35-year-old male sustained a seizure and presents with a locked posterior shoulder dislocation. CT shows a reverse Hill-Sachs lesion involving 35% of the humeral head articular surface. Which of the following is the most appropriate surgical treatment?
Correct Answer & Explanation
. Closed reduction and sling immobilization
Explanation
For locked posterior dislocations with an anteromedial humeral head defect (reverse Hill-Sachs) involving 20-40% of the articular surface, a modified McLaughlin procedure (transfer of the subscapularis and lesser tuberosity into the defect) or osteochondral allografting is recommended to prevent engagement and recurrent instability.
Question 669
Topic: Shoulder & Hip Sports
A 28-year-old overhead athlete is diagnosed with a Type IV SLAP lesion following an MRI arthrogram. Which of the following accurately describes a Type IV SLAP tear?
Correct Answer & Explanation
. Bucket-handle tear of the superior labrum extending into the long head of the biceps tendon
Explanation
According to Snyder's classification of SLAP tears: Type I is fraying; Type II is detachment of the superior labrum and biceps anchor; Type III is a bucket-handle tear of the labrum with an intact biceps anchor; Type IV is a bucket-handle tear of the labrum that extends into the biceps tendon.
Question 670
Topic: Shoulder & Hip Sports
A 52-year-old man underwent arthroscopic repair of a 1-cm supraspinatus tendon tear 3 weeks ago. He was doing well until he fell down three stairs. One week after the fall he continues to report pain similar to his preoperative pain. An MRI scan reveals a minimally retracted 1-cm supraspinatus tendon tear in the same location as his original tear. Management should now consist of
Correct Answer & Explanation
. Revision rotator cuff repair.
Explanation
The patient has retorn his rotator cuff repair. This traumatic retear is different from a chronic tear and should be treated similar to an acute rotator cuff tear. Because the patient is younger than age 65 and has a small, single tendon tear, a revision rotator cuff repair is indicated with an expected tendon healing rate of greater than 95%. A physical therapy program is not indicated, and further delay in repair compromises his functional recovery. A cortisone injection is not indicated for this repairable tendon tear. Immobilization will not allow the tendon to heal once it has retorn. A debridement procedure is not indicated on this repairable tendon tear; this procedure is indicated in painful, chronic, irreparable tendon tears.
Question 671
Topic: Shoulder & Hip Sports
Which of the following clinical findings is commonly associated with symptomatic partial-thickness rotator cuff tears?
Correct Answer & Explanation
. Painful arc with active range of motion
Explanation
In symptomatic partial-thickness rotator cuff tears, a painful arc with active range of motion is common, impingement signs are usually positive, and the lift-off test is normal. Active and passive range of motion measurements are often equal, although active range of motion can be painful. External rotation lag signs are often seen with larger full-thickness tears.
Question 672
Topic: Shoulder & Hip Sports
Figures 45a and 45b show sagittal T1-weighted MRI scans of a 35-year-old man who has had dominant extremity shoulder pain and weakness for the past 6 months. He denies any history of injury. Examination reveals full range of active and passive motion, negative Hawkins and Neer impingement signs, 5/5 abduction strength, 3+/5 external rotation strength with arm adducted at his side, and negative belly press, Hornblower's sign, Gerber lift-off, and O'Brien's test. Radiographs are unremarkable. An MR arthrogram shows no rotator cuff or labral tears and no paralabral cysts. What is the next most appropriate step in management? Review Topic
Correct Answer & Explanation
. Electromyography (EMG) and nerve conduction velocity (NCV) studies of the extremity
Explanation
The clinical history and physical examination are suggestive of weakness of the infraspinatus. An EMG/NCV study should be obtained to determine the etiology of the atrophy. In this case, the patient was shown to have suprascapular nerve entrapment at the suprascapular notch with atrophy of the infraspinatus and early signs of denervation of the supraspinatus. An MRI scan of the cervical spine would provide information if the EMG study revealed a cervical nerve compression as the etiology of the atrophy. Arthroscopic suprascapular nerve release at the suprascapular notch is the correct treatment for the lesion; however, the EMG needs to be obtained first to determine the location of nerve compression. Laboratory evaluation of C-reactive protein, erythrocyte sedimentation rate, and white blood cell count is unnecessary because there are no signs or symptoms of an infection. Corticosteroid injection of the subacromial space would not help the current problem because there are no signs or symptoms of impingement syndrome.
Question 673
Topic: Shoulder & Hip Sports
A 20-year-old college pitcher reports the recent onset of decreased velocity and posterior shoulder pain. He states that it takes him longer to loosen up but denies any mechanical symptoms. When compared to his non-throwing shoulder, glenohumeral examination of his throwing shoulder will most likely reveal which of the following findings? Review Topic
Correct Answer & Explanation
. Coracoid tenderness
Explanation
In symptomatic throwing shoulders, loss of internal rotation in abduction resulting from posteroinferior capsular contraction exceeds adaptive gains in external rotation. Glenohumeral internal rotation deficit (GIRD) is defined as the loss in degrees of glenohumeral internal rotation of the throwing shoulder compared with the nonthrowing shoulder. The pathologic cascade initially begins with decreased velocity and command, followed by posterior stiffness and trouble loosening up. Posterior shoulder pain without mechanical symptom occurs during late cocking and early acceleration phases due to the contracture of the posterior-inferior capsule. This results in a posterosuperior shift of the glenohumeral contact, resulting in internal impingement on the undersurface of the posterior superior rotator cuff and strain on the posterior superior glenoid labral interface. The "slap event" is when the posterior superior labrum and biceps anchor fail in tension. After the "slap event", surgery is the likely solution. Prior to this event, however, posterior inferior capsular stretches may result in resolution of symptoms.
Question 674
Topic: Shoulder & Hip Sports
A 22-year-old collegiate rugby player presents with recurrent anterior shoulder instability. A CT scan with 3D reconstruction demonstrates 22% anterior glenoid bone loss and an engaging Hill-Sachs lesion. Which of the following is the most appropriate definitive surgical management?
Correct Answer & Explanation
. Latarjet procedure (coracoid transfer)
Explanation
Engaging Hill-Sachs lesions in the presence of >20% anterior glenoid bone loss represent 'off-track' lesions with severe bone deficiency. Soft tissue stabilization (Bankart repair), even with remplissage, is associated with unacceptably high failure rates in this setting. The Latarjet procedure (coracoid transfer) restores the bony arc of the glenoid and provides a dynamic soft-tissue sling effect via the conjoint tendon, making it the standard of care.
Question 675
Topic: Shoulder & Hip Sports
A 55-year-old manual laborer has a massive, irreparable posterosuperior rotator cuff tear. The surgeon is considering a latissimus dorsi tendon transfer. Which of the following is considered an absolute contraindication to this procedure?
Correct Answer & Explanation
. Irreparable subscapularis tear
Explanation
Latissimus dorsi tendon transfer is indicated for massive, irreparable posterosuperior rotator cuff tears (supraspinatus/infraspinatus) in younger patients without significant glenohumeral arthritis. An intact and functioning subscapularis is an absolute prerequisite; it is required to provide an anterior force couple. If the subscapularis is incompetent, the humeral head will subluxate anterosuperiorly, leading to clinical failure of the transfer.
Question 676
Topic: Shoulder & Hip Sports
A 22-year-old male presents with recurrent anterior shoulder instability. CT shows a Hill-Sachs lesion engaging the anterior glenoid and 25% anterior glenoid bone loss. What is the most appropriate surgical intervention?
Correct Answer & Explanation
. Arthroscopic Bankart repair
Explanation
The Latarjet procedure is indicated for patients with recurrent anterior shoulder instability and significant glenoid bone loss (typically >20-25%). Arthroscopic Bankart repair alone in this setting has an unacceptably high failure rate.
Question 677
Topic: Shoulder & Hip Sports
A 55-year-old male manual laborer presents with a massive, irreparable posterosuperior rotator cuff tear. He has an intact subscapularis, no glenohumeral arthritis, and lacks forward elevation. Which of the following is the most appropriate surgical treatment?
Correct Answer & Explanation
. Reverse total shoulder arthroplasty
Explanation
A latissimus dorsi tendon transfer is indicated for young, active patients with massive, irreparable posterosuperior cuff tears, intact subscapularis, and no arthritis. It helps restore active external rotation and forward elevation.
Question 678
Topic: Shoulder & Hip Sports
A 45-year-old male presents with a massive, irreparable posterosuperior rotator cuff tear. His subscapularis remains intact, and he has no glenohumeral arthritis. A lower trapezius tendon transfer is planned. To optimize its line of pull, what clinical motion is this transfer primarily designed to restore?
Correct Answer & Explanation
. Forward elevation in the sagittal plane
Explanation
Lower trapezius transfer is indicated for younger patients with irreparable posterosuperior rotator cuff tears. It effectively simulates the line of pull of the infraspinatus, primarily restoring external rotation in abduction and improving overhead function.
Question 679
Topic: Shoulder & Hip Sports
A 22-year-old rugby player has recurrent anterior shoulder instability. MRI arthrogram shows a Hill-Sachs lesion and an anterior glenoid bone loss of 25%. According to the 'glenoid track' concept, how is the track calculated to determine if the Hill-Sachs lesion is engaging?
Correct Answer & Explanation
. 0.83 x (Intact anterior-posterior glenoid width) + (Anterior bone loss)
Explanation
The glenoid track is calculated as 83% of the intact anterior-posterior glenoid width minus the measured anterior glenoid bone loss. If the Hill-Sachs lesion width extends medially beyond this track, it is considered 'off-track' and highly likely to engage.
Question 680
Topic: Shoulder & Hip Sports
A 45-year-old heavy laborer presents with a massive, retracted, and irreducible posterosuperior rotator cuff tear. His subscapularis and teres minor are completely intact. Which tendon transfer is historically indicated to restore external rotation and elevation in this specific scenario?
Correct Answer & Explanation
. Latissimus dorsi transfer
Explanation
Latissimus dorsi tendon transfer is indicated for younger, active patients with massive, irreparable posterosuperior rotator cuff tears (supraspinatus/infraspinatus) who have an intact subscapularis. Lower trapezius transfer is a modern alternative, but latissimus dorsi is the classic historical standard.
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