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Shoulder & Hip Sports MCQs

Practice Set 45 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 881

Topic: Shoulder & Hip Sports

A 19-year-old competitive swimmer presents with bilateral shoulder pain and a sensation of subluxation. Clinical examination reveals a positive sulcus sign and generalized ligamentous laxity. Following an intensive 6-month physical therapy regimen focusing on periscapular and rotator cuff stabilization, she remains highly symptomatic. What is the most appropriate surgical intervention?

. Latarjet procedure
. Arthroscopic Bankart repair
. Inferior capsular shift
. Remplissage procedure

Correct Answer & Explanation

. Inferior capsular shift

Explanation

This patient has Multidirectional Instability (MDI) of the shoulder, characterized by generalized laxity and a positive sulcus sign. The first-line treatment is a prolonged course of physical therapy (often 6 months or more). If conservative management fails, the surgical procedure of choice is an inferior capsular shift to reduce the redundant capsular volume.

Question 882

Topic: Shoulder & Hip Sports

During an open Latarjet procedure for recurrent anterior shoulder instability, the coracoid process is osteotomized and transferred. Which of the following neural structures must be meticulously protected as it enters the conjoint tendon approximately 3-5 cm distal to the coracoid tip?

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

Correct Answer & Explanation

. Musculocutaneous nerve

Explanation

The musculocutaneous nerve routinely enters the deep surface of the coracobrachialis (part of the conjoint tendon) 3 to 8 cm distal to the coracoid process. It is at highest risk during the dissection and retraction of the conjoint tendon in a Latarjet procedure.

Question 883

Topic: Shoulder & Hip Sports

A 65-year-old male undergoes arthroscopic repair of a massive rotator cuff tear. Preoperative MRI demonstrated significant tendon retraction. Which of the following preoperative imaging findings is the strongest independent predictor of structural failure following repair?

. Acromiohumeral interval of 8 mm
. Type II SLAP tear
. Goutallier stage 3 or 4 fatty infiltration of the rotator cuff muscles
. Os acromiale
. Subacromial spurring

Correct Answer & Explanation

. Goutallier stage 3 or 4 fatty infiltration of the rotator cuff muscles

Explanation

High grades of fatty infiltration (Goutallier stage 3 or 4) are irreversible and highly predictive of poor clinical outcomes and structural failure of the repaired rotator cuff tendon.

Question 884

Topic: Shoulder & Hip Sports

A 19-year-old competitive swimmer presents with bilateral shoulder pain and a sensation of "slipping" in all directions. Examination reveals a positive sulcus sign bilaterally that does not decrease with external rotation. What is the first-line treatment?

. Arthroscopic anterior labral repair
. Arthroscopic posterior labral repair
. Open inferior capsular shift
. Prolonged physical therapy emphasizing periscapular and rotator cuff strengthening
. Thermal capsulorrhaphy

Correct Answer & Explanation

. Prolonged physical therapy emphasizing periscapular and rotator cuff strengthening

Explanation

The patient has multidirectional instability (MDI), classically presenting with generalized laxity and a sulcus sign. First-line management is conservative, utilizing a rigorous physical therapy program focused on dynamic stabilizers (rotator cuff and periscapular muscles).

Question 885

Topic: Shoulder & Hip Sports

A 55-year-old right-hand dominant male presents with acute onset severe right shoulder pain after attempting to lift a heavy box. He describes an audible 'pop' and now has weakness in abduction and external rotation. On examination, he has significant tenderness over the greater tuberosity and a positive painful arc sign. Active abduction is limited to 70 degrees, but passive range of motion is full. Which of the following is the MOST appropriate initial investigation to confirm the diagnosis and guide management?

. Plain radiographs (AP, lateral, axillary views)
. MRI scan of the shoulder
. CT scan of the shoulder with contrast
. Diagnostic ultrasound of the shoulder
. EMG/NCS studies

Correct Answer & Explanation

. Diagnostic ultrasound of the shoulder

Explanation

The patient's presentation with an acute 'pop', pain, and weakness in abduction and external rotation strongly suggests an acute rotator cuff tear. While MRI is the gold standard for detailed assessment of rotator cuff integrity, a diagnostic ultrasound is an excellent, cost-effective, and readily available initial investigation to confirm the presence and often the size of a full-thickness rotator cuff tear in the acute setting. It can be performed dynamically and is superior to radiographs for soft tissue assessment. Radiographs rule out fractures or dislocations but provide no information on the rotator cuff. CT scans are primarily for bony pathology. EMG/NCS studies are for nerve entrapment or injury, which is less likely to be the primary acute issue here.

Question 886

Topic: Shoulder & Hip Sports

A 30-year-old male presents with recurrent anterior shoulder dislocations. He has undergone two previous arthroscopic Bankart repairs, but continues to experience instability, particularly with overhead activities. On examination, he has hyperlaxity and a positive apprehension test in abduction and external rotation. Radiographs show a bony Bankart lesion and a significant Hill-Sachs lesion. Which of the following surgical procedures is MOST appropriate to address his recurrent instability?

. Repeat arthroscopic Bankart repair
. Open Bankart repair with capsular shift
. Latarjet procedure
. Remplissage procedure alone
. Arthroscopic capsular plication

Correct Answer & Explanation

. Latarjet procedure

Explanation

This patient has failed previous arthroscopic Bankart repairs, indicating persistent instability likely due to significant bone loss (bony Bankart and Hill-Sachs lesions) or generalized hyperlaxity. The Latarjet procedure is highly effective in cases of significant glenoid bone loss (>20-25%) or failed previous stabilization attempts, as it transfers the coracoid process with the attached conjoint tendon to the anterior glenoid, providing both a bone block effect and a sling effect. A repeat arthroscopic Bankart repair is unlikely to succeed given the previous failures and bone loss. Open Bankart with capsular shift is an option for capsular laxity but doesn't directly address significant bone loss. Remplissage alone is for engaging Hill-Sachs lesions without significant glenoid bone loss. Arthroscopic capsular plication addresses generalized laxity but not the underlying bony deficiency.

Question 887

Topic: Shoulder & Hip Sports

A 40-year-old construction worker presents with chronic, diffuse shoulder pain, weakness, and night pain. He denies any acute trauma. On examination, he has a positive Neer and Hawkins impingement sign, and a painful arc of motion. Resisted external rotation is weak but painless. MRI reveals a large, full-thickness supraspinatus tear and severe tendinopathy of the infraspinatus. What is the MOST appropriate surgical intervention?

. Subacromial decompression alone
. Arthroscopic debridement of the tear
. Rotator cuff repair with acromioplasty
. Superior capsular reconstruction
. Reverse total shoulder arthroplasty

Correct Answer & Explanation

. Rotator cuff repair with acromioplasty

Explanation

The patient has symptoms of impingement and a large, full-thickness supraspinatus tear. The most appropriate surgical intervention for a reparable full-thickness rotator cuff tear is rotator cuff repair, often combined with subacromial decompression (acromioplasty) to address impingement and facilitate healing. Subacromial decompression alone will not heal the tear and is insufficient. Arthroscopic debridement is generally reserved for very small, partial tears or irreparable tears where the goal is symptom management, not repair. Superior capsular reconstruction is for irreparable massive cuff tears. Reverse total shoulder arthroplasty is for rotator cuff tear arthropathy where the cuff is irreparable and severe arthritis exists, which is not described here.

Question 888

Topic: Shoulder & Hip Sports

A 22-year-old female presents with chronic shoulder pain and a sensation of the shoulder 'slipping out' during overhead activities. She has generalized ligamentous laxity and a positive sulcus sign bilaterally. Examination reveals positive apprehension and relocation tests, and generalized hypermobility. What is the MOST likely diagnosis?

. Anterior labral tear (Bankart lesion)
. Posterior instability
. Multidirectional instability (MDI)
. SLAP tear
. Rotator cuff tendinopathy

Correct Answer & Explanation

. Multidirectional instability (MDI)

Explanation

The presence of chronic instability, a sensation of 'slipping out', generalized ligamentous laxity, a positive sulcus sign, and positive apprehension/relocation tests strongly points towards Multidirectional Instability (MDI). MDI is often non-traumatic in origin and associated with generalized ligamentous laxity, affecting anterior, posterior, and inferior directions. Bankart lesions are typically associated with traumatic anterior dislocations. Posterior instability can occur, but MDI encompasses multiple directions. SLAP tears are often associated with overhead activities but typically present with pain and mechanical symptoms rather than global instability. Rotator cuff tendinopathy causes pain and weakness but not instability.

Question 889

Topic: Shoulder & Hip Sports

A 28-year-old male presents with sudden-onset, excruciating right shoulder pain that woke him from sleep. He denies trauma. On examination, the shoulder is exquisitely tender globally, and all active and passive movements are severely restricted and painful. Radiographs reveal a large, well-defined calcific deposit within the supraspinatus tendon. What is the MOST appropriate initial treatment?

. Physical therapy with rotator cuff strengthening
. Oral corticosteroids and NSAIDs, with consideration for subacromial corticosteroid injection
. Arthroscopic debridement of the calcific deposit
. Extracorporeal shockwave therapy (ESWT)
. Needle lavage and aspiration of calcific deposit

Correct Answer & Explanation

. Oral corticosteroids and NSAIDs, with consideration for subacromial corticosteroid injection

Explanation

This is a classic presentation of acute calcific tendinitis, typically characterized by sudden onset, severe pain, and profound restriction of motion due to the inflammatory response to calcium crystal deposition. The initial management is focused on pain control and reducing inflammation. High-dose oral NSAIDs and potentially a short course of oral corticosteroids are often very effective. A subacromial corticosteroid injection can also provide significant pain relief by reducing inflammation. Physical therapy is not indicated during the acute painful phase. Arthroscopic debridement or needle lavage are options for chronic, refractory cases, but not typically the first-line for acute pain. ESWT is for chronic tendinitis.

Question 890

Topic: Shoulder & Hip Sports

A 35-year-old male competitive swimmer presents with chronic posterior shoulder pain, worse during the late cocking and early acceleration phases of his stroke. On examination, he has tenderness in the posterior joint line and a positive 'relocation test' for posterior pain. MRI shows a posterior labral tear and some posterior capsular laxity. What is the MOST likely underlying pathology?

. Anterior glenohumeral instability
. Subacromial impingement
. Internal impingement (postero-superior impingement)
. Biceps tendinopathy
. Adhesive capsulitis

Correct Answer & Explanation

. Internal impingement (postero-superior impingement)

Explanation

The symptoms of posterior shoulder pain in an overhead athlete, particularly during late cocking and early acceleration, tenderness in the posterior joint line, and a positive posterior relocation test (relieving posterior pain), are classic for internal impingement (also known as postero-superior impingement). This condition involves impingement of the undersurface of the rotator cuff (supraspinatus/infraspinatus) and posterior labrum against the postero-superior glenoid rim in the abducted, externally rotated, and extended position, common in throwing athletes. Anterior instability, subacromial impingement, and biceps tendinopathy typically present with different pain patterns and examination findings. Adhesive capsulitis presents with global stiffness.

Question 891

Topic: Shoulder & Hip Sports

A 58-year-old female presents with a chronic posterior shoulder dislocation that was missed for 3 months. She has limited active external rotation and abduction. Radiographs confirm posterior dislocation with a significant anterior impression fracture of the humeral head (reverse Hill-Sachs lesion). What is the MOST appropriate surgical intervention?

. Closed reduction and immobilization
. Latarjet procedure
. Disimpaction and allograft reconstruction of the humeral head defect (e.g., McLaughlin procedure)
. Reverse total shoulder arthroplasty
. Arthroscopic posterior labral repair

Correct Answer & Explanation

. Disimpaction and allograft reconstruction of the humeral head defect (e.g., McLaughlin procedure)

Explanation

Chronic posterior dislocations, especially with a significant reverse Hill-Sachs lesion (anterior humeral head impression fracture), are often irreducible by closed means and require specific surgical approaches. The choice depends on the size of the humeral head defect. For defects involving 25-50% of the articular surface, disimpaction of the humeral head and filling the defect with allograft (e.g., McLaughlin procedure or modified Neer procedure) is a common technique to restore the humeral head contour and improve stability. If the defect is very large (>50%), or if significant glenohumeral arthritis is present, shoulder arthroplasty (hemi or total, or even reverse) may be considered. Closed reduction is unlikely to be successful after 3 months. Latarjet is for anterior instability with glenoid bone loss. Arthroscopic repair is for labral tears without significant bony defects.

Question 892

Topic: Shoulder & Hip Sports

A 60-year-old female presents with a painful shoulder and a history of progressive difficulty with external rotation. She denies trauma. On examination, active external rotation is significantly weaker than passive external rotation. She has no instability and full passive range of motion. MRI shows a massive tear of the supraspinatus and infraspinatus, but the subscapularis is intact. What is the MOST appropriate surgical option?

. Subacromial decompression alone
. Rotator cuff repair of the supraspinatus and infraspinatus
. Latissimus dorsi tendon transfer
. Reverse total shoulder arthroplasty
. Glenohumeral arthrodesis

Correct Answer & Explanation

. Latissimus dorsi tendon transfer

Explanation

This patient has a massive, but potentially reparable, postero-superior rotator cuff tear (supraspinatus and infraspinatus) with an intact subscapularis. Her symptoms indicate functional deficits from this tear. Latissimus dorsi tendon transfer is a recognized surgical option for symptomatic, irreparable postero-superior rotator cuff tears with an intact subscapularis, aiming to restore active external rotation and elevation. Subacromial decompression alone does not address the torn cuff. Repair of a massive tear, while ideal, may not be possible, and the question implies a challenging scenario with 'progressive difficulty'. Reverse total shoulder arthroplasty is typically for rotator cuff tear arthropathy where the cuff is irreparable and severe arthritis is present, or if significant superior migration is already present. Arthrodesis is a salvage procedure.

Question 893

Topic: Shoulder & Hip Sports
A 30-year-old male presents with chronic anterior shoulder pain, clicking, and a sensation of 'catching' with overhead activities. He is a keen tennis player. On examination, O'Brien's test (active compression test) is positive, and he has pain with resisted supination of the forearm while the elbow is flexed (Speed's test). MRI confirms a superior labrum anterior posterior (SLAP) tear. What type of SLAP lesion is MOST likely given his symptoms?
. Type I
. Type II
. Type III
. Type IV
. Type V

Correct Answer & Explanation

. Type II

Explanation

The symptoms of chronic pain, clicking, catching with overhead activities, positive O'Brien's, and Speed's test are highly suggestive of a SLAP tear. Type II SLAP lesions are the most common type and involve detachment of the superior labrum and the biceps anchor from the glenoid, making the biceps unstable. Type I is fraying/degeneration of the superior labrum. Type III involves a bucket-handle tear of the superior labrum with an intact biceps anchor. Type IV involves a bucket-handle tear of the superior labrum extending into the biceps tendon. Type V is a Type II SLAP tear extending into an anterior Bankart lesion.

Question 894

Topic: Shoulder & Hip Sports

A 20-year-old competitive swimmer presents with chronic shoulder pain, particularly during the pull-through phase of his stroke. He has a positive Jobe's test and Empty Can test. Which muscle/tendon unit is MOST likely involved?

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

Correct Answer & Explanation

. Supraspinatus

Explanation

The Jobe's test (Empty Can test) specifically assesses the integrity and strength of the supraspinatus muscle-tendon unit. A positive test indicates weakness or pain originating from the supraspinatus, which is a common cause of shoulder pain and impingement, especially in overhead athletes. Subscapularis is tested with Lift-off or Belly-press. Teres minor and infraspinatus are tested with resisted external rotation. Long head of biceps is assessed with Speed's or Yergason's test.

Question 895

Topic: Shoulder & Hip Sports

A 62-year-old male with a history of recurrent anterior shoulder dislocations now presents with chronic pain and instability. Radiographs reveal significant glenoid bone loss (estimated at 30%) and a large engaging Hill-Sachs lesion. Which of the following procedures is MOST appropriate to address his instability?

. Arthroscopic Bankart repair
. Open Bankart repair with capsular plication
. Latarjet procedure
. Remplissage procedure
. SLAP repair

Correct Answer & Explanation

. Latarjet procedure

Explanation

For recurrent anterior shoulder instability with significant glenoid bone loss (typically >20-25%), the Latarjet procedure is the procedure of choice. It involves transferring the coracoid process with the attached conjoint tendon to the anterior glenoid, providing a bone block effect, a sling effect from the conjoint tendon, and re-tensioning of the anterior capsule. Arthroscopic Bankart repair is typically ineffective with significant bone loss. Open Bankart repair might be considered for isolated soft tissue lesions but not extensive bone loss. Remplissage addresses an engaging Hill-Sachs lesion but not the glenoid bone loss. SLAP repair is for superior labral pathology.

Question 896

Topic: Shoulder & Hip Sports

A 50-year-old female undergoes arthroscopic rotator cuff repair. During the procedure, the posterior portal is placed too medially. Post-operatively, she develops weakness in abduction and external rotation, along with atrophy of the supraspinatus and infraspinatus muscles. Sensation is intact. What nerve is MOST likely injured?

. Axillary nerve
. Musculocutaneous nerve
. Long thoracic nerve
. Suprascapular nerve
. Radial nerve

Correct Answer & Explanation

. Suprascapular nerve

Explanation

The suprascapular nerve is vulnerable during arthroscopic shoulder surgery, particularly during posterior portal placement if it's placed too medially and inferiorly, or during extensive debridement in the suprascapular or spinoglenoid notch. Injury to the suprascapular nerve results in weakness and atrophy of the supraspinatus (abduction) and infraspinatus (external rotation) muscles, typically without sensory deficits, as the nerve is primarily motor. Axillary nerve injury affects the deltoid and teres minor, with sensory loss in the regimental badge area. Musculocutaneous affects biceps. Long thoracic affects serratus anterior. Radial nerve affects wrist/finger extensors.

Question 897

Topic: Shoulder & Hip Sports

A 30-year-old construction worker presents with chronic pain and weakness in his right shoulder, specifically with heavy lifting and forceful internal rotation. He describes an audible 'pop' during a lifting incident 6 months ago. On examination, he has tenderness over the anterior aspect of the shoulder, and weakness with resisted internal rotation (positive 'belly press' and 'lift-off' tests). What structure is MOST likely injured?

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

Correct Answer & Explanation

. Subscapularis tendon

Explanation

The symptoms of anterior shoulder pain, weakness with resisted internal rotation, and positive 'belly press' and 'lift-off' tests are highly suggestive of a subscapularis tendon tear. The subscapularis is the largest and most powerful rotator cuff muscle, primarily responsible for internal rotation and anterior stability. Supraspinatus is tested with abduction (Jobe's test). Infraspinatus and Teres minor are tested with external rotation. Long head of biceps tendinopathy causes pain in the bicipital groove and with resisted elbow flexion/forearm supination.

Question 898

Topic: Shoulder & Hip Sports

A 40-year-old male presents with shoulder pain, clicking, and a 'dead arm' sensation after a forceful throw. He has a positive apprehension test and pain during the late cocking phase of throwing. MRI reveals a Bankart lesion and a significant Hill-Sachs lesion. Which of the following is the MOST appropriate surgical intervention?

. Arthroscopic capsular plication
. Open Bankart repair with capsular shift
. Latarjet procedure
. Remplissage procedure alone
. SLAP repair

Correct Answer & Explanation

. Open Bankart repair with capsular shift

Explanation

The patient has a traumatic anterior shoulder instability with a Bankart lesion (anterior labral tear) and a significant Hill-Sachs lesion (compression fracture of the posterior humeral head). For traumatic anterior instability with a Bankart lesion, an open Bankart repair with capsular shift (if capsular laxity is also present) is a common and effective surgical intervention. Arthroscopic Bankart repair is typically preferred for isolated Bankart lesions without significant bone loss. The Latarjet procedure is usually reserved for cases with significant glenoid bone loss (>20-25%) or failed previous stabilization. Remplissage alone is for engaging Hill-Sachs lesions without significant glenoid bone loss or instability. SLAP repair is for superior labral tears.

Question 899

Topic: Shoulder & Hip Sports

A 31-year-old elite volleyball player complains of vague posterior shoulder pain and isolated weakness in external rotation. MRI reveals a paralabral cyst in the spinoglenoid notch. Which of the following exam findings is most expected?

. Atrophy of both the supraspinatus and infraspinatus
. Isolated atrophy of the infraspinatus
. Positive lift-off test
. Loss of active forward elevation
. Winging of the medial scapula

Correct Answer & Explanation

. Isolated atrophy of the infraspinatus

Explanation

A cyst at the spinoglenoid notch specifically compresses the distal branches of the suprascapular nerve, resulting in isolated denervation and atrophy of the infraspinatus muscle. The supraspinatus is spared because its nerve supply branches off proximal to the notch.

Question 900

Topic: Shoulder & Hip Sports

A 28-year-old professional volleyball player presents with isolated atrophy and weakness of the infraspinatus. An MRI reveals a paralabral cyst located in the spinoglenoid notch. This finding is most highly associated with which of the following concomitant intra-articular pathologies?

. Anterior Bankart lesion
. Posterior superior labral (SLAP) tear
. Anterior superior labral (SLAP) tear
. ALPSA lesion
. Humeral avulsion of the glenohumeral ligament (HAGL)

Correct Answer & Explanation

. Posterior superior labral (SLAP) tear

Explanation

Paralabral cysts at the spinoglenoid notch are strongly associated with posterior superior labral (SLAP) tears, which create a one-way valve allowing joint fluid to accumulate. Compression at the spinoglenoid notch selectively affects the suprascapular nerve branches to the infraspinatus, sparing the supraspinatus.

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