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Shoulder & Hip Sports MCQs

Practice Set 83 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 1641

Topic: Shoulder & Hip Sports

A 35-year-old volleyball player complains of chronic, deep, dull posterior shoulder pain and weakness with overhead activity. He denies any acute injury. Examination reveals atrophy of the infraspinatus muscle and weakness with external rotation. Sensory examination is normal. What is the MOST likely diagnosis?

. Rotator cuff tear
. Adhesive capsulitis
. Long thoracic nerve palsy
. Suprascapular nerve entrapment
. Axillary nerve palsy

Correct Answer & Explanation

. Rotator cuff tear

Explanation

The patient's symptoms of chronic posterior shoulder pain, infraspinatus atrophy, and weakness with external rotation (and often abduction) are classic for suprascapular nerve entrapment. The suprascapular nerve supplies both the supraspinatus (abduction and external rotation) and infraspinatus (external rotation) muscles. Entrapment can occur at the suprascapular notch or spinoglenoid notch. Atrophy of the infraspinatus specifically points to distal entrapment at the spinoglenoid notch (sparing the supraspinatus if proximal to its innervation), but overall, it's a strong indicator. A rotator cuff tear could cause similar pain and weakness, but atrophy might be less pronounced early on, and nerve conduction studies would differentiate. Adhesive capsulitis involves global stiffness. Long thoracic nerve palsy affects the serratus anterior (winging scapula). Axillary nerve palsy affects the deltoid and teres minor (loss of abduction beyond 15 degrees and external rotation), leading to deltoid atrophy, not infraspinatus.

Question 1642

Topic: Shoulder & Hip Sports

A 16-year-old male presents with recurrent anterior shoulder dislocations. He has a history of a seizure disorder, which is poorly controlled. After his most recent seizure, he sustained another dislocation. Radiographs show a large bony Bankart lesion and a significant Hill-Sachs lesion. Given his history, which surgical intervention is MOST appropriate?

. Arthroscopic Bankart repair
. Open Bankart repair with capsular shift
. Latarjet procedure
. Remplissage procedure with Bankart repair
. Conservative management with seizure control

Correct Answer & Explanation

. Arthroscopic Bankart repair

Explanation

Recurrent anterior shoulder dislocations in a patient with a seizure disorder are particularly challenging because the powerful, uncontrolled muscle contractions during seizures place extreme stress on the shoulder, often leading to large bony defects (Bankart and Hill-Sachs). Soft tissue repairs (arthroscopic or open Bankart) have a very high failure rate in this population. The Latarjet procedure, which involves transferring the coracoid process with its attached conjoined tendon to the anterior-inferior glenoid, provides significant bony augmentation to the glenoid, thus preventing engagement of the Hill-Sachs lesion and creating a dynamic sling effect. This bony stabilization is crucial for patients with seizure disorders who are at very high risk for recurrence. Remplissage addresses Hill-Sachs but does not augment the glenoid directly. Conservative management alone is unlikely to be effective given recurrent dislocations.

Question 1643

Topic: Shoulder & Hip Sports

A 65-year-old male presents with a massive, retracted rotator cuff tear (supraspinatus, infraspinatus, partial subscapularis). MRI shows significant fatty infiltration (Goutallier Grade 3-4) in the retracted muscles. He has pain and weakness, but no significant glenohumeral arthritis. He is otherwise healthy. Which of the following is considered a relative contraindication to primary rotator cuff repair?

. Patient age greater than 60
. Partial tear of the subscapularis
. Significant retraction of the rotator cuff
. Goutallier Grade 3 or 4 fatty infiltration
. Presence of a concomitant biceps tendon lesion

Correct Answer & Explanation

. Patient age greater than 60

Explanation

While all options can influence surgical decision-making, Goutallier Grade 3 or 4 fatty infiltration (meaning greater than 50% fat within the muscle belly) is considered a strong predictor of poor healing and a relative contraindication to primary rotator cuff repair. Significant fatty infiltration indicates muscle degeneration and atrophy, which severely compromises the ability of the muscle to heal and function, even if the tear can be physically repaired. Patient age alone is not a contraindication. Partial subscapularis tears are often addressed. Significant retraction makes repair more challenging but not impossible. A biceps lesion is often addressed concurrently (tenotomy/tenodesis).

Question 1644

Topic: Shoulder & Hip Sports

A 28-year-old professional volleyball player complains of vague posterior shoulder pain and weakness with overhead serving. Physical examination reveals isolated weakness in external rotation with the arm at the side and noticeable atrophy of the infraspinatus. Supraspinatus strength is normal. An MRI reveals a paralabral cyst. Where is the cyst most likely located?

. Suprascapular notch
. Spinoglenoid notch
. Quadrilateral space
. Triangular interval
. Spiral groove

Correct Answer & Explanation

. Suprascapular notch

Explanation

Isolated atrophy and weakness of the infraspinatus indicate compression of the suprascapular nerve after it has innervated the supraspinatus. This occurs at the spinoglenoid notch. A paralabral cyst at the spinoglenoid notch (often associated with posterior labral tears) compresses the distal branch of the suprascapular nerve. Compression at the suprascapular notch would affect both the supraspinatus and infraspinatus.

Question 1645

Topic: Shoulder & Hip Sports

A 22-year-old rugby player with recurrent anterior shoulder instability is scheduled for an open Latarjet procedure (coracoid transfer) after a CT scan demonstrates 28% anterior glenoid bone loss. During the osteotomy of the coracoid and its subsequent transfer through the split in the subscapularis tendon, which of the following nerves is at greatest risk of iatrogenic injury?

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

Correct Answer & Explanation

. Axillary nerve

Explanation

The musculocutaneous nerve typically enters the coracobrachialis muscle 3 to 8 cm distal to the tip of the coracoid process. During the Latarjet procedure, the coracoid process (with the attached conjoined tendon) is osteotomized and transferred to the anterior glenoid. The mobilization and retraction of the conjoined tendon place the musculocutaneous nerve at high risk for stretch or direct transection injury.

Question 1646

Topic: Shoulder & Hip Sports

A 50-year-old man presents with profound weakness in external rotation and elevation of his right shoulder following a massive, irreparable posterosuperior rotator cuff tear. Examination reveals a positive Hornblower's sign and intact subscapularis function. There is no evidence of glenohumeral arthritis. Which of the following tendon transfers is biomechanically most appropriate to restore external rotation in this patient?

. Latissimus dorsi transfer
. Pectoralis major transfer
. Lower trapezius transfer
. Serratus anterior transfer
. Teres major transfer

Correct Answer & Explanation

. Latissimus dorsi transfer

Explanation

The lower trapezius transfer is increasingly preferred for massive irreparable posterosuperior rotator cuff tears, particularly when the primary deficit is profound external rotation weakness (indicated by a positive Hornblower's sign). The lower trapezius line of pull closely mimics that of the native infraspinatus, making it biomechanically superior to the latissimus dorsi for restoring external rotation. Latissimus dorsi transfers are traditionally used but have a vector that is less ideal for pure external rotation restoration.

Question 1647

Topic: Shoulder & Hip Sports

A 28-year-old elite volleyball player complains of vague posterior shoulder pain and weakness in external rotation. Clinical examination reveals isolated atrophy of the infraspinatus muscle, while supraspinatus strength and bulk are normal. An MRI confirms the presence of a paralabral cyst. At which of the following anatomic locations is the nerve compression most likely occurring?

. Suprascapular notch
. Spinoglenoid notch
. Quadrilateral space
. Triangular interval
. Coracohumeral ligament

Correct Answer & Explanation

. Suprascapular notch

Explanation

The suprascapular nerve innervates the supraspinatus muscle before passing through the spinoglenoid notch to innervate the infraspinatus. Compression at the spinoglenoid notch (often due to a paralabral cyst associated with a posterior labral tear) results in isolated infraspinatus denervation, leading to atrophy and isolated external rotation weakness. Compression at the suprascapular notch would affect both the supraspinatus and infraspinatus.

Question 1648

Topic: Shoulder & Hip Sports

A 55-year-old man falls while skiing, forcibly externally rotating his right arm. He exhibits increased passive external rotation and tests positive on the belly-press test. MRI confirms an isolated, full-thickness tear of the subscapularis tendon with medial retraction. During arthroscopic repair, which anatomic landmark is most reliable for identifying the superior border of the retracted subscapularis tendon?

. The transverse humeral ligament
. The middle glenohumeral ligament
. The superior labrum
. The comma sign
. The coracoacromial ligament

Correct Answer & Explanation

. The transverse humeral ligament

Explanation

The 'comma sign' is a critical arthroscopic landmark for identifying retracted subscapularis tears. It is formed by the avulsed superior glenohumeral ligament (SGHL) and coracohumeral ligament (CHL) complex, which remains attached to the superomedial corner of the subscapularis tendon. As the subscapularis retracts medially, this tissue forms a distinct comma-shaped arc. Tracing the comma sign distally and laterally guides the surgeon directly to the superior, lateral edge of the retracted subscapularis tendon for mobilization and repair.

Question 1649

Topic: Shoulder & Hip Sports

A 75-year-old active woman sustains a 4-part proximal humerus fracture. Because of the risk of avascular necrosis and severe comminution, she undergoes a shoulder hemiarthroplasty. What is the most critical prognostic factor determining the long-term functional outcome of active forward elevation in this patient?

. Restoration of absolute humeral length
. Anatomical healing of the greater tuberosity
. Retroversion angle of the humeral stem
. Repair of the subscapularis to the lesser tuberosity
. Sizing of the prosthetic head to match the native anatomy

Correct Answer & Explanation

. Restoration of absolute humeral length

Explanation

In proximal humerus fractures treated with hemiarthroplasty, the most critical determinant of functional success, particularly for active forward elevation and overhead function, is the anatomical healing of the greater tuberosity to the humeral shaft and the prosthesis. Failure of the greater tuberosity to heal, or its superior migration, leads to profound rotator cuff dysfunction and poor outcomes.

Question 1650

Topic: Shoulder & Hip Sports

A 22-year-old rugby player presents with recurrent anterior shoulder instability. A pre-operative 3D CT scan of his shoulder reveals anterior glenoid bone loss. Historically, at which of the following percentages of inferior glenoid bone loss is an arthroscopic soft-tissue Bankart repair alone considered to have an unacceptably high failure rate, thus definitively indicating the need for a bony augmentation procedure (e.g., Latarjet)?

. 5%
. 10%
. 15%
. 25%
. 35%

Correct Answer & Explanation

. 5%

Explanation

Critical glenoid bone loss has traditionally been defined as >20-25% of the inferior glenoid diameter. At 25% or greater bone loss, the glenoid acts like an 'inverted pear', and a soft-tissue stabilization (Bankart repair) alone will uniformly fail due to lack of an adequate bony bumper. In these cases, a bone block procedure (such as a Latarjet coracoid transfer) is indicated. Note that recent literature has identified 'subcritical' bone loss thresholds (~13.5-15%) where outcomes may still be compromised in high-demand athletes, but 25% remains the classic absolute indication for bony augmentation.

Question 1651

Topic: Shoulder & Hip Sports

A 60-year-old man with a massive, retracted, chronic posterosuperior rotator cuff tear develops weakness not only in abduction and external rotation but also demonstrates electromyographic (EMG) evidence of denervation of the supraspinatus and infraspinatus. Traction on which of the following structures is most likely responsible for the suprascapular nerve injury in this specific setting?

. Superior transverse scapular ligament
. Inferior transverse scapular ligament (spinoglenoid ligament)
. Coracoacromial ligament
. Coracohumeral ligament
. Superior glenohumeral ligament

Correct Answer & Explanation

. Superior transverse scapular ligament

Explanation

Massive, medially retracted tears of the supraspinatus and infraspinatus can cause a 'bowstringing' medial traction effect on the suprascapular nerve. The nerve becomes tethered at the suprascapular notch by the superior transverse scapular ligament, leading to a traction neuropathy affecting both the supraspinatus and infraspinatus. Compression at the spinoglenoid notch (under the inferior transverse scapular/spinoglenoid ligament) typically occurs secondary to paralabral cysts and isolatedly affects the infraspinatus.

Question 1652

Topic: Shoulder & Hip Sports

A 60-year-old male is evaluated for a massive, retracted rotator cuff tear. Preoperative MRI is obtained to assess the viability of a primary repair. According to the Goutallier classification of fatty infiltration, which stage is defined specifically by the presence of an equal amount of fat and muscle tissue within the muscle belly?

. Stage 1
. Stage 2
. Stage 3
. Stage 4
. Stage 5

Correct Answer & Explanation

. Stage 1

Explanation

The Goutallier classification grades fatty infiltration of the rotator cuff muscles. Stage 0 is normal muscle; Stage 1 has some fatty streaks; Stage 2 has more muscle than fat; Stage 3 has an equal amount of fat and muscle; and Stage 4 has more fat than muscle. Fatty infiltration of Stage 3 or higher generally indicates irreversible changes, carrying a poorer prognosis for successful tendon healing after repair.

Question 1653

Topic: Shoulder & Hip Sports

A 28-year-old elite volleyball player presents with vague posterior shoulder pain and progressive weakness in external rotation. Examination reveals atrophy isolated to the infraspinatus fossa. MRI demonstrates a paralabral cyst in the spinoglenoid notch. Based on the site of nerve compression, which of the following findings on physical examination would also be expected?

. Weakness in shoulder abduction
. Decreased sensation over the lateral deltoid
. Positive Jobe (empty can) test
. Normal strength in forward elevation
. Weakness of the subscapularis muscle

Correct Answer & Explanation

. Weakness in shoulder abduction

Explanation

A cyst at the spinoglenoid notch selectively compresses the suprascapular nerve distal to its innervation of the supraspinatus muscle. Therefore, the supraspinatus remains functional, leading to normal strength in forward elevation and abduction (a negative Jobe test). The infraspinatus is denervated, resulting in isolated external rotation weakness and atrophy. There are no sensory deficits associated with isolated suprascapular nerve entrapment.

Question 1654

Topic: Shoulder & Hip Sports

A 28-year-old elite volleyball player presents with insidious onset of right shoulder pain and weakness, predominantly with external rotation. Examination reveals isolated atrophy of the infraspinatus muscle. The supraspinatus muscle bulk and strength are normal. Where is the most likely location of the nerve entrapment?

. Suprascapular notch
. Spinoglenoid notch
. Quadrilateral space
. Triangular interval
. Spiral groove

Correct Answer & Explanation

. Suprascapular notch

Explanation

The suprascapular nerve innervates the supraspinatus and infraspinatus muscles. It courses through the suprascapular notch (beneath the transverse scapular ligament), where compression affects both the supraspinatus and infraspinatus. It then passes through the spinoglenoid notch (under the spinoglenoid ligament) to innervate the infraspinatus. Compression at the spinoglenoid notch, often due to a paralabral cyst associated with a posterior SLAP or labral tear, typically results in isolated infraspinatus weakness and atrophy, while the supraspinatus is spared. This is a classic presentation in overhead athletes, particularly volleyball players.

Question 1655

Topic: Shoulder & Hip Sports

According to the Snyder classification of Superior Labrum Anterior to Posterior (SLAP) lesions, a Type II tear is characterized by:

. Degenerative fraying of the superior labrum with an intact biceps anchor.
. Detachment of the superior labrum and biceps anchor from the superior glenoid.
. A bucket-handle tear of the superior labrum with an intact biceps anchor.
. A bucket-handle tear of the superior labrum that extends into the biceps tendon.
. An anteroinferior labral tear extending into the superior labrum.

Correct Answer & Explanation

. Degenerative fraying of the superior labrum with an intact biceps anchor.

Explanation

The Snyder classification categorizes SLAP lesions into four initial types: Type I: Degenerative fraying of the superior labrum; the biceps anchor is intact. Type II: Detachment of the superior labrum and the origin of the long head of the biceps tendon from the superior glenoid rim. This is the most common type and often requires surgical repair or biceps tenodesis. Type III: A bucket-handle tear of the superior labrum with an intact biceps anchor. Type IV: A bucket-handle tear of the superior labrum that extends into the substance of the biceps tendon.

Question 1656

Topic: Shoulder & Hip Sports

A 45-year-old male construction worker presents with deep, aching shoulder pain and a positive O'Brien test. An MRI arthrogram reveals a type II SLAP tear. Nonoperative management has failed. Based on recent literature, what is the most appropriate surgical intervention to minimize postoperative stiffness and allow a predictable return to work?

. SLAP repair using multiple suture anchors
. Biceps tenodesis
. Biceps tenotomy
. Arthroscopic debridement of the superior labrum
. Coracoid transfer (Latarjet procedure)

Correct Answer & Explanation

. SLAP repair using multiple suture anchors

Explanation

In patients older than 35-40 years with a type II SLAP tear, particularly manual laborers, primary biceps tenodesis has been shown to have lower complication rates, a lower incidence of postoperative stiffness, and higher rates of return to work compared to SLAP repair. SLAP repair in this demographic is associated with higher rates of persistent pain and stiffness.

Question 1657

Topic: Shoulder & Hip Sports

A 28-year-old elite volleyball player presents with vague posterior shoulder pain and progressive weakness with serving. Physical examination reveals marked atrophy of both the supraspinatus and infraspinatus muscles. At what anatomical location is the neurological compression most likely occurring?

. Quadrilateral space
. Spinoglenoid notch
. Suprascapular notch
. Triangular interval
. Spiral groove

Correct Answer & Explanation

. Quadrilateral space

Explanation

The patient is exhibiting signs of suprascapular nerve entrapment. The suprascapular nerve innervates both the supraspinatus and infraspinatus muscles. Compression at the suprascapular notch (beneath the transverse scapular ligament) affects the nerve before it gives off branches to the supraspinatus, resulting in atrophy and weakness of BOTH the supraspinatus and infraspinatus. Conversely, compression at the spinoglenoid notch (distal to the supraspinatus innervation) typically presents with isolated infraspinatus atrophy.

Question 1658

Topic: Shoulder & Hip Sports

A 22-year-old collegiate rugby player undergoes a Latarjet procedure for recurrent anterior shoulder instability associated with 28% anterior glenoid bone loss. The procedure involves transferring the coracoid process to the anterior glenoid neck. Which muscular structure is transferred along with the coracoid to provide a dynamic 'sling' effect across the anteroinferior capsule?

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

Correct Answer & Explanation

. Pectoralis minor

Explanation

The Latarjet procedure involves osteotomizing the coracoid process and transferring it, along with the attached conjoined tendon (composed of the short head of the biceps and the coracobrachialis), to the anterior glenoid. This provides a 'triple blocking effect': 1) the bone block itself, 2) the dynamic sling effect of the conjoined tendon reinforcing the inferior capsule when the arm is abducted and externally rotated, and 3) the repair of the capsule to the stump of the coracoacromial ligament (if preserved).

Question 1659

Topic: Shoulder & Hip Sports

A 29-year-old elite volleyball attacker reports vague posterior shoulder pain and progressive weakness. Physical examination reveals isolated weakness in external rotation and profound atrophy of the infraspinatus fossa. Abduction strength and supraspinatus bulk are entirely normal. An MRI confirms a paralabral cyst compressing a peripheral nerve. At what specific anatomic location is the nerve compression occurring?

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

Correct Answer & Explanation

. Suprascapular notch

Explanation

The patient has isolated infraspinatus atrophy and external rotation weakness, which indicates compression of the suprascapular nerve distal to the innervation of the supraspinatus. This occurs at the spinoglenoid notch. Compression at the suprascapular notch (proximally) would affect both the supraspinatus (abduction) and the infraspinatus (external rotation). Quadrilateral space syndrome involves the axillary nerve.

Question 1660

Topic: Shoulder & Hip Sports

A 45-year-old manual laborer presents with chronic shoulder pain, profound weakness in external rotation, and a positive hornblower's sign. MRI demonstrates a massive, retracted, and irreparable tear of the supraspinatus and infraspinatus with Goutallier stage 4 fatty infiltration. The subscapularis is intact, and there is no glenohumeral arthritis. Which of the following is the most appropriate tendon transfer to restore active external rotation?

. Pectoralis major tendon transfer
. Lower trapezius tendon transfer
. Latissimus dorsi tendon transfer
. Conjoined tendon transfer
. Teres major tendon transfer

Correct Answer & Explanation

. Pectoralis major tendon transfer

Explanation

In a young, active patient with an irreparable posterosuperior rotator cuff tear (supraspinatus/infraspinatus) without arthritis, a tendon transfer is indicated. Lower trapezius transfer is increasingly favored and highly tested for external rotation deficits (loss of infraspinatus/teres minor) because its force vector more closely replicates the infraspinatus. While latissimus dorsi transfer has historically been used, its primary vector is adduction and internal rotation, requiring significant cortical retraining. Pectoralis major transfer is indicated for irreparable subscapularis tears.

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