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Shoulder & Hip Sports MCQs

Practice Set 93 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 1841

Topic: Shoulder & Hip Sports

A 19-year-old female collegiate swimmer presents with bilateral shoulder pain and a sensation of 'slipping' with overhead activities. Examination demonstrates a positive sulcus sign, generalized ligamentous laxity with a Beighton score of 6/9, and scapular dyskinesia. Radiographs and an MRI arthrogram (Figure 25) reveal a voluminous capsule but no frank labral tear. What is the most appropriate initial management for this patient?

. Arthroscopic capsular plication
. Open inferior capsular shift
. Prolonged physical therapy focusing on periscapular and rotator cuff strengthening
. Thermal capsulorrhaphy
. Arthroscopic SLAP repair

Correct Answer & Explanation

. Prolonged physical therapy focusing on periscapular and rotator cuff strengthening

Explanation

The patient has multidirectional instability (MDI) of the shoulder, characterized by symptomatic instability in more than one direction (anterior, posterior, inferior) and often associated with generalized ligamentous laxity. The mainstay and initial treatment of choice for MDI is a supervised, prolonged physical therapy program (typically 6 months) emphasizing dynamic stabilizer strengthening (rotator cuff and periscapular muscles). Surgery is reserved for patients who fail extensive conservative management.

Question 1842

Topic: Shoulder & Hip Sports

A 27-year-old elite volleyball player complains of vague posterior shoulder pain and progressive weakness in external rotation. Examination reveals isolated atrophy of the infraspinatus muscle with normal supraspinatus bulk and strength. An MRI (Figure 12) demonstrates a paralabral cyst. At which of the following anatomical locations is the suprascapular nerve compression most likely occurring?

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

Correct Answer & Explanation

. Spinoglenoid notch

Explanation

Isolated weakness and atrophy of the infraspinatus muscle point to entrapment of the suprascapular nerve at the spinoglenoid notch, typically caused by a paralabral cyst associated with a posterior superior labral tear. The suprascapular nerve innervates the supraspinatus muscle prior to passing through the spinoglenoid notch; therefore, compression at the suprascapular notch would affect both the supraspinatus and the infraspinatus muscles.

Question 1843

Topic: Shoulder & Hip Sports

A 24-year-old male hockey player presents with gradual onset of groin pain that worsens with deep flexion and internal rotation of the hip. A diagnostic intra-articular injection completely relieves his pain temporarily. Radiographs demonstrate an alpha angle of 75 degrees and normal acetabular version. Which of the following best describes the pathophysiologic mechanism of his condition?

. Linear contact between a prominent anterior acetabular rim and the femoral head-neck junction leading to labral crushing.
. Shear forces generated by an aspherical femoral head entering the acetabulum leading to anterosuperior chondral delamination.
. Degeneration of the ligamentum teres due to repetitive microtrauma.
. Extra-articular impingement of the anterior inferior iliac spine (AIIS) against the femur.
. Avascular necrosis of the femoral head due to compromised medial circumflex femoral artery.

Correct Answer & Explanation

. Shear forces generated by an aspherical femoral head entering the acetabulum leading to anterosuperior chondral delamination.

Explanation

The patient has Cam-type femoroacetabular impingement (FAI), characterized by an abnormally elevated alpha angle (>50-55 degrees) denoting an aspherical femoral head-neck junction. During hip flexion and internal rotation, this cam lesion is forced into the acetabulum, generating significant shear forces. This mechanism classically causes anterosuperior acetabular cartilage delamination and 'inside-out' tearing of the labrum. Linear crushing of the labrum is characteristic of Pincer impingement.

Question 1844

Topic: Shoulder & Hip Sports

A 24-year-old male rugby player undergoes an open Latarjet procedure for recurrent anterior shoulder instability associated with 25% glenoid bone loss. During the anterior approach, the conjoined tendon is aggressively retracted medially to obtain adequate exposure of the anterior glenoid neck. Which of the following nerves is at greatest risk of neuropraxia due to this maneuver?

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

Correct Answer & Explanation

. Musculocutaneous nerve

Explanation

The musculocutaneous nerve typically enters the coracobrachialis muscle 3 to 8 cm distal to the tip of the coracoid process. Overly vigorous medial retraction of the conjoined tendon puts direct traction on this nerve, making it the most commonly injured nerve (usually neuropraxia) during the Latarjet procedure.

Question 1845

Topic: Shoulder & Hip Sports

A 52-year-old recreational tennis player presents with chronic right shoulder pain. MRI shows a massive, retracted, and irreparable tear of the supraspinatus and infraspinatus with Goutallier grade 4 fatty infiltration. The subscapularis and teres minor are completely intact.

Active forward elevation is 150 degrees. The surgeon plans an arthroscopic superior capsular reconstruction (SCR). What are the correct anatomic medial and lateral fixation sites for the graft?

. Superior glenoid tubercle and lesser tuberosity
. Superior glenoid neck and greater tuberosity
. Base of the coracoid process and greater tuberosity
. Undersurface of the acromion and greater tuberosity
. Superior labrum and bicipital groove

Correct Answer & Explanation

. Superior glenoid neck and greater tuberosity

Explanation

Superior capsular reconstruction (SCR) is designed to restore the superior restraints of the glenohumeral joint to prevent superior migration of the humeral head. The graft is anchored medially to the superior glenoid neck (just medial to the superior labrum) and laterally to the superior footprint of the greater tuberosity.

Question 1846

Topic: Shoulder & Hip Sports

A 24-year-old rugby player undergoes an open Latarjet procedure for recurrent anterior shoulder instability with 25% glenoid bone loss. Postoperatively, the patient reports numbness over the lateral forearm and weakness in elbow flexion. Which nerve was most likely injured during the procedure?

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

Correct Answer & Explanation

. Musculocutaneous nerve

Explanation

The musculocutaneous nerve typically enters the coracobrachialis 3-8 cm distal to the coracoid process tip. Vigorous medial retraction of the conjoint tendon during the Latarjet procedure places this nerve at high risk of a traction neuropraxia. Clinical signs include lateral forearm numbness (via the lateral antebrachial cutaneous nerve) and weakness in the biceps and brachialis muscles.

Question 1847

Topic: Shoulder & Hip Sports

A 21-year-old hockey player presents with chronic groin pain exacerbated by hip flexion and internal rotation. Radiographs demonstrate a pistol grip deformity and an alpha angle of 75 degrees. Which of the following is the most likely intra-articular finding associated with this specific morphological variant?

. Chondral delamination of the anterosuperior acetabulum
. Posteromedial labral tear
. Ligamentum teres rupture
. Subspine impingement
. Acetabular retroversion

Correct Answer & Explanation

. Chondral delamination of the anterosuperior acetabulum

Explanation

The patient has a Cam-type femoroacetabular impingement (FAI), indicated by the pistol grip deformity and elevated alpha angle (>50-55 degrees). Cam impingement characteristically causes shear stress on the anterosuperior acetabular cartilage during flexion and internal rotation, leading to chondral delamination from the subchondral bone (the 'peel-back' lesion), often with a relatively intact overlying labrum.

Question 1848

Topic: Shoulder & Hip Sports

A 45-year-old recreational weightlifter presents with deep shoulder pain and clicking. Physical examination reveals positive O'Brien and Crank tests. MRI arthrogram demonstrates a Type II SLAP tear. Six months of physical therapy and injections have failed. What is the most appropriate surgical management for this patient?

. SLAP repair using two suture anchors
. Debridement of the superior labrum only
. Biceps tenodesis
. Glenohumeral arthrodesis
. Coracoid transfer

Correct Answer & Explanation

. Biceps tenodesis

Explanation

In patients older than 40 years with a symptomatic Type II SLAP tear, primary biceps tenodesis has been shown to yield better clinical outcomes, higher rates of return to previous activity levels, and significantly lower complication and stiffness rates compared to primary SLAP repair. SLAP repair in this older demographic is associated with a high rate of postoperative stiffness and clinical failure.

Question 1849

Topic: Shoulder & Hip Sports

A 24-year-old competitive rugby player with recurrent anterior shoulder dislocations undergoes imaging which demonstrates 25% anteroinferior glenoid bone loss and an engaging Hill-Sachs lesion. He is scheduled for a Latarjet procedure.

The conjoint tendon provides a dynamic sling effect. Which nerve is most at risk during the coracoid osteotomy and transfer?

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

Correct Answer & Explanation

. Musculocutaneous nerve

Explanation

The musculocutaneous nerve typically penetrates the coracobrachialis muscle 3 to 8 cm distal to the tip of the coracoid process, making it highly vulnerable during the Latarjet procedure, particularly during coracoid preparation and retraction of the conjoint tendon.

Question 1850

Topic: Shoulder & Hip Sports

A 28-year-old male overhead athlete presents with deep shoulder pain and clicking. The 'peel-back' mechanism is suspected to be the cause of his symptoms. Which of the following best describes the pathophysiology of this mechanism?

. Increased torsional forces at the biceps anchor during late cocking phase of throwing
. Direct compression of the labrum during the follow-through phase
. Traction injury to the inferior glenohumeral ligament during deceleration
. Internal impingement of the rotator cuff against the posterosuperior glenoid
. Subcoracoid impingement of the subscapularis during internal rotation

Correct Answer & Explanation

. Increased torsional forces at the biceps anchor during late cocking phase of throwing

Explanation

The 'peel-back' mechanism occurs in overhead throwing athletes during the late cocking phase (maximal abduction and external rotation). The biceps vector shifts posteriorly, creating a torsional force at the superior labrum-biceps anchor, which can predictably result in a type II SLAP tear.

Question 1851

Topic: Shoulder & Hip Sports

A 24-year-old elite baseball pitcher complains of vague, deep right shoulder pain and a recent decrease in throwing velocity. Physical examination demonstrates normal forward elevation, internal rotation of 25 degrees, and external rotation of 130 degrees. The contralateral shoulder has internal rotation of 60 degrees and external rotation of 95 degrees. MRI arthrogram reveals a type II SLAP tear. What is the most appropriate initial management?

. Arthroscopic SLAP repair
. Open subpectoral biceps tenodesis
. Non-operative management focusing on posterior capsular stretching
. Anterior capsulolabral reconstruction
. Arthroscopic posterior capsular release

Correct Answer & Explanation

. Non-operative management focusing on posterior capsular stretching

Explanation

The patient demonstrates Glenohumeral Internal Rotation Deficit (GIRD) with an essentially normal total arc of motion (155 degrees on the right vs. 155 degrees on the left). In overhead throwers, a type II SLAP tear is often the result of the 'peel-back' mechanism exacerbated by a tight posterior capsule. Initial management must focus on non-operative rehabilitation, specifically utilizing sleeper stretches to address the posterior capsular contracture. Surgical intervention, such as SLAP repair or biceps tenodesis, is reserved for patients who fail an exhaustive trial of targeted physical therapy, as return to prior performance levels after surgery in elite throwers can be unpredictable.

Question 1852

Topic: Shoulder & Hip Sports

A 22-year-old collegiate football player sustains a recurrent anterior shoulder dislocation. Imaging (Figure 15) shows a significant anteroinferior glenoid bone loss estimated at 27%. Which of the following is the most appropriate surgical management?

. Arthroscopic Bankart repair
. Latarjet procedure
. Open capsular shift
. Arthroscopic remplissage procedure
. Biceps tenodesis

Correct Answer & Explanation

. Latarjet procedure

Explanation

A Latarjet procedure (coracoid transfer) is indicated for recurrent anterior shoulder instability in the presence of critical glenoid bone loss, generally accepted as >20-25%. An arthroscopic Bankart repair alone in this setting has an unacceptably high recurrence rate. Remplissage is used to address large engaging Hill-Sachs lesions (humeral bone loss), not critical glenoid bone loss.

Question 1853

Topic: Shoulder & Hip Sports

A 19-year-old female gymnast complains of bilateral shoulder pain and a feeling of her shoulders 'slipping out of place' during routines. Physical examination reveals a positive sulcus sign bilaterally that does not obliterate with external rotation, a positive Beighton score of 7/9, and symmetric voluntary posterior subluxation. What is the most appropriate initial management?

. Arthroscopic capsular plication
. Open inferior capsular shift
. Supervised physical therapy focusing on periscapular and rotator cuff strengthening
. Thermal capsulorrhaphy
. Arthroscopic Bankart repair

Correct Answer & Explanation

. Supervised physical therapy focusing on periscapular and rotator cuff strengthening

Explanation

This patient presents with classic signs of multidirectional instability (MDI) associated with generalized ligamentous laxity. The initial treatment for MDI is always conservative, consisting of a prolonged course (often 6 months or more) of supervised physical therapy emphasizing strengthening of the periscapular musculature and rotator cuff to provide dynamic shoulder stability. Surgery (such as capsular plication or open inferior capsular shift) is reserved for patients who fail extensive conservative management.

Question 1854

Topic: Shoulder & Hip Sports

A 19-year-old competitive swimmer presents with bilateral shoulder pain and a positive sulcus sign. She is diagnosed with multidirectional instability (MDI). What is the mainstay of initial treatment for her condition?

. Pectoralis major strengthening and stretching
. Deltoid isolation exercises
. Rotator cuff and periscapular stabilization program
. Latissimus dorsi aggressive stretching
. Arthroscopic capsular plication

Correct Answer & Explanation

. Rotator cuff and periscapular stabilization program

Explanation

The first line of treatment for multidirectional instability (MDI) is an extensive and prolonged physical therapy program focusing on strengthening the rotator cuff and periscapular stabilizers to improve dynamic joint control.

Question 1855

Topic: Shoulder & Hip Sports

A 55-year-old man presents with chronic shoulder weakness. MRI demonstrates a massive, retracted tear of the supraspinatus and infraspinatus tendons. Fatty infiltration is Goutallier grade 3. Electromyography reveals denervation of the infraspinatus. What is the most likely anatomic cause of this neurologic finding?

. Traction on the suprascapular nerve at the spinoglenoid notch
. Compression of the axillary nerve at the quadrilateral space
. Traction on the suprascapular nerve at the suprascapular notch
. Compression of the spinal accessory nerve
. Traction of the musculocutaneous nerve

Correct Answer & Explanation

. Traction on the suprascapular nerve at the suprascapular notch

Explanation

Retraction of massive posterosuperior rotator cuff tears alters the course of the suprascapular nerve, often tethering or applying traction to it at the suprascapular notch, leading to neuropathy.

Question 1856

Topic: Shoulder & Hip Sports

A 23-year-old rugby player presents with recurrent anterior shoulder instability. CT scan with 3D reconstruction reveals 28% glenoid bone loss. He is planned for a Latarjet procedure. Which of the following best describes the "sling effect" contributing to anterior stability in this procedure?

. The conjoint tendon reinforcing the inferior capsule when the arm is abducted and externally rotated
. The subscapularis muscle acting as a superior dynamic depressor
. The coracoacromial ligament transposed to the greater tuberosity
. The pectoralis minor tendon tensioning the anterior capsule
. The osseous bone block increasing the articular arc length

Correct Answer & Explanation

. The conjoint tendon reinforcing the inferior capsule when the arm is abducted and externally rotated

Explanation

The Latarjet procedure provides stability via the bone block, capsular repair to the coracoacromial ligament stump, and the dynamic sling effect. The sling effect is produced by the conjoint tendon compressing the inferior capsule and subscapularis when the arm is abducted and externally rotated.

Question 1857

Topic: Shoulder & Hip Sports

A 25-year-old hockey player presents with chronic anterior groin pain exacerbated by hip flexion and internal rotation. Radiographs demonstrate an alpha angle of 65 degrees on the Dunn lateral view and normal acetabular version. This condition is most strongly associated with the development of which intra-articular pathology?

. Anterosuperior labral tears and adjacent chondral delamination
. Posteroinferior labral tears and pincer-type lesions
. Ligamentum teres hypertrophy
. Avascular necrosis of the femoral head
. Iliopsoas tendon snapping

Correct Answer & Explanation

. Anterosuperior labral tears and adjacent chondral delamination

Explanation

Cam impingement, characterized by an increased alpha angle (>50-55 degrees) and loss of femoral head-neck offset, results in shear forces on the anterosuperior acetabular rim during flexion. This classically leads to anterosuperior labral tears and outside-in chondral delamination.

Question 1858

Topic: Shoulder & Hip Sports

On an AP pelvis radiograph of a 30-year-old woman with hip pain, the anterior wall of the acetabulum is seen crossing over the posterior wall before reaching the lateral edge of the sourcil. This radiographic finding is indicative of:

. Cam morphology
. Acetabular retroversion
. Coxa profunda
. Protrusio acetabuli
. Femoral retroversion

Correct Answer & Explanation

. Acetabular retroversion

Explanation

The "crossover sign" occurs when the anterior wall line crosses lateral to the posterior wall line on a true AP pelvis radiograph. This indicates acetabular retroversion, a common cause of focal anterior pincer-type femoroacetabular impingement.

Question 1859

Topic: Shoulder & Hip Sports

A 45-year-old male undergoes arthroscopic rotator cuff repair for a massive, retracted, U-shaped tear. Margin convergence is performed prior to securing the tendon to the greater tuberosity. What is the primary biomechanical advantage of margin convergence?

. It increases the ultimate tensile strength of the suture anchors
. It decreases strain on the marginal tendon edges at the repair site
. It medializes the footprint to improve the lever arm of the deltoid
. It biologically enhances healing by increasing vascularity
. It completely prevents the risk of recurrent tendon retraction

Correct Answer & Explanation

. It decreases strain on the marginal tendon edges at the repair site

Explanation

Margin convergence closes the posterior and anterior leaves of a U-shaped tear, converting it to a crescent shape. This significantly decreases tension and strain at the free margin of the tendon where it is repaired to the bone footprint.

Question 1860

Topic: Shoulder & Hip Sports

A 24-year-old rugby player presents with recurrent anterior shoulder instability. 3D CT and MRI indicate 22% anterior glenoid bone loss and an engaging, off-track Hill-Sachs lesion. Which of the following surgical interventions is most appropriate to prevent recurrent instability?

. Arthroscopic Bankart repair alone
. Arthroscopic Bankart repair with remplissage
. Open Latarjet procedure
. Open inferior capsular shift
. Putti-Platt procedure

Correct Answer & Explanation

. Open Latarjet procedure

Explanation

The Latarjet procedure (coracoid transfer) is the standard of care for contact athletes with significant anterior glenoid bone loss (typically >15-20%). An arthroscopic Bankart repair alone or with remplissage is inadequate for critical glenoid bone loss.

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