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5. Sports Medicine MCQs

Practice Set 102 of 360

This practice set contains high-yield board review questions covering key concepts in 5. Sports Medicine. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 2021

Topic: Shoulder & Hip Sports
Figure 14 shows an intra-articular gadolinium-enhanced MRI scan of a 52-year-old woman who has stopped playing tennis because of pain in her left shoulder while serving. What is the most likely diagnosis?
. Superior labral detachment
. Os acromiale
. Partial-thickness rotator cuff tear on the articular side
. Medial subluxation of the long head of the biceps
. Moderate arthrosis of the glenohumeral joint

Correct Answer & Explanation

. Partial-thickness rotator cuff tear on the articular side

Explanation

DISCUSSION: The MRI scan shows increased signal intensity along the deep fibers of the supraspinatus near its insertion. This is typical of tendinosis and a probable partial-thickness rotator cuff tear.

Question 2022

Topic: 5. Sports Medicine

Osteochondritis dissecans of the capitellum is a source of elbow pain and most commonly occurs in what patient population? Review Topic

. Swimmers and divers
. Football lineman
. Rugby players
. Gymnasts and throwing athletes
. Cyclists

Correct Answer & Explanation

. Gymnasts and throwing athletes

Explanation

The etiology of osteochondritis dissecans of the capitellum is somewhat unclear. However, trauma has been implicated in this disease process. Gymnasts who load their upper extremities during tumbling and throwing athletes with repetitive trauma during the throwing motion are common patient subgroups in which osteochondritis dissecans of the elbow is seen. This often occurs in the adolescent age population.

Question 2023

Topic: Knee Sports

A patient has persistent instability symptoms one year after ACL reconstruction. Radiographs and MRI show an intact graft with a femoral tunnel that enters the notch at the 12 o'clock position. These clinical findings have been associated with which of the following? Review Topic

. Lachman 2+, negative pivot shift and higher Lysholm scores
. Lachman 2+, positive pivot shift and no change in Lysholm scores
. Positive pivot shift and lower Lysholm scores
. Lachman 1+, negative pivot shift and lower Lysholm scores
. Lachman 1+, negative pivot shift and no change in Lysholm scores

Correct Answer & Explanation

. Positive pivot shift and lower Lysholm scores

Explanation

The clinical presentation is consistent with a mal-positioned femoral tunnel leading to a vertical graft. Vertical grafts are associated with persistently positive pivot shift and lower Lysholm satisfaction scores. The Lysholm is a commonly used brief subjective questionnaire.Early arthroscopic single-incision transtibial ACL reconstruction often resulted in femoral tunnels which were at the top of the notch (12 o:clock position), rather than at the anatomic origin on the wall. The resulting vertical graft often improved anteroposterior laxity (as tested with the Lachman) but was less able to provide rotational stability (as tested with the Pivot shift).Lee et al. found a significant association between vertically positioned grafts and residual (postoperative) positive pivot shift tests. They also found patients with a vertically positioned graft had lower Lysholm satisfaction scores. They conclude more oblique positioning of the graft may have advantages in rotational stability, which in turn increase subjective patient satisfaction.Yasuda et al. noted that vertical non-anatomic tunnel placement cannot completely restore normal rotatory stability in laboratory studies.Incorrect

Question 2024

Topic: 5. Sports Medicine
In the anterior cruciate ligament (ACL)-deficient knee, which of the following variables has the highest correlation with the development of arthritis?
. Duration of time since the injury
. Patient age
. Additional ligament injury
. Degree of laxity
. Meniscal integrity

Correct Answer & Explanation

. Meniscal integrity

Explanation

DISCUSSION: Ample evidence supports an increased rate of degenerative arthritis in the ACL-deficient knee. Several variables play a role in the development of the arthritis, but the integrity of the meniscus has been shown to be the single most important factor. REFERENCES: Oโ€™Brien WR: Degenerative arthritis of the knee following anterior cruciate ligament injury: Role of the meniscus. Sports Med Arthroscopy Rev 1993;1:114-118. Fetto JF, Marshall JL: The natural history and diagnosis of anterior cruciate ligament insufficiency. Clin Orthop 1980;147:29-38. McDaniel WJ Jr, Dameron TB Jr: The untreated anterior cruciate ligament rupture. Clin Orthop 1983;172:158-163.

Question 2025

Topic: 5. Sports Medicine
What is the maximum acceptable amount of divergence of the interference screw in the femoral tunnel from the bone plug of a bone-patellar tendon-bone graft in anterior cruciate ligament (ACL) reconstruction before pull-out strength is statistically decreased?
. 0 degrees
. 10 degrees
. 15 degrees
. 30 degrees
. 45 degrees

Correct Answer & Explanation

. 15 degrees

Explanation

DISCUSSION: In the early 1990s, a transition was made from a two-incision ACL reconstruction to a single-incision ACL reconstruction, and there was concern over divergence of the femoral screws. It was shown radiographically that approximately 5% of the time, divergence of the screw was greater than 15 degrees from the bone plug. In a bovine model, there was significant loss of pull-out strength with an increase in divergence from 15 degrees to 30 degrees. Therefore, attempts should be made to minimize divergence to 15 degrees or less. REFERENCES: Lemos MJ, Jackson DW, Lee TO, et al: Assessment of initial fixation of endoscopic interference femoral screws with divergent and parallel placement. Arthroscopy 1995;11:37-41. Lemos MJ, Albert J, Simon T, et al: Radiographic analysis of femoral interference screw placement during ACL reconstruction: Endoscopic versus open technique. Arthroscopy 1993;9:154-158.

Question 2026

Topic: 5. Sports Medicine

If the quality of the tendon is poor at the lateral attachment of a partial articular side rotator cuff tear (more than 6 mm of footprint exposure or greater than 50% thickness), what should the surgeon do? Review Topic

. Use an autogenous fascial graft.
. Use an allograft augmentation.
. Complete the tear and then repair the tendon.
. Perform a trans-tendon repair.
. Biopsy the tissue.

Correct Answer & Explanation

. Complete the tear and then repair the tendon.

Explanation

Generally, partial articular side rotator cuff tears are treated by either debridement or repair. The decision to repair depends on the "thickness" of the tear and the retraction of the undersurface of the rotator cuff as well as the quality of the remaining tissue. More than 6 mm of footprint exposure suggests a 50% thicknes tear. If it is poor quality as in this case, the surgeon should complete the tear and repair the tendon as in a small full-thickness tear. Intrasubstance tears with an intact footprint can be treated with trans-tendon repair.

Question 2027

Topic: Shoulder & Hip Sports

A 22-year-old rugby player presents with recurrent anterior shoulder instability. A 3D CT scan demonstrates 25% anterior glenoid bone loss and an engaging Hill-Sachs lesion. What is the most appropriate surgical management?

. Arthroscopic Bankart repair
. Arthroscopic Bankart repair with Remplissage
. Open Latarjet procedure
. Open Bankart repair
. Proximal humerus derotational osteotomy

Correct Answer & Explanation

. Arthroscopic Bankart repair

Explanation

For critical anterior glenoid bone loss (generally >20-25%) in a high-demand collision athlete, an arthroscopic or open Bankart repair has an unacceptably high failure rate. A coracoid transfer (Latarjet) is indicated to restore the glenoid arc and provide the dynamic 'sling' effect of the conjoint tendon.

Question 2028

Topic: Shoulder & Hip Sports

A 38-year-old female presents with chronic groin pain exacerbated by hip flexion and internal rotation. An AP pelvis radiograph reveals a 'crossover sign.' What underlying pathomorphology does this indicate, and what type of impingement is most likely?

. Retroverted acetabulum; Cam impingement
. Anteverted acetabulum; Pincer impingement
. Retroverted acetabulum; Pincer impingement
. Decreased femoral head-neck offset; Cam impingement
. Coxa profunda; Cam impingement

Correct Answer & Explanation

. Retroverted acetabulum; Cam impingement

Explanation

The 'crossover sign' is visible on an AP pelvis radiograph when the anterior wall of the acetabulum crosses lateral to the posterior wall. This indicates cranial acetabular retroversion, leading to anterior overcoverage of the femoral head. It is a classic radiographic hallmark of Pincer-type femoroacetabular impingement (FAI).

Question 2029

Topic: Shoulder & Hip Sports

A 45-year-old laborer has an irreparable posterosuperior rotator cuff tear with an intact subscapularis, severe external rotation lag, and a positive hornblower's sign. There is no glenohumeral arthritis. Which tendon transfer is most biomechanically appropriate to restore external rotation?

. Pectoralis major
. Latissimus dorsi
. Lower trapezius
. Biceps brachii
. Teres major

Correct Answer & Explanation

. Pectoralis major

Explanation

For an irreparable posterosuperior cuff tear with profound external rotation weakness (hornblower's sign indicates teres minor deficiency) and an intact subscapularis, restoring external rotation is paramount. The lower trapezius tendon transfer, often augmented with an Achilles tendon allograft, most closely replicates the force vector of the infraspinatus. Latissimus dorsi is also an option but historically has variable outcomes for pure ER restoration compared to lower trapezius.

Question 2030

Topic: Shoulder & Hip Sports

In the pathophysiology of Cam-type femoroacetabular impingement (FAI), which of the following best describes the primary mechanism of chondral injury?

. Linear contact between the acetabular rim and the femoral neck causing 'contrecoup' posterior cartilage damage
. Outside-in abrasive wear of the posterior acetabular cartilage
. Shear forces generated by an aspherical femoral head entering the acetabulum causing anterosuperior chondral delamination
. Global pincer-type overcoverage causing circumferential labral ossification
. Pincer impingement leading to isolated ligamentum teres avulsion

Correct Answer & Explanation

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

Explanation

Cam FAI is characterized by an aspherical femoral head (decreased head-neck offset) that forces its way into the acetabulum during flexion. This generates significant shear forces at the anterosuperior acetabulum, tearing the labrum from the transitional cartilage and causing an 'inside-out' delamination of the articular cartilage. Contrecoup lesions are typically seen in Pincer impingement.

Question 2031

Topic: Shoulder & Hip Sports

A 28-year-old female presents with deep groin pain exacerbated by hip flexion and internal rotation. An AP pelvis radiograph demonstrates a 'cross-over sign'. What type of femoroacetabular impingement and anatomical abnormality does this represent?

. Cam impingement due to a decreased femoral head-neck offset
. Pincer impingement due to focal acetabular retroversion
. Cam impingement due to an aspherical femoral head
. Pincer impingement due to coxa profunda
. Pincer impingement due to global acetabular anteversion

Correct Answer & Explanation

. Pincer impingement due to focal acetabular retroversion

Explanation

The 'cross-over sign' occurs when the anterior wall of the acetabulum projects lateral to the posterior wall on an AP radiograph. This indicates cranial or focal acetabular retroversion, which leads to pincer-type impingement.

Question 2032

Topic: Shoulder & Hip Sports

A 25-year-old baseball pitcher complains of vague posterior shoulder pain and weakness in external rotation. Examination shows isolated atrophy of the infraspinatus with normal supraspinatus bulk. A paralabral cyst is suspected. Where is the cyst most likely located?

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

Correct Answer & Explanation

. Spinoglenoid notch

Explanation

Compression of the suprascapular nerve at the spinoglenoid notch affects only the motor branch to the infraspinatus. Compression at the suprascapular notch would affect both the supraspinatus and infraspinatus.

Question 2033

Topic: Knee Sports

A 22-year-old collegiate baseball pitcher presents with posterior elbow pain during the deceleration phase of throwing. He lacks 15 degrees of full extension. Radiographs show posteromedial olecranon osteophytes. What is the primary underlying pathomechanical cause?

. Chronic attenuation of the anterior band of the medial ulnar collateral ligament
. Lateral ulnar collateral ligament deficiency
. Partial rupture of the triceps tendon insertion
. Capitellar osteochondritis dissecans
. Hypertrophy of the radiocapitellar plica

Correct Answer & Explanation

. Chronic attenuation of the anterior band of the medial ulnar collateral ligament

Explanation

Valgus extension overload syndrome is primarily caused by chronic insufficiency of the anterior band of the UCL. This permits excessive valgus opening during throwing, leading to reactive osteophyte formation and impingement in the posteromedial olecranon fossa.

Question 2034

Topic: Shoulder & Hip Sports

A 65-year-old male presents with an irreparable subscapularis tear and recurrent anterior shoulder instability. The posterosuperior rotator cuff is intact. Which tendon transfer is most biomechanically appropriate to restore anterior shoulder stability and internal rotation?

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

Correct Answer & Explanation

. Pectoralis major transfer

Explanation

The pectoralis major transfer (either split or entire tendon) is the preferred procedure for irreparable subscapularis tears. It best replicates the vector of the subscapularis to provide anterior stability and internal rotation.

Question 2035

Topic: Shoulder & Hip Sports

A 28-year-old male undergoes arthroscopic osteochondroplasty for femoroacetabular impingement (FAI) due to a large CAM lesion. Over-resection of the anterolateral femoral head-neck junction places the patient at greatest risk for which devastating complication?

. Heterotopic ossification
. Avascular necrosis of the femoral head
. Femoral neck fracture
. Sciatic nerve injury

Correct Answer & Explanation

. Heterotopic ossification

Explanation

Resecting more than 30% of the anterolateral femoral neck diameter significantly alters the biomechanics and dramatically increases the risk of a postoperative iatrogenic femoral neck fracture.

Question 2036

Topic: Shoulder & Hip Sports

A 24-year-old elite baseball pitcher presents with posterior shoulder pain during the late cocking phase. MRI reveals a partial articular-sided supraspinatus tendon avulsion (PASTA) and a superior labrum anterior-posterior (SLAP) tear. This specific triad of "internal impingement" is most strongly associated with which clinical finding?

. Glenohumeral internal rotation deficit (GIRD)
. Anterior capsular laxity
. Scapular winging
. Isolated subscapularis weakness

Correct Answer & Explanation

. Glenohumeral internal rotation deficit (GIRD)

Explanation

Internal impingement in overhead throwing athletes (PASTA lesion, SLAP tear, posterior shoulder pain) is biomechanically driven by a tight posterior capsule, which clinically presents as Glenohumeral Internal Rotation Deficit (GIRD).

Question 2037

Topic: 5. Sports Medicine
A 30-year-old woman injures her knee while skiing. Based on the MRI scan shown in Figure 5, treatment should consist of
. anterior cruciate ligament reconstruction.
. medial collateral ligament (MCL) reconstruction.
. MCL repair.
. functional rehabilitation and early motion.
. medial meniscal repair.

Correct Answer & Explanation

. functional rehabilitation and early motion.

Explanation

The MRI scan demonstrates a grade III MCL tear. Basic science and clinical studies have shown that nonsurgical management is preferred for MCL tears. Functional rehabilitation and early motion have led to consistently better results than has surgical repair.

Question 2038

Topic: 5. Sports Medicine

Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease that is characterized by Review Topic

. onset most often by age 30.
. a temporary state of neuronal and axonal derangement.
. manifestations of affect such as apathy, irritability, and suicidal ideation.
. absence of gross pathological brain changes upon autopsy.

Correct Answer & Explanation

. onset most often by age 30.

Explanation

CTE is a neurodegenerative disease that occurs years or decades after recovery from acute or postacute effects of head trauma. The exact relationship between concussion and CTE is not entirely clear; however, early behavioral manifestations of CTE have been described by family and providers to include apathy, irritability, and suicidal ideation. For some patients, cognitive difficulty such as poor episodic memory and executive function may be the first signs of CTE. Onset most often occurs in midlife after athletes have completed their sports careers, with mean age of onset at 42 years. The effects on the brain are degenerative, leading to a permanent state of derangement. Autopsy findings demonstrate multiple gross pathological findings. The condition is more common among contact athletes.

Question 2039

Topic: Knee Sports

A 25-year-old patent underwent anterior cruciate reconstruction (ACL) surgery 6 months ago. He returns to clinic with persistent instability. Physical examination reveals full range of motion of the knee. Additional tests show a 1A Lachman, 2+ pivot shift, negative external rotation dial, negative reverse pivot shift and negative McMurray. His radiographs are shown in Figure A. What is the likely cause of his persistent symptoms? Review Topic

. Missed posterolateral corner injury
. Femoral tunnel placement did not restore the anteromedial bundle
. Tibial tunnel was positioned too anterior
. Femoral tunnel placement did not restore the posterolateral bundle
. Tibial tunnel was positioned too posterior

Correct Answer & Explanation

. Missed posterolateral corner injury

Explanation

This patient has a vertical femoral tunnel position with rotatory instability. The most likely cause of his symptoms is a femoral tunnel placement that did not restore the posterolateral bundle.An anterior cruciate reconstruction (ACL) surgery with vertically placed grafts will result in persistent knee instability. Complaints will be mainly related to activities that require twisting or cutting movements. Physical examination will likely reveal a positive pivot shift exam due to the failure to reconstruct the posterolateral bundle of the ACL. Current standards for anatomic ACL reconstruction stress the importance of more horizontal graft placement (for example, 10:30 in a right knee vs 1:30 in the left knee). This allows for more rotational stability, while maintaining anterior stability. Improper femoral graft placement is one of the most common reasons for ACL revision surgery.Noyes et al. looked at patients undergoing revision ACL surgery with the use of patellar bone-tendon-bone (BTB) autograft. They showed the rate of graft failure to be three times higher than their reported failure rate after primary ACL reconstructions.Driscoll et al. performed a biomechanical study comparing 2 femoral tunnel locations in anatomic single-bundle anterior cruciate ligament reconstruction. They found that a femoral tunnel positioned in the anatomic center of the femoral origin of the ACL, as opposed to the anteromedial position, provides the greatest amount of rotatory and anterior stability.Figure A shows AP and lateral radiographs of the knee. Note there is a autograft ACL reconstruction with vertical placement of the femoral and tibial tunnel.Incorrect Answers:

Question 2040

Topic: 5. Sports Medicine
A 24-year-old professional male soccer player has lower abdominal pain on exertion. He has pain with resisted hip adduction and with sit-ups. There is no palpable inguinal hernia with a Valsalva maneuver. Nonsurgical management has failed to provide relief. After ruling out malignancies, what is the next most appropriate step in management?
. Additional nonsurgical management
. Referral to a general surgeon
. Ultrasound of the scrotum
. CT of the pelvis
. Cortisone injection

Correct Answer & Explanation

. Referral to a general surgeon

Explanation

DISCUSSION: The patient has a sports hernia or athletic pubalgia. In high-performance athletes who have failed to respond to nonsurgical management, surgical intervention is needed to strengthen the anterior pelvic floor. Additional nonsurgical management at this point will not improve symptoms. CT scan of the pelvis is valuable to rule out bony injuries such as osteitis pubis, but surgical referral is the next step for definitive management of the athletic pubalgia.

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