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 2281
Topic: Knee Sports
A 24-year-old athlete sustains a twisting injury to his knee. On physical examination, he demonstrates 15 degrees of increased external tibial rotation compared to the contralateral side at 30 degrees of flexion, but symmetric external rotation at 90 degrees of flexion. What is the most likely injured structure?
Correct Answer & Explanation
. Posterolateral corner (PLC) isolated injury
Explanation
The Dial test assesses external tibial rotation. Increased rotation at 30 degrees but not at 90 degrees indicates an isolated posterolateral corner (PLC) injury. Combined PCL and PLC injuries show increased rotation at both 30 and 90 degrees.
Question 2282
Topic: Knee Sports
A 24-year-old male sustains a high-energy posterior knee dislocation (KD III). Following successful closed reduction, his foot is warm and pink, and ABIs are >0.9 bilaterally. He undergoes multi-ligament knee reconstruction 3 weeks later. During surgery on the posterolateral corner, the common peroneal nerve is visualized and protected. However, postoperatively he has a new-onset foot drop. What is the most likely cause of this isolated nerve palsy?
Correct Answer & Explanation
. Traction injury to the nerve due to a tight fascial band at the fibular neck during surgical positioning/manipulation
Explanation
The common peroneal nerve is tightly tethered at the fibular neck. Indirect traction injuries during posterolateral corner reconstruction or positioning are the most common cause of iatrogenic palsy in this setting, even when the nerve is directly visualized and protected.
Question 2283
Topic: 5. Sports Medicine
A 40-year-old male with a BMI of 38 presents with a complete, mid-substance patellar tendon rupture sustained 6 months ago. He has a high-riding patella and a severe extensor lag. Primary end-to-end repair is impossible due to massive retraction. Which of the following is the most appropriate surgical reconstruction option?
Correct Answer & Explanation
. Reconstruction using an Achilles tendon allograft with a calcaneal bone block
Explanation
Chronic patellar tendon ruptures with severe retraction cannot be repaired primarily. Reconstruction using an Achilles tendon allograft with a calcaneal bone block press-fit into the tibial tubercle provides excellent biological fixation and restores extensor mechanism length.
Question 2284
Topic: 5. Sports Medicine
A 21-year-old male sustains a gunshot wound to the anterior knee. Radiographs reveal a retained bullet fragment completely within the intra-articular space of the knee joint. There are no associated fractures, and the neurovascular exam is normal. What is the most appropriate definitive management for the retained bullet?
Correct Answer & Explanation
. Arthroscopic removal of the intra-articular bullet
Explanation
Retained intra-articular bullets exposed to synovial fluid can dissolve and lead to systemic lead toxicity (plumbism) and localized lead arthropathy. They should be surgically removed, typically via arthroscopy if accessible, to prevent these complications.
Question 2285
Topic: Shoulder & Hip Sports
Figures 45a and 45b show sagittal T1-weighted MRI scans of a 35-year-old man who has had dominant extremity shoulder pain and weakness for the past 6 months. He denies any history of injury. Examination reveals full range of active and passive motion, negative Hawkins and Neer impingement signs, 5/5 abduction strength, 3+/5 external rotation strength with arm adducted at his side, and negative belly press, Hornblower's sign, Gerber lift-off, and O'Brien's test. Radiographs are unremarkable. An MR arthrogram shows no rotator cuff or labral tears and no paralabral cysts. What is the next most appropriate step in management? Review Topic
Correct Answer & Explanation
. Electromyography (EMG) and nerve conduction velocity (NCV) studies of the extremity
Explanation
The clinical history and physical examination are suggestive of weakness of the infraspinatus. An EMG/NCV study should be obtained to determine the etiology of the atrophy. In this case, the patient was shown to have suprascapular nerve entrapment at the suprascapular notch with atrophy of the infraspinatus and early signs of denervation of the supraspinatus. An MRI scan of the cervical spine would provide information if the EMG study revealed a cervical nerve compression as the etiology of the atrophy. Arthroscopic suprascapular nerve release at the suprascapular notch is the correct treatment for the lesion; however, the EMG needs to be obtained first to determine the location of nerve compression. Laboratory evaluation of C-reactive protein, erythrocyte sedimentation rate, and white blood cell count is unnecessary because there are no signs or symptoms of an infection. Corticosteroid injection of the subacromial space would not help the current problem because there are no signs or symptoms of impingement syndrome.
Question 2286
Topic: Shoulder & Hip Sports
A 20-year-old college pitcher reports the recent onset of decreased velocity and posterior shoulder pain. He states that it takes him longer to loosen up but denies any mechanical symptoms. When compared to his non-throwing shoulder, glenohumeral examination of his throwing shoulder will most likely reveal which of the following findings? Review Topic
Correct Answer & Explanation
. Coracoid tenderness
Explanation
In symptomatic throwing shoulders, loss of internal rotation in abduction resulting from posteroinferior capsular contraction exceeds adaptive gains in external rotation. Glenohumeral internal rotation deficit (GIRD) is defined as the loss in degrees of glenohumeral internal rotation of the throwing shoulder compared with the nonthrowing shoulder. The pathologic cascade initially begins with decreased velocity and command, followed by posterior stiffness and trouble loosening up. Posterior shoulder pain without mechanical symptom occurs during late cocking and early acceleration phases due to the contracture of the posterior-inferior capsule. This results in a posterosuperior shift of the glenohumeral contact, resulting in internal impingement on the undersurface of the posterior superior rotator cuff and strain on the posterior superior glenoid labral interface. The "slap event" is when the posterior superior labrum and biceps anchor fail in tension. After the "slap event", surgery is the likely solution. Prior to this event, however, posterior inferior capsular stretches may result in resolution of symptoms.
Question 2287
Topic: 5. Sports Medicine
A 14-year-old gymnast misses her dismount off of the uneven bars, hits the mat face first, and loses consciousness for about 15 seconds. She is dazed and confused for several minutes. She does not complain of pain, numbness, or weakness and she is moving all extremities without deficit. The athlete and coach would like to return to competition that day. What is the best next step?
Correct Answer & Explanation
. Advise that loss of consciousness precludes same day return to play.
Explanation
A 19-year-old linebacker underwent a coracoid transfer procedure for recurrent anterior glenohumeral instability. At his 1-week postsurgical check-up, his incision is healing well; however, he reports numbness over the lateral aspect of his forearm. What nerve may have been injured during his surgery?A. AxillaryB. MedianC. MusculocutaneousD. Radial
Question 2288
Topic: 5. Sports Medicine
A 12-year-old boy who pitches on two select baseball teams has had pain in his dominant right shoulder for the past 6 weeks. The pain is present only with throwing and is associated with decreased throwing velocity and control. He has no radiation of pain or paresthesias of the upper extremity. An AP radiograph and MRI scan are shown in Figures 19a and 19b, respectively. Management should consist of
Correct Answer & Explanation
. rest from throwing activities.
Explanation
The imaging study demonstrates characteristics of Little Leaguer’s shoulder, including physeal widening. This condition is secondary to overuse (typically throwing) and responds well to rest from the inciting activity. There is no evidence from the patient’s history or examination that he has an impingement syndrome, nor is there any indication of labral pathology on the MRI scan. The changes in the proximal humerus are classic for this condition and are not suggestive of a neoplastic process requiring biopsy for definitive diagnosis.
Question 2289
Topic: Shoulder & Hip Sports
A 22-year-old collegiate rugby player presents with recurrent anterior shoulder instability. A CT scan with 3D reconstruction demonstrates 22% anterior glenoid bone loss and an engaging Hill-Sachs lesion. Which of the following is the most appropriate definitive surgical management?
Correct Answer & Explanation
. Latarjet procedure (coracoid transfer)
Explanation
Engaging Hill-Sachs lesions in the presence of >20% anterior glenoid bone loss represent 'off-track' lesions with severe bone deficiency. Soft tissue stabilization (Bankart repair), even with remplissage, is associated with unacceptably high failure rates in this setting. The Latarjet procedure (coracoid transfer) restores the bony arc of the glenoid and provides a dynamic soft-tissue sling effect via the conjoint tendon, making it the standard of care.
Question 2290
Topic: Shoulder & Hip Sports
A 55-year-old manual laborer has a massive, irreparable posterosuperior rotator cuff tear. The surgeon is considering a latissimus dorsi tendon transfer. Which of the following is considered an absolute contraindication to this procedure?
Correct Answer & Explanation
. Irreparable subscapularis tear
Explanation
Latissimus dorsi tendon transfer is indicated for massive, irreparable posterosuperior rotator cuff tears (supraspinatus/infraspinatus) in younger patients without significant glenohumeral arthritis. An intact and functioning subscapularis is an absolute prerequisite; it is required to provide an anterior force couple. If the subscapularis is incompetent, the humeral head will subluxate anterosuperiorly, leading to clinical failure of the transfer.
Question 2291
Topic: Shoulder & Hip Sports
A 22-year-old male presents with recurrent anterior shoulder instability. CT shows a Hill-Sachs lesion engaging the anterior glenoid and 25% anterior glenoid bone loss. What is the most appropriate surgical intervention?
Correct Answer & Explanation
. Arthroscopic Bankart repair
Explanation
The Latarjet procedure is indicated for patients with recurrent anterior shoulder instability and significant glenoid bone loss (typically >20-25%). Arthroscopic Bankart repair alone in this setting has an unacceptably high failure rate.
Question 2292
Topic: Shoulder & Hip Sports
A 55-year-old male manual laborer presents with a massive, irreparable posterosuperior rotator cuff tear. He has an intact subscapularis, no glenohumeral arthritis, and lacks forward elevation. Which of the following is the most appropriate surgical treatment?
Correct Answer & Explanation
. Reverse total shoulder arthroplasty
Explanation
A latissimus dorsi tendon transfer is indicated for young, active patients with massive, irreparable posterosuperior cuff tears, intact subscapularis, and no arthritis. It helps restore active external rotation and forward elevation.
Question 2293
Topic: Shoulder & Hip Sports
A 45-year-old male presents with a massive, irreparable posterosuperior rotator cuff tear. His subscapularis remains intact, and he has no glenohumeral arthritis. A lower trapezius tendon transfer is planned. To optimize its line of pull, what clinical motion is this transfer primarily designed to restore?
Correct Answer & Explanation
. Forward elevation in the sagittal plane
Explanation
Lower trapezius transfer is indicated for younger patients with irreparable posterosuperior rotator cuff tears. It effectively simulates the line of pull of the infraspinatus, primarily restoring external rotation in abduction and improving overhead function.
Question 2294
Topic: Shoulder & Hip Sports
A 22-year-old rugby player has recurrent anterior shoulder instability. MRI arthrogram shows a Hill-Sachs lesion and an anterior glenoid bone loss of 25%. According to the 'glenoid track' concept, how is the track calculated to determine if the Hill-Sachs lesion is engaging?
Correct Answer & Explanation
. 0.83 x (Intact anterior-posterior glenoid width) + (Anterior bone loss)
Explanation
The glenoid track is calculated as 83% of the intact anterior-posterior glenoid width minus the measured anterior glenoid bone loss. If the Hill-Sachs lesion width extends medially beyond this track, it is considered 'off-track' and highly likely to engage.
Question 2295
Topic: Shoulder & Hip Sports
A 45-year-old heavy laborer presents with a massive, retracted, and irreducible posterosuperior rotator cuff tear. His subscapularis and teres minor are completely intact. Which tendon transfer is historically indicated to restore external rotation and elevation in this specific scenario?
Correct Answer & Explanation
. Latissimus dorsi transfer
Explanation
Latissimus dorsi tendon transfer is indicated for younger, active patients with massive, irreparable posterosuperior rotator cuff tears (supraspinatus/infraspinatus) who have an intact subscapularis. Lower trapezius transfer is a modern alternative, but latissimus dorsi is the classic historical standard.
Question 2296
Topic: Shoulder & Hip Sports
A 24-year-old professional rugby player undergoes an open Latarjet procedure for recurrent anterior shoulder instability. Postoperatively, he presents with weakness in elbow flexion and forearm supination, as well as altered sensation over the lateral aspect of the forearm. Which nerve is most likely injured?
Correct Answer & Explanation
. Musculocutaneous nerve
Explanation
The musculocutaneous nerve courses near the conjoined tendon and is at high risk during the coracoid transfer in a Latarjet procedure. Injury results in biceps and brachialis weakness (elbow flexion/supination) and sensory loss in the lateral antebrachial cutaneous nerve distribution.
Question 2297
Topic: Shoulder & Hip Sports
During a Latarjet procedure for recurrent anterior shoulder instability with significant glenoid bone loss, the coracoid process is transferred to the anterior glenoid. The primary dynamic stabilizing effect of this procedure is provided by which of the following mechanisms?
Correct Answer & Explanation
. The osseous block extending the glenoid articular arc
Explanation
The Latarjet procedure provides stability through a 'triple blocking' effect. While the bone block increases the glenoid articular surface (static stability), the primary dynamic stabilizing mechanism is the 'sling effect' created by the conjoint tendon (short head of the biceps and coracobrachialis). In abduction and external rotation, the conjoint tendon tensions across the inferior subscapularis and anteroinferior capsule, preventing anterior humeral translation.
Question 2298
Topic: Shoulder & Hip Sports
A 68-year-old male is 6 weeks status-post an anatomic total shoulder arthroplasty using a lesser tuberosity osteotomy approach. He presents with sudden onset of anterior shoulder pain and subjective weakness after attempting to lift a heavy box. On examination, he demonstrates a positive 'belly-press' test and increased passive external rotation compared to the contralateral side. What is the most likely diagnosis?
Correct Answer & Explanation
. Subscapularis failure
Explanation
Subscapularis failure is a known complication following anatomic total shoulder arthroplasty, particularly when a subscapularis peel, tenotomy, or lesser tuberosity osteotomy is utilized for anterior access. Clinical signs of subscapularis failure include a positive belly-press or lift-off test, weakness in internal rotation, an unexpected increase in passive external rotation, and anterior shoulder pain.
Question 2299
Topic: Shoulder & Hip Sports
A 22-year-old collegiate baseball pitcher presents with anterior shoulder pain and a 'dead arm' feeling during the late cocking phase of throwing. MRI arthrogram reveals a SLAP tear. Diagnostic arthroscopy confirms a Type II SLAP tear. Which of the following anatomical findings defines a Type II SLAP tear?
Correct Answer & Explanation
. Detachment of the superior labrum and biceps anchor from the superior glenoid
Explanation
The Snyder classification of SLAP tears is as follows: Type I: Fraying of the superior labrum, biceps anchor intact. Type II: Detachment of the superior labrum and biceps anchor from the glenoid. Type III: Bucket-handle tear of the labrum, biceps anchor intact. Type IV: Bucket-handle tear of the labrum that extends into the biceps tendon. Therefore, Type II is defined by detachment of the labrum and biceps anchor.
Question 2300
Topic: Shoulder & Hip Sports
A 55-year-old manual laborer presents with an irreparable massive posterior-superior rotator cuff tear. He has isolated loss of external rotation but intact subscapularis function and forward elevation. He is deemed a candidate for a lower trapezius tendon transfer. The transferred lower trapezius tendon most closely replicates the force vector of which native muscle?
Correct Answer & Explanation
. Infraspinatus
Explanation
The lower trapezius tendon transfer is increasingly utilized for massive, irreparable posterosuperior rotator cuff tears. Due to its origin, insertion, and line of pull, the lower trapezius muscle most closely replicates the exact force vector of the native infraspinatus. This makes it an excellent option for restoring active external rotation when prolonged by an Achilles tendon or hamstring allograft to reach the greater tuberosity.
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