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5. Sports Medicine MCQs

Practice Set 129 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 2561

Topic: 5. Sports Medicine

A 16-year-old boy sustains a twisting injury to the left knee while wrestling. MRI scans are shown in Figures 22a through 22c. What is the most likely diagnosis?

. Anterior cruciate ligament rupture
. Posterior cruciate ligament rupture
. Bucket-handle medial meniscus tear
. Lateral meniscus tear
. Osteochondral lesion

Correct Answer & Explanation

. Bucket-handle medial meniscus tear

Explanation

The MRI scans show a displaced bucket-handle medial meniscus tear that can be visualized on coronal, sagittal, and axial views. The sagittal view shows the typical "double posterior cruciate ligament sign," in which the low-signal bucket-handle fragment parallels the normal low-signal posterior cruciate ligament. The coronal and axial images both show the displaced medial meniscus in the notch. Sanders TG, Miller MD: A systematic approach to magnetic resonance imaging interpretation of sports medicine injuries of the knee. Am J Sports Med 2005;33:131-148.

Question 2562

Topic: Shoulder & Hip Sports

A 35-year-old recreational basketball player reports shoulder pain following a sprawl for a rebound. While examination reveals that he can actively elevate the arm with pain, a subacromial injection fails to provide relief. An MRI scan reveals medial subluxation of the long head of the biceps. Which of the following structures most likely has also been injured?

. Inferior glenohumeral ligament
. Middle glenohumeral ligament
. Superior labrum
. Subscapularis tendon
. Supraspinatus tendon

Correct Answer & Explanation

. Subscapularis tendon

Explanation

Subscapularis tears can be associated with disruption of the transverse ligament supporting the biceps. The remaining aspects of the rotator cuff, superior labrum, and capsule can be intact with this injury. Petersson CJ: Spontaneous medial dislocation of the tendon of the long biceps brachii. Clin Orthop 1986;211:224-227.

Question 2563

Topic: Shoulder & Hip Sports

A 36-year-old woman has pain and swelling of the anterior arm after undergoing arthroscopic shoulder surgery 8 months ago. At the time of the procedure, extensive debridement and synovectomy of the anterior aspect of the joint was performed to remove scar tissue that had formed after an open rotator cuff repair. Examination reveals a golf ball-sized swelling just lateral to the coracoid. The area is not warm and shows no other signs of infection. An MRI scan is shown in Figure 1. Management should now consist of

Upper Extremity 2005 Practice Questions: Set 1 (Solved) - Figure 1

. aspiration of the ganglion cyst.
. repair of the supraspinatus tendon.
. repair of the subscapularis tendon.
. repair of the rotator cuff interval.
. repair of the anterior labrum.

Correct Answer & Explanation

. repair of the rotator cuff interval.

Explanation

Deficiency of the rotator cuff interval may be acquired or congenital. In this patient, extensive debridement of the rotator cuff interval capsule at the time of arthroscopy most likely is the cause of the defect seen on the MRI scan. Surgical closure of the defect is the treatment of choice. During the repair, the shoulder should be placed in 30 degrees of external rotation to avoid overtightening. Care should be taken to include the leading edge of both the supraspinatus and subscapularis tendons in the repair because the rotator cuff interval capsular tissue is likely to be of poor quality. Cole BJ, Rodeo SA, O'Brien SJ, et al: The anatomy and histology of the rotator interval capsule of the shoulder. Clin Orthop 2001;390:129-137.

Question 2564

Topic: 5. Sports Medicine

Figure 19 shows an arthroscopic view from the anterior lateral portal of the knee looking into the suprapatella pouch. The use of an electrothermal device during this procedure most commonly causes significant postoperative complications by damaging which of the following structures?

Anatomy Board Review 2002: High-Yield MCQs (Set 2) - Figure 11

. Lateral facet articular cartilage of the patella
. Peroneal nerve
. Superior lateral geniculate artery
. Inferior lateral geniculate artery
. Lateral collateral ligament femoral insertion

Correct Answer & Explanation

. Superior lateral geniculate artery

Explanation

While it is possible to damage any of these structures, unrecognized intraoperative laceration without adequate coagulation of the superior lateral geniculate artery is common. This can result in significant postoperative hemarthrosis and a return to surgery when bleeding cannot be controlled. Cash JD, Hughston JC: Treatment of acute patella dislocation. Am J Sports Med 1988;16:244-249.

Question 2565

Topic: 5. Sports Medicine

A 22-year-old man reports anterior knee pain, swelling, and is unable to perform a straight leg raise after undergoing endoscopic anterior cruciate ligament (ACL) reconstruction with a bone-patellar tendon-bone autograft 1 week ago. He is afebrile. Examination reveals a clean incision, moderate effusion, a weak isometric quadriceps contraction, active knee range of motion of 5 degrees to 45 degrees, and the patella is ballottable. Knee radiographs show postoperative changes with good femoral and tibial tunnel placements, and normal patellar height. What is the next most appropriate step in management?

. Electromyography (EMG) and nerve conduction velocity studies (NCVS)
. Diagnostic ultrasonography of the patellar tendon
. MRI
. Continuous passive motion
. Knee aspiration

Correct Answer & Explanation

. Knee aspiration

Explanation

Knee pain and swelling in the first week after ACL reconstruction is usually related to a postoperative hemarthrosis. A large hemarthrosis creates capsular distension, which inhibits active quadriceps contraction by a neurologic reflex, the H. reflex. Kennedy and associates reported that an experimentally induced knee effusion at 60 mL was found to result in profound inhibition of reflexly evoked quadriceps contraction. Removal of the hemarthrosis by aspiration will improve strength and often instantaneously restore the ability to contract the quadriceps muscle. A large effusion will also limit knee flexion. EMG and NCVS are not necessary unless there is a high index of suspicion of a femoral neuropathy. Diagnostic ultrasonography is not necessary in this patient but can be useful in the assessment of patellar tendon integrity. MRI is not indicated and would most likely be limited by artifact and postoperative changes. Continuous passive motion is not indicated and would most likely worsen the patient's symptoms. Kennedy JC, Alexander IJ, Hayes KC: Nerve supply of the human knee and its functional importance. Am J Sports Med 1982;10:329-335.

Question 2566

Topic: 5. Sports Medicine

A professional pitcher reports pain localized to the medial aspect of his throwing elbow. History reveals that he was pitching in a playoff game and heard and felt a pop in his elbow. MRI reveals a complete ulnar-sided avulsion of the medial collateral ligament (MCL). Examination reveals valgus instability and ulnar nerve involvement. What recommendations should be made based on the patient's desire to return to sport?

. Surgical reconstruction
. Rest, followed by physical therapy
. Splinting in 15 degrees of flexion
. Primary repair
. Arthroscopic debridement, followed by bracing in full extension for 4 weeks

Correct Answer & Explanation

. Surgical reconstruction

Explanation

Injuries to the MCL usually result from repetitive high valgus stress on the medial aspect of the elbow joint due to overhead throwing or racquet sports. Excessive stresses during the late cocking and acceleration phase of throwing can injure the anterior band of the MCL. Clinically, the injuries may present as chronic or acute, and a pop may be noted in the latter. Associated ulnar nerve involvement is common. Valgus instability is present in about 25% of patients. Patients typically are athletes who participate in throwing and have localized medial elbow pain and tenderness along the course of a ligament that extends from the medial epicondyle of the distal humerus to the sublime tubercle of the ulna. Surgical reconstruction is the procedure of choice in an athlete desiring a return to a high level of throwing. Miller MD, Cooper DE, Warner JJP (eds): Review of Sports Medicine and Arthroscopy. Philadelphia, PA, WB Saunders, 1995, p 230. Arendt EA (ed): Orthopaedic Knowledge Update: Sports Medicine 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, p 227.

Question 2567

Topic: 5. Sports Medicine

The primary function of structure "A" in Figure 29 is to limit

Sports Medicine 2004 Practice Questions: Set 3 (Solved) - Figure 15

. posterior tibial displacement at 90 degrees of flexion.
. varus knee laxity at 30 degrees of flexion.
. varus knee laxity at 0 degrees of flexion.
. anterolateral rotation of the tibia on the femur.
. posterolateral rotation of the tibia on the femur.

Correct Answer & Explanation

. posterolateral rotation of the tibia on the femur.

Explanation

The primary function of the popliteofibular ligament is to resist posterolateral rotation of the tibia on the femur, although it also secondarily resists varus angulation and posterior displacement of the tibia on the femur. The posterior cruciate ligament resists posterior tibial displacement, especially at 90 degrees of flexion. The lateral collateral ligament primarily resists varus displacement at 30 degrees of flexion but also resists posterolateral rotatory displacement with flexion that is less than approximately 50 degrees. The anterior and posterior cruciate ligaments resist varus displacement (along with the lateral collateral ligament) at 0 degrees of flexion. The anterior cruciate ligament primarily resists anterolateral displacement of the tibia on the femur. Sugita T, Amis AA: Anatomic and biomechanical study of the lateral collateral and popliteofibular ligaments. Am J Sports Med 2001;29:466-472.

Question 2568

Topic: 5. Sports Medicine

A 40-year-old woman reports the atraumatic onset of severe knee pain and swelling after undergoing an uncomplicated elective cholecystectomy 1 week ago. She denies any history of diabetes mellitus or HIV but has had occasional episodes of mild knee pain and swelling that have always responded to nonsteroidal anti-inflammatory drugs. Radiographs are shown in Figures 5a and 5b. A knee aspiration yields a WBC count of 35,000/mm3. The aspirate should also yield which of the following findings?

. Strongly negative needle-shaped crystals
. Weakly positive birefringent rhomboid-shaped crystals
. Gross blood
. Gram-positive cocci
. Gram-negative rods

Correct Answer & Explanation

. Weakly positive birefringent rhomboid-shaped crystals

Explanation

The radiographs reveal chondrocalcinosis of the menisci. This is caused by calcium pyrophosphate crystals, which are weakly positive birefringent rhomboid-shaped crystals. Frequently, this condition is asymptomatic; however, routine abdominal surgery may cause precipitation of these crystals and pain. Gout, which is caused by strongly negative birefringent needle-shaped sodium urate crystals, is not associated with chondrocalcinosis and is rare in younger women. Gross blood is uncommon without trauma. Infection is not likely in a healthy patient who underwent uncomplicated surgery. Fisseler-Eckhoff A, Muller KM: Arthroscopy and chondrocalcinosis. Arthroscopy 1992;8:98-104.

Question 2569

Topic: Shoulder & Hip Sports

A 35-year-old woman dislocated her right shoulder in a fall from a step stool several months ago. She now reports several painful recurrences. Examination reveals anterior and inferior apprehension that reproduces her symptoms. An MRI scan is shown in Figure 17. Management should consist of

Upper Extremity Board Review 2005: High-Yield MCQs (Set 2) - Figure 16

. open repair of the lateral joint capsule disruption.
. open Bankart-type repair of the labral-glenoid tear.
. arthroscopic repair of the Bankart lesion.
. physical therapy for rotator cuff strengthening.
. immobilization for 6 weeks, followed by rehabilitation.

Correct Answer & Explanation

. open repair of the lateral joint capsule disruption.

Explanation

The MRI findings reveal a disruption of the humeral insertion of the glenohumeral ligaments and joint capsule (humeral avulsion of the glenohumeral ligament). This lesion has been reported to account for an 8% rate of recurrent dislocation in a subset of patients who are typically older than those with the more common lesions of the glenoid labrum (Bankart lesion). Open repairs have been reported to be successful in the prevention of recurrent instability. Since there is no Bankart lesion, open or arthroscopic labral repairs are not indicated. Nonsurgical management is possible if the patient does not want to undergo surgery; however, the recurrence rate is very high. Wolf EM, Cheng JC, Dickson K: Humeral avulsion of glenohumeral ligaments as a cause of anterior shoulder instability. Arthroscopy 1995;11:600-607. Bokor DJ. Conboy VB. Olson C: Anterior instability of the glenohumeral joint with humeral avulsion of the glenohumeral ligament: A review of 41 cases. J Bone Joint Surg Br 1999;81:93-96.

Question 2570

Topic: 5. Sports Medicine

What percent of the adult human meniscus is vascularized?

. 0%
. 5%
. 25%
. 50%
. 100%

Correct Answer & Explanation

. 25%

Explanation

The adult menisci are considered to be relatively avascular structures, with the peripheral blood supply originating predominately from the lateral and medial genicular arteries. Branches of these vessels form the perimeniscal capillary plexus, which supplies the peripheral border throughout its attachment to the joint capsule. Vascular penetration studies have shown that 10% to 30% of the peripheral portion of the medial meniscus and 10% to 25% of the lateral meniscus are vascularized. Arnoczky SP, Warren RF: Microvasculature of the human meniscus. Am J Sports Med 1982;10:90-95.

Question 2571

Topic: 5. Sports Medicine

A 15-year-old boy who participates in track reports acute pain along the left iliac crest during a sprint. Examination reveals that the anterior superior iliac spine is nontender. The most likely diagnosis is an injury to the

Sports Medicine 2001 Practice Questions: Set 1 (Solved) - Figure 29

. epiphysis.
. apophysis.
. enthesis.
. tendon.
. muscle.

Correct Answer & Explanation

. apophysis.

Explanation

The patient has iliac apophysitis. The radiographic findings are easily overlooked but usually reveal slight asymmetric widening of the iliac crest apophysis. The apophysis is the most vulnerable structure, as it is three to five times weaker than the tendon. This is not an epiphyseal site, and injury to the muscle or the tendinous insertion to bone (enthesis) is unlikely. Clancy WG Jr, Foltz AS: Iliac apophysitis and stress fractures in adolescent runners. Am J Sports Med 1976;4:214-218. Waters PM, Millis MB: Hip and pelvic injuries in the young athlete, in Stanitski CL, DeLee JC, Drez D Jr (eds): Pediatric and Adolescent Sports Medicine. Philadelphia, PA, WB Saunders, 1994, pp 279-293. Lombardo SJ, Retting AC, Kerlan RK: Radiographic abnormalities of the iliac apophysis in adolescent athletes. J Bone Joint Surg Am 1983;65:444-446.

Question 2572

Topic: Shoulder & Hip Sports

A 65-year-old woman sustained an axial load on the arm followed by an abduction injury after falling on ice. Treatment in the emergency department consisted of reduction of an anterior dislocation. She now has a positive drop arm sign and a positive lift-off test. An MRI scan is shown in Figure 9. Based on these findings, management should consist of

Upper Extremity 2005 Practice Questions: Set 1 (Solved) - Figure 22

. tenolysis of the biceps.
. repair of the subscapularis using suture anchors.
. repair of the subscapularis tendon and biceps tenodesis.
. repair of the subscapularis tendon and removal of the loose body.
. observation.

Correct Answer & Explanation

. repair of the subscapularis tendon and biceps tenodesis.

Explanation

Dislocation of the long head of the biceps tendon is the result of a defect in the region of the rotator cuff interval, coracohumeral ligament-superior glenohumeral ligament pulley, or an associated tear of the medial insertion of the subscapularis tendon. In the case of an intra-articular dislocation of the long head of the biceps tendon associated with a tear of the subscapularis tendon, stabilization of the biceps tendon is difficult in this situation; therefore, biceps release or tenodesis and repair of the subscapularis tendon is the treatment of choice. Eakin CL, Faber KJ, Hawkins RJ, et al: Biceps tendon disorders in athletes. J Am Acad Orthop Surg 1999;7:300-310. Sethi N, Wright R, Yamaguchi K: Disorders of the long head of the biceps tendon. J Shoulder Elbow Surg 1999;8:644-654.

Question 2573

Topic: Shoulder & Hip Sports
A 43-year-old bus driver sustains a hyperextension injury to her arm and shoulder 4 months after undergoing an open Bankart repair. Examination reveals increased external rotation, anterior shoulder pain, and internal rotation weakness. Her examination also reveals the findings shown in Figure 44. What is the most likely diagnosis?
. Superior labrum anterior and posterior lesion, type III
. Isolated traumatic dislocation
. Axillary nerve disruption
. Subscapularis rupture
. Internal impingement

Correct Answer & Explanation

. Subscapularis rupture

Explanation

An isolated tear of the subscapularis tendon has been noted as early as 1835 by Smith. In Gerber and associates' 1991 report of 16 men with an average age of 51 years, isolated subscapularis tendon rupture was often caused by a violent hyperextension injury. All patients reported pain anteriorly along with night pain. They also noted pain and weakness of the arm. The lift-off test is performed by having the patient lift the palm of the hand away from the small of the back. The patient must have sufficient internal rotation to allow this test to be performed. A subscapularis rupture is likely if the patient cannot perform the lift-off test.

Question 2574

Topic: 5. Sports Medicine

A 26-year-old ballet dancer reports posterolateral ankle pain, especially with maximal plantar flexion. Examination reveals maximal tenderness just posterior to the lateral malleolus, and symptoms are heightened with forced passive plantar flexion. Radiographs are shown in Figures 42a and 42b. What is the most likely cause of the patient's symptoms?

. Posterior impingement of the os trigonum
. Subluxation of the peroneal tendon
. Posterior tibial stress fracture
. Osteochondritis dissecans of the lateral dome of the talus
. Stenosis of the peroneal tendon sheath

Correct Answer & Explanation

. Posterior impingement of the os trigonum

Explanation

The patient has a symptomatic os trigonum caused by impingement that occurs with maximal plantar flexion of the ankle in the demi-pointe or full-pointe position. Patients frequently report posterolateral pain localized behind the lateral malleolus that may be misinterpreted as a disorder of the peroneal tendon. Pain with passive plantar flexion (the plantar flexion sign) indicates posterior impingement, not a problem with the peroneal tendon. The symptoms are not characteristic of a stress fracture, nor do the radiographs show a stress fracture or an osteochondritis dissecans lesion. The os trigonum is modest in its dimensions. The incidence or magnitude of symptoms does not correlate with the size of the fragment. Large fragments may be asymptomatic, while small lesions may create significant symptoms. Marotta JJ, Micheli LJ: Os trigonum impingement in dancers. Am J Sports Med 1992;20:533-536.

Question 2575

Topic: 5. Sports Medicine

A 15-year-old high school soccer player collides with an opponent and is unconscious when the trainer arrives on the field. He is conscious within 15 seconds, breathing appropriately, and denies any headache, neck pain, or nausea. It is his first head injury. Provided that the athlete is free of symptoms, when should he be allowed to return to athletic activity?

Sports Medicine 2007 Practice Questions: Set 1 (Solved) - Figure 29

. Immediately
. After 30 minutes
. After 24 hours
. After 4 weeks
. Next season

Correct Answer & Explanation

. After 4 weeks

Explanation

The loss of consciousness indicates a grade 2 concussion, which necessitates a 4-week period out of sport. The last week prior to return must be symptom-free and the athlete should not have symptoms in practice. Cantu RC: Return to play guidelines after a head injury. Clin Sports Med 1998;17:45-60.

Question 2576

Topic: Shoulder & Hip Sports
A 58-year-old woman with a history of severe asthma and long-term prednisone use reports a progression of chronic shoulder pain for the past 6 months. Radiographs and MRI scans are shown in Figures 30a through 30d. What is the most likely diagnosis?
. Osteonecrosis of the humeral head
. Partial-thickness supraspinatus tendon tear
. Full-thickness supraspinatus tendon tear
. Glenohumeral septic arthritis
. Rheumatoid arthritis

Correct Answer & Explanation

. Osteonecrosis of the humeral head

Explanation

The patient has osteonecrosis of the humeral head. The radiographs show increased density in the superior subchondral region of the humeral head. The MRI scans reveal a central collapse of the humeral head. The patient's history of severe asthma and long-term prednisone use predisposes her to this condition. The MRI scans show no evidence of a full- or partial-thickness rotator cuff tear. Without a history of fevers, chills, or other systemic signs or symptoms, there is no indication of septic arthritis. The radiographs do not reveal periarticular erosions, commonly seen in rheumatoid arthritis. Matsen FA III, Rockwood CA Jr, Wirth MA, et al: Glenohumeral arthritis and its management, in Rockwood CA Jr, Matsen FA III (eds): Rockwood and Matsen The Shoulder, ed 2. Philadelphia, PA, WB Saunders, 1998, pp 871-874.

Question 2577

Topic: 5. Sports Medicine

A 38-year-old left hand-dominant bodybuilder reports ecchymosis in the left axilla and anterior brachium after sustaining an injury while bench pressing 3 weeks ago. Coronal and axial MRI scans are shown in Figures 16a and 16b. What treatment method yields the best long-term results?

. Physical therapy and nonsteroidal anti-inflammatory drugs
. Local corticosteroid injection and physical therapy
. Open repair of the long head of the biceps
. Open repair of the sternocostal portion of the pectoralis major tendon
. Open repair of the clavicular portion of the pectoralis major tendon

Correct Answer & Explanation

. Open repair of the sternocostal portion of the pectoralis major tendon

Explanation

The MRI scans show a rupture of the sternocostal portion of the pectoralis major tendon. This is the most common site of rupture and bench pressing is the most common etiology. Surgical repair yields better functional outcomes and patient satisfaction for tears not only at the tendon/bone interface but also at the myotendinous junction. Bak K, Cameron EA, Henderson IJ: Rupture of the pectoralis major: A meta-analysis of 112 cases. Knee Surg Sports Traumatol Arthrosc 2000;8:113-119.

Question 2578

Topic: Shoulder & Hip Sports

A 72-year-old woman who fell on her right shoulder while using a treadmill is now unable to elevate her right arm. An MRI scan is shown in Figure 7. What is the most likely diagnosis?

Upper Extremity 2005 Practice Questions: Set 1 (Solved) - Figure 18

. Axillary nerve injury
. Anterior dislocation
. Extension of a chronic large rotator cuff tear
. Suprascapular nerve entrapment from a ganglion cyst
. Greater tuberosity avulsion

Correct Answer & Explanation

. Extension of a chronic large rotator cuff tear

Explanation

The MRI scan reveals a large chronic rotator cuff tear with retraction and fatty infiltration atrophy of the supraspinatus and infraspinatus tendons. This tear is responsible for the patient's severe weakness and inability to elevate the arm.

Question 2579

Topic: 5. Sports Medicine

A 10-year-old boy has activity-related knee pain that is poorly localized. He denies locking, swelling, or giving way. Examination shows mild tenderness at the medial femoral condyle and painless full range of motion without ligamentous instability. Radiographs are shown in Figures 2a through 2c. What is the best course of action?

. Knee arthroscopy with drilling of the lesion
. Limited activity for 6 to 12 weeks
. Removal of the loose body
. Biopsy of the lesion
. Open reduction and internal fixation

Correct Answer & Explanation

. Limited activity for 6 to 12 weeks

Explanation

The radiographs show an osteochondritis dissecans (OCD) lesion in the medial femoral condyle of a skeletally immature patient. The lesion is not displaced from its bed. Nonsurgical management of a stable OCD lesion in a patient with open physes consists of a period of activity limitation and occasional immobilization. Unstable lesions, loose bodies, and patients with closed physes require more aggressive treatment. Most of the surgical procedures can be done arthroscopically. Because the radiographic appearance is typical, biopsy is unnecessary. The radiographs do not show an osteocartilaginous loose body, and the patient reports no catching or locking; therefore, removal of the loose body is not indicated. Linden B: Osteochondritis dissecans of the femoral condyles: A long term follow-up study. J Bone Joint Surg Am 1977;59:769-776. Cahill BR: Osteochondritis dissecans of the knee: Treatment of juvenile and adult forms. J Am Acad Orthop Surg 1995;3:237-247.

Question 2580

Topic: Shoulder & Hip Sports

A 67-year-old woman is seen in the emergency department after falling at home. Radiographs before and after treatment are shown in Figures 49a and 49b, respectively. Which of the following best explains the 8-week postinjury clinical findings seen in Figure 49c?

. Axillary nerve palsy
. Spinal accessory nerve palsy
. Deltoid avulsion
. Rotator cuff tear
. Unreduced posterior glenohumeral dislocation

Correct Answer & Explanation

. Rotator cuff tear

Explanation

Patients older than age 40 years at the time of initial anterior dislocation have low rates of redislocation; however, 15% of these patients experience a rotator cuff tear. Moreover, there is a dramatic increase (up to 40%) in the incidence of rotator cuff tears in patients older than age 60 years. Axillary nerve injury may occur but is less common than rotator cuff tear. Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 273-284.

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