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 2581
Topic: 5. Sports Medicine
A 36-year-old recreational tennis player sustains the injury shown in Figure 16. Management should consist of
Correct Answer & Explanation
. primary repair.
Explanation
The MRI scan shows a rupture of the patellar tendon. This injury is most appropriately addressed with primary repair. For athletic individuals, the results of nonsurgical management are suboptimal. Reconstructive procedures are not necessary. Matava MJ: Patellar tendon ruptures. J Am Acad Orthop Surg 1996;4:287-296.
Question 2582
Topic: 5. Sports Medicine
Examination of a 23-year-old female college basketball player who has had anterior knee pain for the past 3 weeks reveals tenderness and fullness over the inferior patella and proximal patellar tendon. There is no patellofemoral crepitus, patella apprehension sign, or anterior or posterior instability. Initial management should include
Correct Answer & Explanation
. ice, rest, avoidance of the offending activity, and rehabilitation.
Explanation
The patient has patellar tendinitis (jumper's knee). It is a common overuse condition seen in runners, volleyball players, soccer players, and jumpers but can be seen in any activity in which repeated extension of the knee is required. In the acute setting, the pain is well localized and there is tenderness and sometimes swelling of the tendon. MRI is recommended for evaluating chronic cases and for surgical planning. In the acute phases, ice, rest, and avoidance of the offending activity are recommended. Weakness of the quadriceps and hamstring muscle are thought to contribute to this problem; therefore, stretching and isometric exercise in a limited range of motion are important. Complete rest and intratendinous injections of steroids are detrimental to tendon physiology. Stanish WD, Rubinovich RM, Curwin S: Eccentric exercise in chronic tendinitis. Clin Orthop 1986;208:65-68.
Question 2583
Topic: Shoulder & Hip Sports
A 45-year-old recreational tennis player underwent arthroscopic decompression and mini-open repair of a small supraspinatus tendon tear 3 weeks ago after nonsurgical management failed to provide relief. He now has pain, swelling about the wound, erythema, and purulent drainage. The patient is returned to the operating room for irrigation, debridement, and cultures. What is the most common organism causing this infection?
Correct Answer & Explanation
. Propionibacterium acnes
Explanation
In a large series of mini-open rotator cuff repairs, an infection rate of at least 2% was found, with the majority of the infections caused by Propionibacterium acnes. To prevent this complication, the shoulder should be re-prepped before the mini-open incision is made to prevent bacterial contamination from the arthroscopic procedure. Herrera MF, Bauer G, Reynolds F, et al: Infection after mini-open rotator cuff repair. J Shoulder Elbow Surg 2002;11:605-608.
Question 2584
Topic: Shoulder & Hip Sports
A 64-year-old man who underwent total shoulder arthroplasty 4 weeks ago is making satisfactory progress in physical therapy, but his therapist notes limitations in external rotation to neutral. A stretching program is started, and the patient suddenly gains 90 degrees of external rotation but now reports increased pain and weakness. What is the best course of action?
Correct Answer & Explanation
. Early surgical exploration and repair of the torn subscapularis tendon
Explanation
Nearly all approaches to shoulder arthroplasty require detachment of the subscapularis tendon from the humerus and subsequent repair. Healing of this tenotomy is one of the limiting factors in postoperative recovery. Failure of the tenotomy repair must be recognized and treated early with repeat repair or pectoralis muscle transfer for optimal results. Failure of the subscapularis is diagnosed clinically as excessive external rotation and weakness, especially in the lift-off or belly press position. Muscle testing can be difficult in the postoperative period and may not be possible to assess in those positions. Although MRI might be useful to confirm the diagnosis, studies may be limited by artifact. CT or electromyography would not be diagnostic. Wirth MA, Rockwood CA Jr: Complications of total shoulder-replacement arthroplasty. J Bone Joint Surg Am 1996;78:603-616.
Question 2585
Topic: 5. Sports Medicine
A 24-year-old runner who underwent an allograft reconstruction of the anterior cruciate ligament (ACL) 3 years ago now reports anterior knee pain. Examination reveals no swelling or effusion, and the patient has full motion. A Lachman test and a pivot-shift test are negative. Palpation reveals tenderness on the patellar tendon and at the inferior pole of the patella. AP and lateral radiographs are shown in Figures 41a and 41b. Management should consist of
Correct Answer & Explanation
. observation with activity modification.
Explanation
The radiographs show tunnel enlargement, which is seen after ACL reconstruction, particularly with allografts. Occasionally, there will be formation of an associated subcutaneous pretibial cyst. It has been proposed that the tunnel enlargement and cyst are the result of incomplete incorporation of allograft tissues within the bone tunnels. There may be residual graft necrosis, allowing synovial fluid to be transmitted through the tunnel to collect in the pretibial area, manifesting as a synovial cyst. In the absence of cyst formation, the presence of tunnel enlargement does not appear to adversely affect the clinical outcome. Based on studies by Fahey and associates, continued tunnel expansion does not occur. Victoroff and associates report good results with curettage and bone grafting of the tibial tunnel if a pretibial cyst is present. Because this patient does not have a pretibial cyst, observation with activity modification is the preferred treatment. Fahey M, Indelicato PA: Bone tunnel enlargement after anterior cruciate ligament replacement. Am J Sports Med 1994;22:410-414.
Question 2586
Topic: Shoulder & Hip Sports
A patient reports persistent anterior shoulder pain following a forceful external rotation injury to the shoulder. An MRI scan is shown in Figure 4. The patient remains symptomatic despite 3 months of nonsurgical management. Treatment should now consist of
Correct Answer & Explanation
. subscapularis repair and biceps tenodesis.
Explanation
The MRI scan reveals a subscapularis tear with a biceps that is out of the groove. Treatment in this patient is most predictable if the subscapularis is repaired. The biceps should either be tenodesed or tenotomized since it is unstable. Recentering of the biceps has been found to be unpredictable. Treatment of these lesions has been shown to have better results if the biceps is either released or tenodesed. This prevents recurrent biceps symptoms that can be source of surgical failure. Edwards TB, Walch G, Sirvenaux F, et al: Repair of tears of the subscapularis: Surgical technique. J Bone Joint Surg Am 2006;88:1-10. Deutsch A, Altcheck DW, Veltri DM, et al: Traumatic tears of the subscapularis tendon: Clinical diagnosis, magnetic resonance imaging findings, and operative treatment. Am J Sports Med 1997;25:13-22.
Question 2587
Topic: Shoulder & Hip Sports
Figure 40 shows the MRI scan of a 23-year-old man with a history of recurrent anterior shoulder instability. What is the most likely diagnosis?
The MRI scan shows an ALPSA lesion. This is also known as a medialized Bankart with medial displacement of the torn anterior labrum. During surgical stabilization, the labrum and periosteal sleeve must be mobilized and repaired laterally to reduce recurrent instability. A Perthes lesion is a nondisplaced labral tear. A GLAD lesion represents a nondisplaced anterior labral tear with an associated articular cartilage injury. Neviaser TJ: The anterior labroligamentous periosteal sleeve avulsion lesion: A cause of anterior instability of the shoulder. Arthroscopy 1993;9:17-21.
Question 2588
Topic: 5. Sports Medicine
An 18-year-old lacrosse player is diagnosed with infectious mononucleosis. What is the recommendation for return to play?
Correct Answer & Explanation
. Full participation 4 weeks after both the onset of illness and findings of a normal-sized spleen
Explanation
Infectious mononucleosis commonly affects adolescents and young adults. It is a febrile illness accompanied by acute pharyngitis. Splenomegaly may occur and predispose the athlete to splenic rupture. Splenic rupture has been reported in nonathletes as well as in patients with normal-sized spleens. Clinical evidence supports a return to all sports 4 weeks after the onset of symptoms provided that the spleen has returned to normal size. Auwaerter PG: Infectious mononucleosis: Return to play. Clin Sports Med 2004;23:485-497.
Question 2589
Topic: 5. Sports Medicine
A 29-year-old man who lifts weights states that he injured his left shoulder while performing a bench press 2 days ago. The following morning he noted ecchymosis and swelling in the left chest wall. Examination reveals ecchymosis and tenderness and deformity in the left anterior chest wall and axillary fold that is accentuated with resisted adduction of the arm. Passive range of motion beyond 90 degrees of forward flexion and 45 degrees of external rotation is extremely painful. Glenohumeral stability is difficult to assess because of severe guarding. Figure 29 shows an MRI scan. Management should consist of
Correct Answer & Explanation
. repair of the pectoralis major tendon.
Explanation
Rupture of the pectoralis major tendon most commonly occurs during bench pressing. Wolfe and associates have shown that the most inferiorly located fibers of the sternal head lengthen disproportionately during the final 30 degrees of humeral extension during the bench press. This creates a mechanical disadvantage in the final portion of the eccentric phase of the lift; with forceful flexion of the shoulder these maximally stretched fibers may rupture. In most patients, particularly in young athletes, the treatment of choice is anatomic repair of the ruptured tendon to its insertion in the proximal humerus either with suture anchors or transosseous sutures. Following surgery, most patients experience a near normal return of strength and significant improvement in the cosmetic appearance of the deformity. While more technically challenging, repair of chronic rupture is possible and is indicated in some patients. Wolfe SW, Wickiewicz TL, Cavanaugh JT: Ruptures of the pectoralis major muscle: An anatomic and clinical analysis. Am J Sports Med 1992;20:587-593.
Question 2590
Topic: 5. Sports Medicine
A 20-year-old athlete sustains a 2- x 3-cm grade IV chondral injury to the right knee. After failure of nonsurgical management, which of the following procedures would ensure the highest percentage of hyaline-like cartilage?
Correct Answer & Explanation
. Autologous chondrocyte implantation
Explanation
Autologous chondrocyte implantation was first reported by Brittberg in 1994 and has resulted in predominantly type II collagen (hyaline-like articular cartilage) in the repair tissue. The extracellular matrix in articular cartilage is made up primarily of type II collagen, proteoglycans, and water. Arthroscopic chondroplasty, microfracture, drilling, and abrasion arthroplasty all result eventually in fibrocartilage fill of the defect (predominantly type I collagen). Brittberg M, Lindahl A, Nilsson A, et al: Treatment of deep cartilage defects in the knee with autologous chondrocyte transplantation. N Engl J Med 1994;331:889-895.
Question 2591
Topic: 5. Sports Medicine
Figure 37 shows the radiograph of a 21-year-old collegiate basketball player who has had mild midfoot aching for the past 4 months. What is the best course of action?
Correct Answer & Explanation
. Open reduction and internal fixation
Explanation
A stress fracture of the navicular is considered a high-risk injury because of the incidence of nonunion. If identified early, cast immobilization with no weight bearing is appropriate. However, this patient is a high-caliber athlete who has had symptoms for 4 months. Therefore, surgery is recommended to expedite recovery and optimize the chance of healing. Meyer SA, Saltaman CL, Albright JP: Stress fractures of the foot and ankle. Clin Sports Med 1993;12:395-413. Kahn JM, Fuller PJ, Burkner PD, et al: Outcome of conservative and surgical management of navicular stress fractures in athletes: Eighty-six cases proven with computerized tomography. Am J Sports Med 1992;20:657-666.
Question 2592
Topic: Shoulder & Hip Sports
A baseball pitcher has intractable posterior and superior shoulder pain. The arthroscopic view seen in Figure 25 shows no Bankart or Hill-Sachs lesion and a negative drive-through sign. There are no signs of ligamentous laxity, but active compression and anterior slide tests are positive. Treatment should consist of
Correct Answer & Explanation
. arthroscopic repair of the SLAP lesion with suture anchors.
Explanation
According to Morgan and associates, a type II SLAP lesion can create or is associated with a superior instability pattern. They suggest that this can exist without a co-existing anteroinferior instability pattern. They reported that repair of the SLAP lesion alone resulted in satisfactory outcomes in 90% of patients and a return to throwing in more than 90% of pitchers. The arthroscopic findings in this patient do not support a diagnosis of anteroinferior laxity or instability; therefore, thermal capsular shift or capsular placation is not necessary. Morgan CD, Burkhart SS, Palmeri M, et al: Type II SLAP lesions: Three subtypes and their relationships to superior instability and rotator cuff tears. Arthroscopy 1998;14:553-565. Mileski RA, Snyder RJ: Superior labral lesions in the shoulder: Pathoanatomy and surgical management. J Am Acad Orthop Surg 1998;6:121-131.
Question 2593
Topic: 5. Sports Medicine
A young active patient with a complete isolated posterior cruciate ligament (PCL) tear undergoes a double bundle PCL reconstruction. The tensioning pattern of the anterolateral (AL) and posteromedial (PM) bundles most likely to reproduce the most normal knee kinematics would be to tension
Correct Answer & Explanation
. bundle AL at 90 degrees of flexion and bundle PM at 0 degrees of flexion.
Explanation
During flexion and extension of the normal knee, the AL bundle of the PCL is taut in flexion, and the PM bundle is taut when the knee is near extension. The AL bundle is approximately two times larger at its midsubstance, stiffer, and has a higher ultimate load than the PM bundle. In vitro testing has demonstrated that by tensioning the AL bundle at 90 degrees of flexion and the PM bundle at 0 degrees of flexion, essentially normal knee kinematics are restored. Tensioning the AL bundle at 45 degrees of flexion and the PM bundle at 0 degrees of flexion would result in increased laxity with flexion at 90+ degrees. Tensioning the AL bundle at 90 degrees of flexion and the PM bundle at 45 degrees of flexion would result in increased laxity near extension. Harner CD, Janaushek MA, Kanamori A, Yagi M, Vogrin T, Woo SL: Biomechanical analysis of a double-bundle posterior cruciate ligament reconstruction. Am J Sports Med 2000;28:144-151.
Question 2594
Topic: 5. Sports Medicine
The mother of a healthy 8-month-old boy reports that her son refuses to use his left arm. Examination reveals that the arm hangs limp at his side in an adducted and internally rotated position, and the affected shoulder subluxates posteriorly. Passive external rotation measures 15 degrees. Management should consist of
Correct Answer & Explanation
. passive range-of-motion exercises.
Explanation
Injury to the upper trunk of the brachial plexus during birth (Erb's palsy) occurs in approximately 1 in 3,000 births. In a complete lesion, paralysis of the deltoid, supraspinatus, infraspinatus, teres minor, biceps, and brachioradialis results in the findings described above. Spontaneous recovery may occur for up to 2 years. Passive exercises administered daily by the parents are the initial recommended treatment at this age. If significant contracture results in posterior dislocation, surgical correction may be considered. Neer CS: Shoulder Reconstruction. Philadelphia, PA, WB Saunders, 1990, pp 452-454. Pearl ML: Arthroscopy release of shoulder contracture secondary to birth palsy: An early report on findings and surgical technique. Arthroscopy 2003;19:577-582.
Question 2595
Topic: Shoulder & Hip Sports
A 54-year-old man undergoes total shoulder arthroplasty for osteoarthritis. Despite compliance with an early passive range-of-motion exercise program, he does not regain more than 90 degrees of elevation, 10 degrees of external rotation, and has internal rotation to the fifth lumbar vertebra. At 6 months, his motion fails to improve. Radiographs are shown in Figures 18a and 18b. What is the best course of action?
Correct Answer & Explanation
. Perform an open release.
Explanation
The patient has a global loss of motion that has failed to improve with 6 months of nonsurgical treatment; because he has reached a plateau, further nonsurgical management will likely be ineffective. Revision in the form of an open release is indicated to lyse intra- and extra-articular adhesions; subscapularis lengthening may be done concurrently as needed. Revising to a smaller head can be considered if adequate motion is not achieved. The radiographs reveal an adequate neck cut with appropriate seating of the component. Removing the glenoid component will decrease capsular tension but will probably increase pain because of the lack of glenoid resurfacing. Increasing humeral retroversion will not improve motion. Cuomo F, Checroun A: Avoiding pitfalls and complication in total shoulder arthroplasty. Orthop Clin North Am 1998;29:507-518.
Question 2596
Topic: 5. Sports Medicine
A 16-year-old boy with osteochondritis dissecans of the capitellum has intermittent symptoms of catching and locking. Examination is unremarkable. Radiographs reveal a loose body anteriorly with a diameter of 10 mm. To remove the loose body, elbow arthroscopy is being considered. Which of the following procedures would minimize the risk of neurovascular complication during the procedure?
Correct Answer & Explanation
. Distending the elbow joint capsule prior to establishing the anterolateral portal
Explanation
Complications of elbow arthroscopy are usually minor or temporary. However, serious complications include nerve injuries. The deep radial nerve is the closest to any of the portals, resting as close as 1 mm away from the scope inserted in the anterolateral portal. The capsule can be displaced anteriorly by distending the joint with about 25 mL of saline solution, thus moving the deep radial nerve approximately 1 cm anteriorly and decreasing the risk of injuring it while establishing the anterolateral portal. Keeping plastic cannulae in the portals may help to diminish fluid extravasation and swelling, which is more of an impediment than a serious complication. The image intensifier has no documented role in guiding loose body removal. While the proximal anteromedial portal is probably the safest anterior portal to establish, it is actually easier to remove a large loose body from this portal while viewing it from an anterolateral position. There is less tendon and muscle bulk to pass through at the site of the proximal anteromedial portal than at the anterolateral portal, making it less likely for the loose body to get stuck in the soft tissues. Techniques have been developed to permit removal of loose bodies as large as 2 cm in diameter without breaking them up into pieces. If it is possible to remove a large loose body intact, doing so greatly simplifies and shortens the procedure. Lynch GJ, Meyers JF, Whipple TL, Caspari RB: Neurovascular anatomy and elbow arthroscopy: Inherent risks. Arthroscopy 1986;2:190-197.
Question 2597
Topic: 5. Sports Medicine
A 30-year-old man underwent an open Bankart repair with capsulorrhaphy for recurrent anterior instability 6 months ago. In a recent fall, he described a hyperabduction and external rotation mechanism of injury. He denies dislocating his shoulder. He now has anterior shoulder pain, weakness, and the sensation of instability. Examination reveals tenderness just lateral to the coracoid and bicipital groove. An MRI scan is shown in Figure 31. Management should now consist of
Correct Answer & Explanation
. subscapularis repair.
Explanation
Subscapularis tendon tears are being recognized with increasing frequency, and the mechanism of injury involves hyperabduction and external rotation. The patient will have anterior shoulder pain and may report a sensation of instability. Examination will reveal anterior shoulder tenderness over the lesser tuberosity and bicipital groove, and the Gerber lift-off test usually is positive. The MRI scan shown here reveals an intact anterior labrum. The subscapularis tendon is avulsed and retracted, with no evidence of the biceps tendon within the groove; this implies dislocation of the biceps, a common accompanying feature of a subscapularis tear. This injury is also recognized as a complication after open anterior shoulder stabilizations where the subscapularis has been incised as part of the approach. Therefore, the appropriate management involves repair of the subscapularis. The injury does not represent a recurrence so immobilization or revision stabilization, which may be reasonable treatment for recurrent instability, is not indicated. The findings are not consistent with a superior labral tear. Deutsch A, Altchek DW, Veltri DM, et al: Traumatic tears of the subscapularis tendon: Clinical diagnosis, magnetic resonance imaging findings, and operative treatment. Am J Sports Med 1997;25:13-22.
Question 2598
Topic: Shoulder & Hip Sports
A 68-year-old woman has been progressing slowly after undergoing humeral head replacement for a four-part fracture 3 months ago. She has not regained active elevation, she feels an audible clunk on attempting elevation, and she reports pain and weakness. She used a sling for 2 weeks in the immediate postoperative period. Radiographs are shown in Figure 37a through 37c. Management should consist of
Correct Answer & Explanation
. tuberosity and rotator cuff repair with bone graft.
Explanation
Immediate repair of the tuberosity and rotator cuff is recommended on identifying the avulsion or nonunion. Revising the humeral component to increase tension and length will overtighten the cuff and increase the chance of tuberosity pull-off. The glenoid is uninvolved and should not be replaced. Attempts to strengthen the rotator cuff will be unsuccessful because the insertions are no longer attached to the humerus when the tuberosities avulse. Brown TD, Bigliani LU: Complications with humeral head replacement. Orthop Clin North Am 2000;31:77-90.
Question 2599
Topic: 5. Sports Medicine
A 40-year-old woman underwent an arthroscopic acromioplasty and mini-open rotator cuff repair 4 weeks ago. At follow-up examination, the incision is painful, erythematous, and draining fluid. The patient is febrile and has an elevated WBC count. What infectious organism should be under high suspicion of causing this outcome?
Correct Answer & Explanation
. Proprionobacter acnes
Explanation
Proprionobacter acnes has been a leading cause of indolent shoulder infections. During shoulder arthroscopy, the arthroscopic fluid may actually dilute the shoulder preparation and lead to a higher rate of infection during subsequent mini-open rotator cuff repair surgery. The remaining bacteria listed are rarely associated with shoulder infections after arthroscopy. Herrera MF, Bauer G, Reynolds F, et al: Infection after mini-open rotator cuff repair. J Shoulder Elbow Surg 2002;11:605-608.
Question 2600
Topic: Shoulder & Hip Sports
A patient has right shoulder pain. Figure 1a shows a gadolinium-enhanced transverse MRI scan at the level of the coracoid. Figure 1b shows an arthroscopic view of the anterior structures from a posterior portal. These images reveal which of the following findings?
Correct Answer & Explanation
. Normal anatomic variant (Buford complex)
Explanation
The area shown in the arthroscopic view and MRI scan is referred to as a Buford complex and represents a normal labral variant. It consists of a thickened, cord-like middle glenohumeral ligament, a superior labral attachment of the middle glenohumeral ligament just anterior to the biceps tendon, and absence of the anterosuperior labrum. This combination of findings can be confusing and may simulate labral pathology. Mistaken repair of the lesion back to the glenoid rim can result in significant loss of external rotation. A Bankart lesion would be located at the inferior anterior glenoid rim. The subscapularis is seen anterior to the labrum. Normal variations that occur in the anterosuperior labrum can simulate pathology. Gusmer PB, Potter HG, Schatz JA, et al: Labral injuries: Accuracy of detection with unenhanced MR imaging of the shoulder. Radiology 1996;200:519-524. Griffin LY (ed): Orthopaedic Knowledge Update: Sports Medicine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 47-63.
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