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5. Sports Medicine MCQs

Practice Set 131 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 2601

Topic: Shoulder & Hip Sports

During shoulder motion with the elbow controlled in a brace, electromyographic studies of the supraspinatus show significant activity with all range-of-motion testing. Concurrent electromyographic studies of the long head of the biceps will most likely show

Upper Extremity Board Review 2005: High-Yield MCQs (Set 2) - Figure 13

. minimal activity.
. moderate activity compared to the supraspinatus.
. significant activity with a supraspinatus tear.
. significant activity with an intact supraspinatus.
. significant activity with both intact and torn rotator cuffs.

Correct Answer & Explanation

. minimal activity.

Explanation

During electromyographic studies, the long head of the biceps has been shown to have little activity throughout a wide range of shoulder motion as long as the elbow is immobilized. The supraspinatus is active throughout the range of shoulder motion. Rotator cuff tears do not influence biceps activity as long as the elbow is controlled. Yamaguchi K, Riew KD, Galutz LM, et al: Biceps activity during shoulder motion: An electromyographic analysis. Clin Orthop 1997;336:122-129.

Question 2602

Topic: Knee Sports

Figures 21a through 21c show the MRI scans of a 21-year-old football player who sustained a valgus knee injury while changing direction. Examination reveals swelling and tenderness along the medial aspect of the knee. There is a positive Lachman test, 3+ valgus laxity at 30 degrees, and 1+ valgus laxity at 0 degrees extension. The anterior drawer test is increased with the tibia in external rotation. The increase in the anterior drawer test with the tibia in external rotation is most likely the result of

. an occult fracture of the tibial plateau.
. a tear of the medial collateral ligament and the posteromedial capsule.
. a tear of the posterior cruciate ligament.
. a tear of the anterior and posterior cruciate ligaments.
. a tear of the anterior cruciate and medial collateral ligaments and the posteromedial capsule.

Correct Answer & Explanation

. a tear of the anterior cruciate and medial collateral ligaments and the posteromedial capsule.

Explanation

The injury mechanism involves a valgus load applied to the knee with the foot in external rotation. The primary stabilizer to valgus laxity is the medial collateral ligament. The secondary restraints to valgus rotation are the cruciate ligaments. Examination indicates disruption of the medial collateral and anterior cruciate ligaments. Valgus opening in extension should also arouse suspicion for an injury to the posterior cruciate ligament; however, in this patient, the valgus opening in extension is mild. The slight opening in extension and the increased anterior drawer, especially with external rotation, indicates disruption of the posteromedial capsule and posterior oblique ligament. Figure 21a shows complete disruption of the superficial and deep medial collateral ligaments involving the meniscofemoral ligament. Figure 21b shows a more posterior coronal section with a torn posterior oblique ligament. Figure 21c shows disruption of the anterior cruciate ligament, while the posterior cruciate ligament at the tibial insertion appears with a homogenous normal signal. Warren LA, Marshall JL, Girgis F: The prime static stabilizer of the medial side of the knee. J Bone Joint Surg Am 1974;56:665-674.

Question 2603

Topic: 5. Sports Medicine

Figure 50 shows the cross table lateral radiograph of a 31-year-old paratrooper who has recalcitrant groin pain. The pain is worse after activities such as standing or sitting (driving). Examination reveals that pain can be reproduced by internal rotation of the leg with the hip and knee in 90 degrees of flexion. Extensive nonsurgical managment has failed to provide relief. What is the treatment of choice?

Hip & Knee Reconstruction Board Review 2007: High-Yield MCQs (Set 4) - Figure 7

. Periacetabular osteotomy
. Femoral neck osteotomy
. Femoroacetabular osteoplasty
. Hip arthroscopy and labral debridement
. Hip arthrodesis

Correct Answer & Explanation

. Femoroacetabular osteoplasty

Explanation

The radiograph reveals the classic "bump" that is seen in patients with femoroacetabular impingement (FAI). Ganz and associates described two types of FAI. This patient has cam impingement, which describes a nonspherical femoral head being forced into the acetabulum during hip motion and resulting in labral and chondral injury. Hip arthroscopy and labral debridement is unlikely to control the symptoms because the underlying anatomic abnormality is often difficult to address with arthroscopy. The treatment involves surgical dislocation of the hip with preservation of the blood supply to the femoral head, removal of the asphericity on the femoral side (femoral osteoplasty), and removal of the acetabular rim (acetabular osteoplasty) if the latter is found to contribute to impingement. Ganz R, Gill TJ, Gautier E, et al: Surgical dislocation of the adult hip a technique with full access to the femoral head and acetabulum without the risk of avascular necrosis. J Bone Joint Surg Br 2001;83:1119-1124. Ganz R, Parvizi J, Beck M, et al: Femoroacetabular impingement: A cause for early osteoarthritis of the hip. Clin Orthop 2003;417:112-120.

Question 2604

Topic: Shoulder & Hip Sports

A 72-year-old woman who was doing well after undergoing total shoulder arthroplasty for arthritis 4 months ago is suddenly unable to elevate her arm. Examination reveals 70 degrees of external rotation compared with 45 degrees on the uninvolved side, and she is unable to lift her hand off her lower back. Radiographs are shown in Figures 43a through 43c. Treatment should consist of

. fascia lata graft to restore the coracoacromial arch.
. immediate subscapularis repair.
. revision arthroplasty with glenoid reaming to centralize the component.
. revision arthroplasty with increased retroversion in the humeral component.
. arthroscopic subacromial decompression.

Correct Answer & Explanation

. immediate subscapularis repair.

Explanation

Results of treatment of subscapularis rupture are best when immediate repair is performed. When the cause of the anterior instability is the result of rupture of the subscapularis tendon and the component position is acceptable, revising the position of the component is unnecessary. Restoring the coracoacromial arch and subacromial decompression are related to superior instability and rotator cuff pathology, respectively, and would not correct the instability caused by subscapularis rupture. Moeckel BH, Altchek DW, Warren RF, Wickiewicz TL, Dines DM: Instability of the shoulder after arthroplasty. J Bone Joint Surg Am 1993;75:492-497.

Question 2605

Topic: 5. Sports Medicine

A 29-year-old woman who underwent an anterior cruciate ligament (ACL) reconstruction 6 months ago now reports difficulty achieving full knee extension, and physical therapy fails to provide relief. The knee is stable on ligament testing. Figure 3 shows the findings at a repeat arthroscopy. Treatment should now include

Sports Medicine 2001 Practice Questions: Set 1 (Solved) - Figure 6

. revision of the failing ACL reconstruction.
. arthroscopic lysis of adhesions and manipulation of the knee.
. surgical removal of hypertrophic fibrous tissue.
. excision of the torn medial meniscus.
. continued aggressive physical therapy.

Correct Answer & Explanation

. surgical removal of hypertrophic fibrous tissue.

Explanation

The patient has a cyclops lesion. This is a nodule of fibroproliferative tissue that originates from either drilling debris from the tibial tunnel or remnants of the ACL stump; more rarely it is the result of broken graft fibers. The treatment of choice is excision of the nodule and, if needed, additional notchplasty. Marked improvements in function and symptoms have been noted after removal of the extension block and resumption of a rehabilitation program. Delince P, Krallis P, Descamps PY, et al: Different aspects of the cyclops lesion following anterior cruciate ligament reconstruction: A multifactorial etiopathogenesis. Arthroscopy 1998;14:869-876.

Question 2606

Topic: Shoulder & Hip Sports

A 22-year-old wrestler who underwent an open anterior shoulder reconstruction to repair a dislocated shoulder 6 months ago now reports shoulder pain after attempting a takedown. Examination reveals external rotation that is 15 degrees greater than the contralateral side. He has pain associated with abduction and external rotation but no apprehension. Which of the following tests would most likely reveal positive findings?

. Impingement injection test
. Lift-off test
. Weakness with "empty-can" abduction test
. Load-and-sift maneuver
. MRI with contrast

Correct Answer & Explanation

. Lift-off test

Explanation

Postoperative subscapularis detachment can be identified with a positive lift-off test that reveals weakness in internal rotation. This complication does not necessarily compromise the anterior capsule repair. The load-and-sift maneuver and articular contrast studies may be normal. Supraspinatus tests for impingement and weakness should be negative. Gerber C, Krushell RJ: Isolated ruptures of the tendon of the subscapularis muscle: Clinical fractures in 16 cases. J Bone Joint Surg Br 1991;73:389-394.

Question 2607

Topic: 5. Sports Medicine

A collegiate rower reports the sudden onset of right chest pain while rowing. The athlete states that the pain is worse with deep inspiration and coughing. Examination reveals localized tenderness over the posterolateral corner of the eighth rib. What is the most likely diagnosis?

Sports Medicine Board Review 2004: High-Yield MCQs (Set 2) - Figure 12

. Intercostal muscle strain
. Rib stress fracture
. Pneumothorax
. Costochondritis
. Empyema

Correct Answer & Explanation

. Rib stress fracture

Explanation

A rib stress fracture, the most common injury to the thorax in rowing athletes, generally occurs during periods of intense training with a low stroke rate and heavy loads. It is characterized by the sudden onset of sharp, localized chest pain while rowing. The fifth through the ninth rib is generally affected, and the diagnosis is best established with a bone scan. An intercostal muscle strain generally has an insidious onset and may be poorly localized. Costochondritis affects the anterior costochondral junction. A pneumothorax and an empyema can cause nonlocalized chest pain but are associated with respiratory distress and systemic physical findings. Karlson KA: Rib stress fractures in elite rowers. Am J Sports Med 1998;26:516-520.

Question 2608

Topic: 5. Sports Medicine

A college basketball player is struck in the eye by a player's hand while driving to the basket. Fluorescein evaluation reveals the injury shown in Figure 18. Management should consist of

Sports Medicine Board Review 2001: High-Yield MCQs (Set 2) - Figure 20

. administration of ophthalmic corticosteroids and antibiotics with application of an eye patch.
. evaluation of intact visual fields and pupillary responses prior to a return to play.
. consultation with an ophthalmologist prior to emergent repair of the damaged structure.
. measurement of ocular pressure and fundoscopic examination in a properly lit examination room.
. strict bed rest with the head elevated, minimizing head motion during the healing process.

Correct Answer & Explanation

. administration of ophthalmic corticosteroids and antibiotics with application of an eye patch.

Explanation

The athlete has a corneal abrasion. Fluorescein staining identifies the break in the epithelium when examined with ultraviolet light. Topical antibiotics are used as prophylaxis against secondary bacterial infection, and the patch, applied with the lid closed, is used for comfort and to promote epithelial healing. The accompanying symptoms, including pain, tearing, and photophobia, are usually too intense to allow a return to play. Surgery is reserved for a corneal laceration with associated loss of the anterior chamber. While a proper fundoscopic examination may be a consideration, increased intraocular pressure is not typically associated with this injury. Traumatic hemorrhage in the anterior chamber (hyphema) necessitates strict bed rest during the early phases of healing; examination will most likely reveal the red fluid level of blood settling inferiorly in the anterior chamber. It is often associated with increased intraocular pressure. Brucker AJ, Kozart DM, Nichols CW, et al: Diagnosis and management of injuries to the eye and orbit, in Torg JS (ed): Athletic Injuries to the Head, Neck, and Face. St Louis, MO, Mosby-Year Book, 1991, pp 650-670.

Question 2609

Topic: 5. Sports Medicine

A 47-year-old male tennis player has pain in his nondominant shoulder that has failed to respond to 4 months of nonsurgical management. Examination reveals acromial tenderness and pain at the supraspinatus tendon insertion. He has a positive impingement sign, pain on forward elevation, and minimal cuff weakness. The MRI scans are shown in Figures 30a and 30b. To completely resolve his symptoms, treatment should consist of

. rigid open reduction and internal fixation of the os acromiale with autologous bone graft.
. arthroscopic repair of the rotator cuff and acromioplasty.
. arthroscopic excision of the os acromiale.
. arthroscopic decompression of the supraglenoid cyst.
. open distal clavicle excision (Mumford procedure).

Correct Answer & Explanation

. rigid open reduction and internal fixation of the os acromiale with autologous bone graft.

Explanation

The MRI scans show a mesoacromion with tendonopathy of the supraspinatus. The history and physical findings indicate that the patient has a symptomatic os acromiale. Simple excision of the unstable os acromiale has not yielded consistently good results. Meticulous internal fixation using tension banding with cannulated screws and autologous bone grafting has shown good results for this problem. Hutchinson MR, Veenstra MA: Arthroscopic decompression of shoulder impingement secondary to os acromiale. Arthroscopy 1993;9:28-32.

Question 2610

Topic: Knee Sports

A 10-year-old boy sustained an injury to the left knee. The radiographic findings shown in Figure 19 are most commonly associated with injury to which of the following structures?

Sports Medicine Board Review 2001: High-Yield MCQs (Set 2) - Figure 22

. Anterior cruciate ligament (ACL)
. Posterior cruciate ligament (PCL)
. Patellar tendon
. Lateral capsule
. Pes anserinus

Correct Answer & Explanation

. Anterior cruciate ligament (ACL)

Explanation

The radiograph shows a bony avulsion of the ACL attachment site on the tibial spine in this skeletally immature patient. In this age group, injury often results in failure of the bony attachment site rather than the substance of the ligament. Avulsion of the patellar tendon insertion site can occur, but this structure is located at the apophysis of the tibial tubercle. The attachment site of the PCL is much more posterior. In adults, bony avulsion is more commonly associated with PCL injuries than with ACL injuries. When a small bony avulsion of the lateral capsule from the lateral tibial plateau is seen on the AP view, this finding is considered pathognomonic of an ACL injury (Segond sign) in adults. The area of the pes anserinus is anterior and distal; avulsion would be unusual. Baxter MP, Wiley JJ: Fractures of the tibial spine in children: An evaluation of knee stability. J Bone Joint Surg Br 1988;70:228-230. Meyers MH, McKeever FM: Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am 1970;52:1677-1684.

Question 2611

Topic: 5. Sports Medicine

A 21-year-old professional ballet dancer reports a painful popping sensation over her right hip joint. Examination reveals that symptoms are reproduced with hip flexion and external rotation. Which of the following studies will best confirm the diagnosis?

Sports Medicine 2007 Practice Questions: Set 1 (Solved) - Figure 17

. Radiographs
. Bone scan
. CT
. Ultrasonography
. MRI

Correct Answer & Explanation

. Ultrasonography

Explanation

The patient has snapping hip syndrome of the internal type, which is more common in ballet dancers. It is caused by the iliopsoas tendon gliding over the iliopectineal line or the femoral head. The diagnosis usually can be made by the history and physical examination. Snapping is reproduced by hip flexion and extension or flexion with external rotation and abduction. Conventional and dynamic ultrasonography will confirm the snapping structure. Radiographs occasionally show calcifications near the lesser trochanter. MRI can be used to rule out other diagnoses that can simulate snapping hip. Gruen GS, Scioscia TN, Lowenstein JE: The surgical treatment of internal snapping hip. Am J Sports Med 2002;30:607-613.

Question 2612

Topic: 5. Sports Medicine

A 17-year-old football player is injured during a play and reports abdominal pain that is soon followed by nausea and vomiting. What organ has most likely been injured?

Sports Medicine 2007 Practice Questions: Set 1 (Solved) - Figure 28

. Liver
. Pancreas
. Spleen
. Kidney
. Large intestine

Correct Answer & Explanation

. Spleen

Explanation

The spleen is the most common organ injured in the abdomen as the result of blunt trauma. It is also the most common cause of death because of an abdominal injury. The liver is the second most commonly injured organ. Injury to the other organs is rare. The diagnosis can be made with CT. Treatment ranges from observation to splenectomy, depending on the severity of injury. Green GA: Gastrointestinal disorders in the athlete. Clin Sports Med 1992;11:453-470.

Question 2613

Topic: Knee Sports

An 18-year-old man underwent open reduction and internal fixation of a tibial spine avulsion and a posterolateral corner repair. Two years later, he underwent lateral collateral ligament (LCL) and posterolateral corner reconstruction because of instability. Examination reveals a pronounced lateral varus knee thrust when ambulating. Varus stress in 30 degrees of flexion produces a 10-mm opening that is eliminated in extension. The Lachman's test is 2 mm with a firm end point, and the posterior drawer test is negative. Standing radiographs show widening of the lateral joint space and a 5-degree mechanical varus alignment. What is the most effective course of treatment?

. Physical therapy for quadriceps strengthening
. Functional bracing
. Anterior cruciate ligament (ACL) reconstruction
. Revision reconstruction of the LCL and posterolateral corner
. Valgus-producing high tibial osteotomy (HTO)

Correct Answer & Explanation

. Valgus-producing high tibial osteotomy (HTO)

Explanation

The patient has chronic posterolateral instability with a varus knee alignment; therefore, the most effective treatment is a valgus-producing HTO. A repeat soft-tissue reconstruction without correction of the varus alignment will most likely fail. An ACL reconstruction is not indicated with a normal Lachman's test. Physical therapy and bracing will have little effect. Naudie DD, Amendola A, Fowler PJ: Opening wedge high tibial osteotomy for symptomatic hyperextension-varus thrust. Am J Sports Med 2004;32:60-70.

Question 2614

Topic: 5. Sports Medicine

A 16-year-old cheerleader reports an ache in the right shoulder and arm that is worse after activity. She denies any history of acute trauma. Examination reveals a positive sulcus sign and an AP glide test with a posterior and anterior apprehension sign. To confirm a diagnosis of multidirectional instability, which of the following imaging studies is most appropriate?

Anatomy 2002 Practice Questions: Set 1 (Solved) - Figure 31

. Ultrasound
. CT
. Bone scan
. Scapular Y-view of the shoulder
. Stress views of the shoulder

Correct Answer & Explanation

. Stress views of the shoulder

Explanation

Multidirectional instability is a common finding in young female athletes. The anatomic structures are all intact but are hypermobile; therefore, CT and bone scans and scapular Y-views are often normal. Obtaining a weighted or AP stress view while applying downward traction on the arm will document instability and hypermobility of the joint. MRI generally is not indicated in this condition. Ultrasound is used primarily for rotator cuff pathology. Neer CS II, Foster CR: Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder: A preliminary report. J Bone Joint Surg Am 1980;62:897-908.

Question 2615

Topic: 5. Sports Medicine

A 15-year-old athlete collapses suddenly during practice and dies. What is the most likely cause of death?

Sports Medicine Board Review 2004: High-Yield MCQs (Set 2) - Figure 2

. Hypertrophic cardiomyopathy
. Atrial fibrillation
. Pulmonary embolism
. Ruptured aorta
. Mitral valve prolapse

Correct Answer & Explanation

. Hypertrophic cardiomyopathy

Explanation

The number one cause of sudden death in the young athlete is myocardial pathology, with hypertrophic cardiomyopathy being most common. Because of cardiac muscle hypertrophy, the ventricular capacity is diminished and can result in decreased cardiac output. During exertional activities, the increased demand may not be able to be met and leads to sudden death. While the other choices can be the cause of sudden death in an otherwise healthy young athlete, their incidence is even more rare. Van Camp SP, Bloor CM, Mueller FO, et al: Nontraumatic sports death in high school and college athletes. Med Sci Sports Exerc 1995;27:641-647. Maron BJ, Shirani J, Pollac LC, et al: Sudden death in young competitive athletes: Clinical, demographic, and pathological profiles. JAMA 1996;276:199-204.

Question 2616

Topic: 5. Sports Medicine

A 54-year man has left shoulder pain and weakness after falling while skiing 4 months ago. Examination reveals full range of motion passively, but he has a positive abdominal compression test and weakness with the lift-off test. External rotation strength with the arm at the side and strength with the arm abducted and internally rotated are normal. MRI scans are shown in Figures 1a and 1b. Treatment should consist of

. arthroscopy and labral repair.
. arthroscopy and supraspinatus repair.
. arthroscopy and subscapularis repair.
. arthroscopy and supraspinatus and infraspinatus repair.
. open repair of the pectoralis major.

Correct Answer & Explanation

. arthroscopy and subscapularis repair.

Explanation

The examination findings are consistent with subscapularis muscle weakness but normal supraspinatus and infraspinatus strength. The lift-off test and abdominal compression test are specific for subscapularis function. The MRI scan reveals a chronic avulsion and retraction of the subscapularis. The transverse image reveals a normal infraspinatus muscle, and the sagittal image reveals an atrophic subscapularis. Surgical repair of the isolated subscapularis tendon is indicated. Iannotti JP, Williams GR: Disorders of the Shoulder: Diagnosis and Management, ed 1. Philadelphia, PA, Lippincott Williams & Wilkins, 1999, pp 31-56.

Question 2617

Topic: 5. Sports Medicine

Myositis ossificans is a recognized complication of contusion to the quadriceps muscle. During early rehabilitation, this condition is most likely to be exacerbated by

. electrical stimulation.
. iontophoresis.
. isometric exercise.
. ice/heat contrast.
. passive stretching.

Correct Answer & Explanation

. passive stretching.

Explanation

Passive stretching is contraindicated during rehabilitation as it may potentiate the severity of the myositis ossificans. Electrical stimulation, iontophoresis, isometric exercise, and ice/heat contrast are not known to exacerbate this process. Brunet ME, Hontas RB: The thigh, in DeLee JC, Drez D (eds): Orthopaedic Sports Medicine. Philadelphia, PA, WB Saunders, 1994, pp 1086-1112.

Question 2618

Topic: Shoulder & Hip Sports

A 19-year-old wrestler has numbness along the radial aspect of the forearm after undergoing an open Bankart repair through an anterior deltopectoral approach. Motor weakness would be expected along with what other finding?

Anatomy 2005 Practice Questions: Set 1 (Solved) - Figure 9

. Diminished elbow flexion and supination strength
. Reduced grip strength
. Weakness in shoulder abduction
. Weakness in flexion of the distal interphalangeal joint in the index finger
. Weakness of the abductor digiti minimi

Correct Answer & Explanation

. Diminished elbow flexion and supination strength

Explanation

The musculocutaneous nerve may be injured by retracting the conjoined tendon medially. This nerve enters the coracobrachialis 5 cm distal to its origin. Its sensory distribution is the radial forearm, and its motor supply is to the biceps and brachialis. Bach BR, O'Brien SJ, Warren RF, et al: An unusual neurologic complication of the Bristow procedure. J Bone Joint Surg Am 1988;70:458-460.

Question 2619

Topic: 5. Sports Medicine

A 28-year-old woman who is an avid runner reports pain about the left hip with activities. Nonsurgical management has failed to provide relief. An MRI arthrogram is shown in Figure 47. What is the most likely diagnosis?

Hip & Knee Reconstruction Board Review 2007: High-Yield MCQs (Set 4) - Figure 3

. Osteonecrosis
. Transient osteoporosis
. Loose chondral fragment
. Labral tear
. Femoral neck stress fracture

Correct Answer & Explanation

. Labral tear

Explanation

The MRI arthrogram reveals dye extravasation into the labrum, consistent with a labral tear. The MRI findings are not typical of osteonecrosis, stress fracture, or transient osteoporosis. There is no increase in bone marrow edema in the neck or femoral head. Guanche CA, Sikka RS: Acetabular labral tears with underlying chondralmalacia: A possible association with high-level running. Arthroscopy 2005;21:580-585.

Question 2620

Topic: Shoulder & Hip Sports

A 25-year-old man injures his shoulder while skiing. Examination reveals increased passive external rotation, pain in the cocked position, and a positive lift-off test. What is the most likely diagnosis?

Sports Medicine Board Review 2001: High-Yield MCQs (Set 2) - Figure 19

. Ruptured biceps tendon
. Subscapularis tear
. Anterior subluxation
. Internal impingement syndrome
. Locked posterior dislocation

Correct Answer & Explanation

. Subscapularis tear

Explanation

A positive lift-off test and increased passive external rotation are diagnostic of a subscapularis tear or detachment. Although a similar injury could produce anterior instability, this will test the integrity of the subscapularis. A locked dislocation has limited passive movement. A ruptured biceps tendon will most likely produce ecchymosis and findings similar to supraspinatus trauma. Internal impingement is not associated with subscapularis weakness. Gerber C, Krushell RJ: Isolated rupture of the tendon of the subscapularis muscle: Clinical features in 16 cases. J Bone Joint Surg Br 1991;73:389-394.

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