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5. Sports Medicine MCQs

Practice Set 132 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 2621

Topic: 5. Sports Medicine

What is the effect on knee kinematics following placement of an anterior cruciate ligament (ACL) graft at the 12 o'clock position?

. Decreased rotational stability
. Decreased anterior-posterior stability
. Decreased flexion
. Decreased extension
. Graft failure secondary to impingement

Correct Answer & Explanation

. Decreased rotational stability

Explanation

Endoscopic ACL reconstructive techniques may result in a vertical graft placement. The reconstructed ligament will resist anterior translation of the tibia but the graft will not restore rotatory stability. Decreased flexion and extension are caused by placement of the femoral tunnel too anterior and posterior, respectively. Impingement of the graft on the femoral notch is caused by anterior placement of the tibial tunnel or inadequate notchplasty. Scopp JM, Jasper LE, Belkoff SM, et al: The effect of oblique femoral tunnel placement on rotational constraint of the knee reconstructed using patellar tendon autografts. Arthroscopy 2004;20:294-299.

Question 2622

Topic: Shoulder & Hip Sports

Figures 49a and 49b show MRI scans of the shoulder. What is the most likely diagnosis?

. Rotator cuff tear
. Normal anatomic variant
. Stage II impingement
. Bankart lesion
. Acromioclavicular grade II sprain

Correct Answer & Explanation

. Rotator cuff tear

Explanation

The supraspinatus tendon shows clear detachment and retraction from its greater tuberosity attachment by the absence of the normal dark subacromial signal extending to the attachment on the greater tuberosity. There is no anterior inferior glenoid labral detachment that usually is seen in a Bankart lesion. The acromioclavicular joint shows no evidence of separation. The humeral head is migrated cranially, indicating a chronic rotator cuff tear. Iannotti JP, Zlatkin MB, Esterhai JL, Kressel HY, Dalinka MK, Spindler KP: Magnetic resonance imaging of the shoulder: Sensitivity, specificity, and predictive value. J Bone Joint Surg Am 1991;73:17-29. Seeger LL, Gold RH, Bassett LW, Ellman H: Shoulder impingement syndrome: MR findings in 53 shoulders. Am J Roentgenol 1988;150:343-347.

Question 2623

Topic: 5. Sports Medicine

A 26-year-old right hand-dominant man has had right shoulder pain for the past 6 months. History reveals that he was the starting pitcher for his high school team. Activity modification, physical therapy, cortisone injection, and anti-inflammatory drugs have failed to improve his symptoms. He has a positive O'Brien's active compression test. What is the next most appropriate step in the diagnosis of this patient?

Upper Extremity Board Review 2008: High-Yield MCQs (Set 2) - Figure 24

. Diagnostic arthroscopy
. MRI-arthrography
. Stress radiographs
. CT
. Weighted radiographs of the arm

Correct Answer & Explanation

. MRI-arthrography

Explanation

MRI-arthrography has been shown to be an accurate technique for assessing the glenoid labrum in patients with suspected labral tears. Often standard MRI technique will not identify labral lesions. The use of MRI-arthrography with an intra-articular injection of gadolinium provides improved visualization of labral lesions. Bencardino and associates demonstrated a sensitivity of 89%, a specificity of 91%, and an accuracy of 90% in detecting labral lesions. SLAP lesions can be visualized on coronal oblique sequences as a deep cleft between the superior labrum and the glenoid that extends well around and below the biceps anchor. Often, contrast will diffuse into the labral fragment, causing it to appear ragged or indistinct. Applegate GR, Hewitt M, Snyder SJ, et al: Chronic labral tears: Value of magnetic resonance arthrography in evaluating the glenoid labrum and labral-bicipital complex. Arthroscopy 2004;20:959-963. Bencardino JT, Beltran J, Rosenberg ZS, et al: Superior labrum anterior-posterior lesions: Diagnosis with MR arthrography of the shoulder. Radiology 2000;214:267-271.

Question 2624

Topic: 5. Sports Medicine

Figure 11 shows the anatomic dissection of the medial side of the knee joint after removal of the superficial fascia. The arrow is pointing to what structure?

Anatomy 2002 Practice Questions: Set 1 (Solved) - Figure 28

. Semitendinosus tendon
. Gracilis tendon
. Sartorius tendon
. Semimembranosus tendon
. Medial collateral ligament

Correct Answer & Explanation

. Semitendinosus tendon

Explanation

The semitendinosus and gracilis tendons lie beneath the superficial fascia and superficial to the medial collateral ligament. The semitendinosus is located more inferior to the gracilis tendon. The sartorius is more posterior and distal as is the medial collateral ligament. The semimembranosus is posterior. Pagnani MJ, Warner JJ, O'Brien SJ, Warren RF: Anatomic considerations in harvesting the semitendinosus and gracilis tendons and a technique of harvest. Am J Sports Med 1993;21:565-571.

Question 2625

Topic: Shoulder & Hip Sports

Figures 39a and 39b show the MRI scans of a 25-year-old man with right shoulder pain. Figure 39c shows the arthroscopic view from a posterior portal in the beach chair position. What is the most likely diagnosis?

. Bankart lesion
. Superior labral tear
. Partial articular surface supraspinatus tear
. Partial bursal surface supraspinatus tear
. Full-thickness supraspinatus tear

Correct Answer & Explanation

. Partial articular surface supraspinatus tear

Explanation

The MRI scans show coronal oblique and sagittal oblique views of a partial articular surface supraspinatus tear or tendon avulsion (PASTA lesion). The arthroscopic view is a posterior portal of the glenohumeral joint viewing the articular surface of the supraspinatus. These tears are a common source of shoulder pain and are often amenable to transtendon arthroscopic repair without detachment of the intact bursal surface. Sanders TG, Miller MD: A systematic approach to magnetic resonance imaging interpretation of sports medicine injuries of the shoulder. Am J Sports Med 2005;33:1088-1105. McConville OR, Iannotti JP: Partial-thickness tears of the rotator cuff: Evaluation and management. J Am Acad Orthop Surg 1999;7:32-43.

Question 2626

Topic: 5. Sports Medicine

A 20-year-old collegiate football player who sustained blunt head trauma during the first half of a game is emotional and confused. During the halftime intermission, his affect, memory, and disorientation are totally resolved and have returned to preinjury baseline. The only residual finding is a very mild headache. He wants to play the second half. What is the most appropriate course of action?

. Permit him to play after a 15-minute cardiovascular challenge.
. Permit him to play after he satisfactorily completes "field-ready" neuropsychiatric testing.
. Do not permit return to play until he can perform sport-specific skills.
. Do not permit return to play for 1 week.
. Do not permit return to play until all symptoms have resolved.

Correct Answer & Explanation

. Do not permit return to play until all symptoms have resolved.

Explanation

There is almost universal acceptance that an athlete may return to play after blunt head trauma only if he or she is totally asymptomatic. Mild residual symptoms are considered an absolute contraindication for return to play. Returning to play after a cardiovascular challenge or sport-specific activities is permitted on the pretext that the athlete is totally asymptomatic prior to these maneuvers. Neuropsychiatric testing is being used more frequently to monitor residual cognitive effects after head trauma. It has not been used as a return to play criterion. Garrick J (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 29-48.

Question 2627

Topic: Knee Sports

A 48-year-old man has recurrent right knee pain. Figure 52a shows the sagittal proton density T2-weighted MRI scan, and Figure 52b shows the sagittal T2-weighted MRI scan at the same level. The arrow is pointing to a

. popliteal cyst.
. posterior cruciate ligament tear.
. torn and displaced posterior horn of the medial meniscus.
. normal meniscofemoral ligament of Humphry.
. normal meniscofemoral ligament of Wrisberg.

Correct Answer & Explanation

. torn and displaced posterior horn of the medial meniscus.

Explanation

Meniscal tears have many configurations and locations. The normal medial meniscus has a bow-tie configuration on the two most medial consecutive sagittal views. Toward the center of the joint the anterior and posterior horns have a triangular shape. These images show an abnormal intra-articular low-signal structure located anterior to the intact posterior cruciate ligament. This most likely represents a torn and displaced posterior horn of the medial meniscus, sometimes called "double PCL sign". A popliteal cyst and ligaments of Wrisberg and Humphry are not visible on these figures. Helms CA: MR image of the knee, in Fundamentals of Skeletal Radiology, ed 2. Philadelphia, PA, WB Saunders, 1995, pp 172-191.

Question 2628

Topic: Shoulder & Hip Sports

Figure 47 shows a transverse MRI scan of a patient's left shoulder. The findings reveal which of the following abnormalities?

Anatomy Board Review 2002: High-Yield MCQs (Set 4) - Figure 9

. Subscapularis tear
. Coracoid fracture
. Osteonecrosis of the humeral head
. Posterior labral tear
. Hill-Sachs lesion

Correct Answer & Explanation

. Hill-Sachs lesion

Explanation

The MRI scan shows a defect in the posterior aspect of the humeral head, commonly referred to as a Hill-Sachs lesion. This is an impaction fracture of the humeral head that occurs during anterior shoulder dislocation. The abnormality on this image is an irregularity of the posterior humeral head; the humeral head otherwise has a homogenous appearance. The coracoid, subscapularis, and posterior labrum are normal. Griffin LY (ed): Orthopaedic Knowledge Update: Sports Medicine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 47-63.

Question 2629

Topic: 5. Sports Medicine

A patient undergoes a proximal tibial resection that is reconstructed with a fresh frozen osteoarticular allograft. Eleven months later, the graft is retrieved. Histologically, the articular cartilage and subchondral bone retrieved would be expected to show evidence of

. host chondrocytes in the articular cartilage.
. subchondral revascularization and fragmentation, without evidence of cartilage degeneration.
. an articular surface covered with a pannus of synovial tissue.
. radiographically normal thickness of the articular surface, with evidence of cellular debris in the lacuna.
. severe degenerative changes in the articular cartilage surface with complete loss of the tidemark.

Correct Answer & Explanation

. an articular surface covered with a pannus of synovial tissue.

Explanation

Osteoarticular allografts are devoid of host chondrocytes but do contain "mummified" cellular debris left over from donor processing. The cartilage architecture is preserved in the first 2 to 3 years after transplantation. The articular surface is covered with a pannus of fibrocartilage maintaining the joint space radiographically; this pannus later contains islands of fibrocartilage containing host mesenchymal stem cells. Degenerative changes to the joint surface occur earlier and are more severe in joints that are unstable. Only with degenerative changes at the surface is there histologic evidence of subchondral revascularization. Often degenerative changes involving the articular cartilage reach the tidemark, but the tidemark itself remains structurally intact. Enneking WF, Campanacci DA: Retrieved human allografts: A clinicopathological study. J Bone Joint Surg Am 2001;83:971-986.

Question 2630

Topic: Knee Sports
A 19-year-old rugby player has severe knee pain after being injured in a game 2 weeks ago. Examination reveals a knee effusion, limited motion, and increased 3+ Lachman's test and anterior drawer. There is also increased external rotation at 30 degrees of knee flexion when the patient is placed in the prone position. Based on these findings, which of the following actions would most likely increase the risk of anterior cruciate ligament (ACL) reconstruction failure?
. Inadvertent rotation of the graft 90 degrees internally prior to its final fixation
. Lack of full knee extension at the time of surgery
. Persistent posterolateral corner injury
. Leaving 1 to 2 mm of bone posterior to the femoral tunnel at the time of the ACL reconstruction
. Placing the tibial tunnel within the ACL footprint

Correct Answer & Explanation

. Persistent posterolateral corner injury

Explanation

The patient has a combined ACL and posterolateral corner injury. Failure to diagnose and treat an injury of the posterolateral corner in a patient who has a tear of the anterior or posterior cruciate ligament can result in failure of the reconstructed cruciate ligament. The tibial external rotation test is best performed with the patient in the prone position. A 10-degree side-to-side difference of external rotation at 30 degrees of knee flexion indicates injury to the posterolateral corner. Acute grade III isolated or combined injuries of the posterolateral corner are best treated early by direct repair or by augmentation or reconstruction of all injured ligaments. Postoperative arthrofibrosis after an ACL reconstruction has been observed with preoperative deficiencies of knee motion.

Question 2631

Topic: 5. Sports Medicine

Figure 41 shows the MRI scan of a 38-year-old weightlifter. What does the arrow on the MRI scan indicate?

Anatomy 2008 Practice Questions: Set 3 (Solved) - Figure 23

. Biceps tear
. Pectoralis minor tear
. Pectoralis major tear
. Subscapularis tear
. Abscess formation

Correct Answer & Explanation

. Pectoralis major tear

Explanation

Pectoralis major ruptures typically occur in avid weightlifters (often on supplements) and typically while bench-pressing. Clinically there is significant discoloration/bruising over the pectoralis and into the axilla. MRI helps confirm the diagnosis and may help determine if the tear is in the muscle belly or at the bone-tendon junction. Bal GK, Basamania CJ: Pectoralis major tendon ruptures: Diagnosis and treatment. Tech Shoulder Elbow Surg 2005;6:128-134.

Question 2632

Topic: 5. Sports Medicine
A 23-year-old soccer player sustains a grade III complete posterior cruciate ligament (PCL) tear after colliding with another player. In reconstructing the PCL, it is optimal to reconstruct the
. anterolateral bundle and tension the graft at 10 degrees of flexion.
. anterolateral bundle and tension the graft at 90 degrees of flexion.
. posteromedial bundle and tension the graft at 10 degrees of flexion.
. posteromedial bundle and tension the graft at 45 degrees of flexion.
. posteromedial bundle and tension the graft at 90 degrees of flexion.

Correct Answer & Explanation

. anterolateral bundle and tension the graft at 90 degrees of flexion.

Explanation

The PCL is a nonisometric structure with nonuniform tension during knee motion, with maximum tension at 90 degrees of flexion. While the posteromedial PCL fibers have been found to be the most isometric, the anterolateral fibers represent the bulk of the ligament. Studies have suggested that anterior placement of the femoral tunnel is superior to placement in an isometric position. The anterolateral bundle tightens as the knee flexes; therefore, it is optimal to tension the graft at 90 degrees of flexion.

Question 2633

Topic: Shoulder & Hip Sports

A 22-year-old female collegiate javelin thrower has shoulder pain. She notes that her pain is primarily located in the posterior aspect of her shoulder, is exacerbated with throwing, and she experiences maximal tenderness in the extreme cocking phase of the throwing cycle. On examination, she reports deep posterior shoulder pain when the arm is abducted 90 degrees and maximally externally rotated to 110 degrees. This reproduces her symptoms precisely. Shoulder radiographs are normal. What is the most likely diagnosis?

. Anterior shoulder instability
. Early adhesive capsulitis
. Internal impingement
. Subacromial impingement
. Full-thickness rotator cuff tear

Correct Answer & Explanation

. Internal impingement

Explanation

The patient has internal impingement. Internal impingement is commonly seen in overhead throwing athletes. When positioned in the extreme cocking phase of the throwing cycle, the posterior glenoid impacts the articular surface of the infraspinatus and posterior fibers of the supraspinatus tendon. This impact can cause partial-thickness rotator cuff tearing and posterosuperior labral lesions. She has no evidence of anterior shoulder instability, and her range of motion is excellent which rules out adhesive capsulitis. Subacromial impingement is identified with anterolateral shoulder pain with internal rotation in the abducted position. A full-thickness rotator cuff tear in a 22-year-old individual would require significant trauma and would likely result in pain at rest and with lifting. Meister K, Buckley B, Batts J: The posterior impingement sign: Diagnosis of rotator cuff and posterior labral tears secondary to internal impingement in overhand athletes. Am J Orthop 2004;33:412-415.

Question 2634

Topic: Shoulder & Hip Sports
A 72-year-old man injured his right shoulder after tripping over a chair leg. Radiographs obtained in the emergency department reveal an isolated anterior dislocation. After successful closed reduction, the patient has recurrent anterior instability and is unable to elevate the arm. What is the most likely cause of the recurrent instability?
. Infection of the anterior glenoid labral detachment
. Anterior glenoid fracture
. Axillary nerve palsy
. Occult surgical neck fracture
. Rotator cuff tear

Correct Answer & Explanation

. Rotator cuff tear

Explanation

A rotator cuff tear is the most common cause of recurrent instability following a first-time dislocation in patients older than age 40 years. Dislocations occur through a posterior mechanism rather than by an isolated labral avulsion or a Bankart lesion as seen in younger patients.

Question 2635

Topic: 5. Sports Medicine

A 12-year-old boy reports the acute onset of pain and a pop over the right side of his pelvis while swinging a baseball bat during a Little League game. Radiographs reveal an avulsion of the anterior superior iliac spine with 2 cm of displacement. Management should consist of

. open reduction and internal fixation of the fragment along with the rectus femoris.
. open reduction and internal fixation of the fragment along with the sartorius.
. open reduction and internal fixation of the fragment along with the iliopsoas.
. rest and protected weight bearing with crutches.
. excision of the fragment.

Correct Answer & Explanation

. rest and protected weight bearing with crutches.

Explanation

Anterior superior iliac spine avulsion fractures are caused by sudden, forceful contractions of the sartorius and tensor fascia lata. These injuries occur in young athletes through the growth plate with the hip extended and the knee flexed, such as while sprinting or swinging a baseball bat. The athlete will often report a pop or snap at the time of injury. Displaced fractures usually can be seen on radiographs. CT or MRI can be obtained to confirm the diagnosis. In most patients, nonsurgical management consisting of rest and protected weight bearing yields satisfactory outcomes. Surgery is usually reserved for fractures with displacement of more than 3 cm and painful nonunions. Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 139-153.

Question 2636

Topic: 5. Sports Medicine

A 28-year-old man has left knee pain after a snow skiing accident. The MRI scan shown in Figure 47 reveals which of the following?

Anatomy Board Review 2008: High-Yield MCQs (Set 4) - Figure 10

. Osteosarcoma
. Bucket-handle medial meniscal tear
. Lateral collateral ligament tear
. Bone bruise
. Tibial spine avulsion

Correct Answer & Explanation

. Bone bruise

Explanation

Bone bruises are often noted on MRI after anterior cruciate and medial collateral ligament injuries. The significance of these injuries awaits long-term follow-up studies. The areas of increased signal on T2-weighted images represent areas of acute hemorrhage and are secondary to microfractures of the adjacent medullary trabeculae. Wright RW, Phaneuf MA, Limbird TJ, et al: Clinical outcome of isolated subcortical trabecular fractures (bone bruise) detected on magnetic resonance imaging in knees. Am J Sports Med 2000;28:663-667.

Question 2637

Topic: 5. Sports Medicine
Examination of an 18-year-old professional soccer player who was forcefully kicked across the shin while attempting a slide tackle reveals a marked effusion and limited motion of the knee. The tibia translates 12 mm posterior to the femoral condyles when the knee is held in 90 degrees of flexion. There is no posteromedial or posterolateral instability. Management should consist of
. early reconstruction of all injured structures.
. knee immobilization in 30 degrees of flexion for 2 to 4 weeks.
. knee immobilization in full extension for 2 to 4 weeks.
. protected weight bearing and intense hamstring strengthening.
. no weight bearing, followed by a gradual return to sports.

Correct Answer & Explanation

. knee immobilization in full extension for 2 to 4 weeks.

Explanation

The patient has an acute grade III posterior cruciate ligament injury. The majority of grade I and II injuries can be treated with protected weight bearing and quadriceps rehabilitation, and most patients can return to sports within 2 to 4 weeks. In contrast, grade III injuries require immobilization in full extension for 2 to 4 weeks to protect the posterior cruciate ligament and the other posterolateral structures presumed to be damaged. The mainstay of postinjury rehabilitation for all posterior cruciate ligament injuries is quadriceps strengthening exercises, which have been shown to counteract posterior tibial subluxation.

Question 2638

Topic: 5. Sports Medicine
With a full-thickness articular cartilage injury, the body's healing response produces cartilage mainly composed of what type of collagen?
. I
. II
. III
. IV
. X

Correct Answer & Explanation

. I

Explanation

With a full-thickness articular cartilage injury, a healing response is initiated with hematoma, stem cell migration, and vascular ingrowth. This response produces type I collagen and resultant fibrous cartilage rather than the desired hyaline cartilage produced by chondrocytes. This repair cartilage has diminished resiliency, stiffness, poor wear characteristics, and a predilection for arthritis. Type I collagen is also found in the annulus of intervertebral disks, tendon, bone, meniscus, and skin. Type II is found in articular cartilage and the nucleus pulposus of intervertebral disks. Type III is found in skin and blood vessels, type IV is found in basement membranes, and type X is found in the calcified layer of cartilage.

Question 2639

Topic: Shoulder & Hip Sports

A 62-year-old man with a long history of right shoulder pain and weakness is scheduled to undergo hemiarthroplasty. Based on the radiographs shown in Figures 6a through 6c, what preoperative factor will most affect postoperative functional outcome?

. Humeral head erosion
. Glenoid erosion
. Rotator cuff integrity
. Status of the coracoacromial ligament
. Acromioclavicular arthritis

Correct Answer & Explanation

. Rotator cuff integrity

Explanation

The radiographs reveal osteoarthritis and proximal humeral head migration. Integrity of the rotator cuff must be questioned based on these radiographic changes. The status of the rotator cuff is the most influential factor affecting postoperative function in shoulder hemiarthroplasty. The coracoacromial ligament provides a barrier to humeral head proximal migration in the face of a rotator cuff tear. The radiographs do not indicate significant humeral head or glenoid erosion. Acromioclavicular arthritis is often asymptomatic. Iannotti JP, Norris TR: Influence of preoperative factors on outcome of shoulder arthroplasty for glenohumeral osteoarthritis. J Bone Joint Surg Am 2003;85:251-258.

Question 2640

Topic: 5. Sports Medicine

A 15-year-old girl who competes in gymnastics has immediate pain and giving way of the left elbow after falling from the uneven parallel bars and landing on her outstretched arms. Examination reveals swelling and tenderness about the elbow, especially over the medial side. Measurement of elbow motion shows 0 degrees to 125 degrees of flexion, and valgus stress at the elbow is painful. AP, lateral, and stress radiographs are shown in Figures 9a through 9c. Management should consist of

. arthroscopic repair of the ulnar collateral ligament.
. direct surgical repair of the ulnar collateral ligament.
. reconstruction of the ulnar collateral ligament with a palmaris longus tendon autograft.
. a hinged elbow brace to allow early protected range of motion.
. immobilization of the elbow to allow healing of the ulnar collateral ligament.

Correct Answer & Explanation

. reconstruction of the ulnar collateral ligament with a palmaris longus tendon autograft.

Explanation

While many low-demand patients with injuries to the ulnar collateral ligament can be treated nonsurgically, Jobe and associates described two situations in which ulnar collateral ligament reconstruction is indicated: (1) an acute complete rupture in a competitive athlete who uses the upper extremities extensively and who wishes to remain active; and (2) chronic pain or instability that does not improve after at least 3 months of nonsurgical management. Rarely is direct surgical repair of the ligament possible or able to withstand the valgus stresses applied to the elbow. Most authors recommend surgical reconstruction of the ulnar collateral ligament using a palmaris longus, plantaris, or fourth toe extensor tendon from the fourth autograft. Andrews JR, Jelsma RD, Joyce ME, et al: Open surgical procedures for injuries to the elbow in throwers. Oper Tech Sports Med 1994;4:109-133. Jobe FW, Kvitne RS: Elbow instability in the athlete. Instr Course Lect 1991;40:17-23.

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