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5. Sports Medicine MCQs

Practice Set 133 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 2641

Topic: Shoulder & Hip Sports

A 15-year-old wrestler sustains an abduction, hyperextension, and external rotation injury to his right shoulder. The MRI scan findings shown in Figures 27a and 27b are most consistent with

. an avulsion of the lesser tuberosity.
. a midsubstance tear of the capsule.
. a tear of the anterior inferior labrum.
. a tear of the subscapularis.
. a tear of the humeral insertion of the inferior glenohumeral ligament.

Correct Answer & Explanation

. a tear of the humeral insertion of the inferior glenohumeral ligament.

Explanation

An isolated avulsion of the lesser tuberosity occurs very rarely and usually is found in 12- and 13-year-old adolescents. The MRI scans reveal a tear of the humeral attachment of the inferior glenohumeral ligament, a so-called HAGL lesion. This injury to the inferior glenohumeral ligament occurs much less commonly than the classic Bankart lesion (anterior inferior labral tear). A tear of the subscapularis occurs with a similar mechanism of injury but generally occurs in older individuals. 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 2642

Topic: 5. Sports Medicine

What neurovascular structure is at greatest risk when creating a proximal anterolateral elbow arthroscopy portal?

. Lateral antebrachial cutaneous nerve
. Radial nerve
. Posterior interosseous nerve
. Median nerve
. Brachial artery

Correct Answer & Explanation

. Radial nerve

Explanation

The radial nerve is 4 to 7 mm from the anterolateral portal, which is placed 1 cm anterior and 3 cm proximal to the lateral epicondyle. The posterior interosseous nerve can lie 1 to 14 mm from the portal site. Andrews JR, Carson WG: Arthroscopy of the elbow. Arthroscopy 1985;1:97-107.

Question 2643

Topic: Shoulder & Hip Sports

A 22-year-old professional baseball catcher has posterior shoulder pain and severe external rotation weakness with the arm in adduction. Radiographs are normal. MRI scans are shown in Figures 15a through 15c. Management should consist of

. aspiration and steroid injection.
. rest.
. acromioplasty.
. arthroscopic repair and decompression.
. rehabilitation.

Correct Answer & Explanation

. arthroscopic repair and decompression.

Explanation

The MRI scans reveal a large posterior paralabral cyst associated with a posterior-superior labral tear. The cyst appears as a well-defined, smoothly marginated mass with low signal intensity on T1-weighted MRI scans and with high signal intensity on T2-weighted MRI scans. MRI also reveals changes in the supraspinatus and infraspinatus muscles secondary to denervation, including decreased muscle bulk and fatty infiltration. MRI has the added advantage, compared with other imaging modalities, of detecting intra-articular lesions, such as labral tears, which are frequently associated with ganglion cysts of the shoulder. In this case of a professional baseball player with a space-occupying lesion causing nerve compression with an associated labral tear, the treatment of choice is arthroscopic decompression of the cyst and repair of the tear. Acromioplasty would not address the primary pathology in this patient. Cummins CA, Messer TM, Nuber GW: Suprascapular nerve entrapment. J Bone Joint Surg Am 2000;82:415-424.

Question 2644

Topic: Shoulder & Hip Sports

A coronal MRI scan through the shoulder joint is shown in Figure 26. The cyst indicated by the arrow will most likely cause compression of what nerve?

Anatomy Board Review 2002: High-Yield MCQs (Set 2) - Figure 27

. Subscapular
. Suprascapular
. Axillary
. Musculocutaneous
. Medial pectoral

Correct Answer & Explanation

. Suprascapular

Explanation

The MRI scan shows a ganglion cyst in the region of the spinoglenoid notch. These are difficult to diagnose clinically but are readily apparent on MRI. They usually cause compression of the suprascapular nerve and weakness of the infraspinatus and supraspinatus muscles. Resnick D, Kang HS (eds): Internal Derangements of Joints: Emphasis on MR Imaging. Philadelphia, PA, WB Saunders, 1997, pp 306-309.

Question 2645

Topic: 5. Sports Medicine

Radiographs of a 12-year-old boy who has knee pain show a 2-cm osteochondral lesion of the lateral aspect of the medial femoral condyle. The fragments are not detached from the femur. Initial management should consist of

. casting in flexion.
. observation.
. arthroscopic drilling and pinning of the lesion.
. removal and reattachment of the osteochondral lesion.
. allograft transplantation for the lesion.

Correct Answer & Explanation

. casting in flexion.

Explanation

For a pediatric patient without mechanical symptoms, initial management of an osteochondral defect lesion that is not detached should consist of casting in flexion. Failure to respond to several weeks or months of nonsurgical management may warrant surgical treatment.

Question 2646

Topic: 5. Sports Medicine

A 21-year-old professional baseball player has had painful catching and stiffness in his dominant right elbow for the past year. Examination reveals a flexion contracture of 2 degrees and mild pain with full elbow flexion. Radiographs are shown in Figures 33a and 33b. The most effective management should consist of

. reconstruction of the medial collateral ligament.
. a short period of rest followed by a gradual return to activity.
. physical therapy and dynamic extension splinting.
. arthroscopic removal of the loose body.
. a corticosteroid injection.

Correct Answer & Explanation

. arthroscopic removal of the loose body.

Explanation

The radiographs show osteochondritis dissecans of the capitellum and a loose body in the anterior compartment. Arthroscopic removal is indicated because symptoms referable to the loose body are present. Baumgarten TE: Osteochondritis dissecans of the capitellum. Sports Med Arthroscopy Rev 1995;3:219-223.

Question 2647

Topic: 5. Sports Medicine
Figure 22 shows the MRI scan of a 20-year-old female basketball player who has pain over the anterior knee that interferes with her performance. Examination reveals phase III Blazina patellar tendinosis. Management should consist of
. local modalities including iontophoresis.
. quadriceps and iliotibial band stretching exercises.
. progressive eccentric strengthening exercises.
. a patellar tendon strap.
. excision of the abnormal area.

Correct Answer & Explanation

. excision of the abnormal area.

Explanation

Excision of the affected mucoid degenerative area is considered appropriate management in the Blazina classification system. A finding of phase III indicates persistent pain with or without activities, as well as deterioration of performance. With the appearance of the mucoid degeneration and the vigorous activity level of the intercollegiate basketball player, it is unlikely that nonsurgical management will provide adequate relief. When excising the affected degenerative area, care must be taken to retain normal tendon fibers.

Question 2648

Topic: Shoulder & Hip Sports

A 42-year-old man sustained a fracture of the distal radius with subsequent stiffness in the ipsilateral shoulder. Despite a 6-month program of range-of-motion exercises, external rotation at the side is limited to 10 degrees. Attempts at closed manipulation are unsuccessful. Treatment should now consist of

Upper Extremity 2005 Practice Questions: Set 1 (Solved) - Figure 17

. open release of the posterior capsule.
. arthroscopic release of the rotator cuff interval.
. arthroscopic release of the anteroinferior capsule.
. open subscapularis lengthening.
. open extra-articular release.

Correct Answer & Explanation

. arthroscopic release of the rotator cuff interval.

Explanation

When external rotation at the side is limited, the most likely diagnosis is contracture of the rotator cuff interval, including the superior glenohumeral and coracohumeral ligaments. Therefore, the treatment of choice is arthroscopic release of the rotator cuff interval.

Question 2649

Topic: 5. Sports Medicine

A 50-year-old patient who plays tennis sustained the deformity shown in Figure 27 following a high volley. Further diagnostic work-up should include

Sports Medicine 2001 Practice Questions: Set 3 (Solved) - Figure 5

. an electromyogram (EMG) of the upper extremity.
. an ultrasound of the short head of the biceps.
. an MRI scan of the rotator cuff.
. a CT scan with contrast of the anterior labrum.
. a subclavian venogram.

Correct Answer & Explanation

. an MRI scan of the rotator cuff.

Explanation

The patient has a rupture of the long head of the biceps; however, patients older than age 45 years are at greater risk of having an associated rotator cuff tear. An MRI scan should be ordered to avoid missing concomitant rotator cuff pathology. While patients may report pain radiating down the arm at the time of the tendon rupture, an EMG is not indicated. The short head of the biceps is intact and needs no further work-up, even though the muscle descends in most cases. The anterior labrum can be injured but is not associated with this deformity. Neer CS II, Bigliani LU, Hawkins RJ: Rupture of the long head of the biceps related to the subacromial impingement. Orthop Trans 1977;1:114.

Question 2650

Topic: 5. Sports Medicine

A 16-year-old ice hockey player is struck on the chest by the puck. He skates a few strides and then collapses. What is the most likely diagnosis?

. Acute aortic dissection
. Pulmonary contusion
. Commotio cordis
. Acute cardiac tamponade
. Splenic rupture

Correct Answer & Explanation

. Commotio cordis

Explanation

Sudden cardiac arrest following a blow to the chest in young athletes has been termed "commotio cordis." It is most common in Little League and other youth projectile sports (eg, ice hockey, lacrosse). The cause, although not completely determined, is most likely an arrhythmia related to the impact in a vulnerable time in the cardiac cycle. Resuscitation has proven to be exceedingly difficult, resulting in a high mortality rate. Maron BJ, Strasburger JF, Kugler JD, Bell BM, Brodkey FD, Poliac LC: Survival following blunt chest impact-induced cardiac arrest during sports activities in young athletes. Am J Cardiol 1997;79:840-841.

Question 2651

Topic: Shoulder & Hip Sports

Initial repair of the large U-shaped rotator cuff tear shown in Figure 12 consists of closing the tear side-to-side to take advantage of margin convergence. The most significant biomechanical consequence of this repair step results in

Sports Medicine Board Review 2004: High-Yield MCQs (Set 2) - Figure 1

. increased strength of the rotator cuff repair by creating thicker repair construct.
. decreased size of the defect exposing the humeral head.
. decreased stress in the rotator cuff at the site of the side-to-side repair.
. decreased stress in the rotator cuff at the free margin and greater tuberosity interface.
. decreased stress in the rotator cuff crescent cable.

Correct Answer & Explanation

. decreased stress in the rotator cuff at the free margin and greater tuberosity interface.

Explanation

Margin convergence refers to the phenomenon that occurs with side-to-side closure of large U- or L-shaped rotator cuff tears in which the free margin of the tear converges toward the greater tuberosity as the side-to-side tear progresses. The creation of the converged cuff margin creates decreased strain in the free margin of the repaired cuff, resulting in a decreased strain in the repair sutures. While the size of the humeral head defect is made smaller with side-to-side closure, biomechanically, this is less significant. The mild increase in thickness of the repair at the side-to-side margin is less important than a reduction in stress in the repaired tissue. Stress in the crescent cable region of the cuff actually increases and becomes more physiologic in transmitting force from the cuff to the greater tuberosity. Burkhart SS: A stepwise approach to arthroscopic rotator cuff repair based on biomechanical principles. Arthroscopy 2000;16:82-90.

Question 2652

Topic: 5. Sports Medicine

A football player sustains a traumatic anterior inferior dislocation of the shoulder in the last game of the season. It is reduced 20 minutes later in the locker room. The patient is neurologically intact and has regained motion. If the patient undergoes arthroscopic evaluation, what finding is seen most consistently?

Upper Extremity Board Review 2008: High-Yield MCQs (Set 2) - Figure 12

. Superior labral detachment
. Engaging Hill-Sachs lesion
. Large glenoid rim fracture
. Avulsion of the inferior glenohumeral ligament from the humerus
. Avulsion of the anterior inferior glenoid labrum

Correct Answer & Explanation

. Avulsion of the anterior inferior glenoid labrum

Explanation

In an acute first-time dislocation, arthroscopy has been shown to reveal a Bankart lesion in most shoulders. The classic finding of labral detachment from the anterior inferior glenoid along with occasional hemorrhage within the inferior glenohumeral ligament is the most common sequelae of a traumatic anterior inferior dislocation. Acute treatment, if chosen, is repair of the labral tissue back to the glenoid plus or minus any capsular plication to address potential plastic deformation of the glenohumeral ligament. Acute treatment of a patient sustaining a first-time dislocation remains controversial. The potential indications may be patients whose dislocation occurs at the end of a season and when the desire to minimize risk of future instability outweighs the risks of surgical intervention. Taylor DC, Arciero RA: Pathologic changes associated with shoulder dislocations: Arthroscopic and physical examination findings in first-time, traumatic anterior dislocations. Am J Sports Med 1997;25:306-311. DeBerardino TM, Arciero RA, Taylor DC, et al: Prospective evaluation of arthroscopic stabilization of acute, initial anterior shoulder dislocations in young athletes: Two- to five-year follow-up. Am J Sports Med 2001;29:586-592.

Question 2653

Topic: 5. Sports Medicine

A 17-year-old high school long distance runner is seeking advice before running a marathon for the first time. What advice should be given regarding his fluid, carbohydrate, and electrolyte intake around the time of the race?

Sports Medicine 2004 Practice Questions: Set 1 (Solved) - Figure 6

. Restrict fluid intake 2 hours before the start of the race to avoid abdominal cramping.
. Drink low osmolality (less than 10%) solutions before, during, and after the race.
. Drink fruit juice, such as orange juice, instead of water to replenish essential carbohydrates.
. Drink high osmolality (greater than 10%) solutions before and during the race and low osmolality solutions after the race.
. Avoid the use of glucose polymers because they slow down gastric emptying and may lead to abdominal cramping.

Correct Answer & Explanation

. Drink low osmolality (less than 10%) solutions before, during, and after the race.

Explanation

The goal of fluid replenishment should be to replace the sweat that has been lost. Sweat is mostly water, with a small concentration of salts and other electrolytes. Absorption is enhanced by solutions of low osmolality. Scientific research has also shown that adding carbohydrates to the drink improves athletic performance. Carbohydrates such as glucose and maltodextrins (glucose polymers) stimulate fluid absorption by the intestines. Fructose slows intestinal absorption of fluids. Drinks that are high in fructose, such as orange juice, can lead to gastrointestinal distress and osmotic diarrhea. Kirkendall D: Fluids and electrolytes, in The U.S. Soccer Sports Medicine Book. Baltimore, MD, Williams and Wilkins, 1996.

Question 2654

Topic: 5. Sports Medicine
Figure 42 shows the sagittal T2-weighted MRI scan of a patient's right knee. These findings are most commonly seen with a complete tear of the
. patellar tendon.
. lateral collateral ligament.
. medial collateral ligament.
. posterior cruciate ligament.
. anterior cruciate ligament.

Correct Answer & Explanation

. lateral collateral ligament.

Explanation

The MRI scan reveals disruption of the lateral capsule and ligaments with fluid in the soft tissues laterally. Additionally, there is a large bone bruise on the medial femoral condyle. This combination indicates injury to the posterolateral complex. These injuries often have coexisting anterior and/or posterior cruciate ligament injuries. Failure to recognize the posterolateral corner injury can lead to failure of anterior or posterior cruciate ligament reconstructions.

Question 2655

Topic: Shoulder & Hip Sports

Figure 7 shows a sagittal T1-weighted MRI scan. What muscle/tendon is identified by the arrow?

Upper Extremity 2008 Practice Questions: Set 1 (Solved) - Figure 15

. Infraspinatus
. Teres minor
. Subscapularis
. Long head of triceps
. Latissimus dorsi

Correct Answer & Explanation

. Teres minor

Explanation

The sagittal T1-weighted MRI scan is useful for interpreting the quality of muscle. The arrow is pointing to the teres minor. Goutallier D, Postel JM, Gleyze P, et al: Influence of cuff muscle fatty degeneration on anatomic and functional outcomes after simple suture of full-thickness tears. J Shoulder Elbow Surg 2003;12:550-554.

Question 2656

Topic: 5. Sports Medicine

A 20-year-old soccer player who collapsed after a goal kick reports weakness and nausea. He appears slightly confused. Examination reveals that he is not sweating. His skin is warm and dry. The outdoor temperature is 80 degrees F (26.6 degrees C) with a relative humidity of 80%. Management should consist of

. a drink of water.
. a sports drink with electrolytes.
. placement in the reverse Trendelenburg position in a shaded area.
. immersion in a warm water bath.
. transportation to the emergency department.

Correct Answer & Explanation

. transportation to the emergency department.

Explanation

There is a spectrum of heat-related conditions. Heat cramps are the mildest form of heat illness. In heat exhaustion, cramps are associated with headache and weakness, and the skin is pale and moist. Treatment of heat cramps or heat exhaustion consists of removing and loosening excess clothing, applying ice to the axilla and groin, ingestion of cool water, and cool water sprays. This patient demonstrates symptoms of heat stroke which is a medical emergency. The core body temperature may be as high as 106 to 110 degrees F (41.1 to 43.3 degrees C). In heat stroke, the patient may no longer be sweating, and the skin may be hot and red. The athlete is usually confused, weak, nauseated, and may have seizure activity. Central nervous system depression has been called the most important marker of heat stroke, and progresses from confusion and bizarre behavior to collapse, delirium, and coma. Bizarre behavior is often the first sign of heat stroke. The patient needs to be treated and moved to a medical facility rapidly. During transfer, IV fluids and cooling of the athlete should be initiated. The best treatment of heat-related illness appears to be prevention with adequate hydration and monitoring of conditions (temperature and humidity), with cancellation of competition when conditions do not comply with guidelines. Griffin LY: Emergency preparedness: Things to consider before the game starts. J Bone Joint Surg Am 2005;87:894-902. Barker TA, Motz HA, Gersoff WK: Environmental factors in athletic performance, in Fu FH, Stone DA (eds): Sports Injuries, ed 2. Philadelphia, PA, Lippincott, 2001, pp 67-68.

Question 2657

Topic: Knee Sports

Figure 16 shows an axial MRI scan through the knee joint. What structure is identified by the arrow?

Anatomy Board Review 2002: High-Yield MCQs (Set 2) - Figure 6

. Anterior cruciate ligament
. Posterior cruciate ligament
. Ligament of Wrisberg
. Ligamentum mucosum
. Popliteus tendon

Correct Answer & Explanation

. Anterior cruciate ligament

Explanation

The anterior cruciate ligament can be visualized on an axial MRI scan as a low-signal structure lying in the lateral aspect of the intercondylar notch. Visualization in multiple planes increases the accuracy of MRI to view the anterior cruciate ligament. The posterior cruciate ligament and ligament of Wrisberg are located on the medial wall of the notch. The ligamentum mucosum is anterior to the notch, and the popliteus tendon is posterior to the lateral femoral condyle. Resnick D, Kang HS (eds): Internal Derangements of Joints: Emphasis on MR Imaging. Philadelphia, PA, WB Saunders, 1997, pp 675-699.

Question 2658

Topic: Shoulder & Hip Sports

A right-handed 24-year-old woman underwent an arthroscopic Bankart repair for recurrent anterior dislocations 9 months ago. Despite extensive physical therapy for 8 months, the patient has very limited range of motion (elevation to 130 degrees and external rotation to 10 degrees with the arm at the side). Shoulder radiographs are normal. The next step in management should consist of

Shoulder Board Review 2002: High-Yield MCQs (Set 2) - Figure 23

. cessation of physical therapy and acceptance of the limited range of motion.
. additional physical therapy for 3 to 4 months.
. arthroscopic capsular release.
. open release with Z-plasty lengthening of the subscapularis tendon.
. closed manipulation under anesthesia.

Correct Answer & Explanation

. arthroscopic capsular release.

Explanation

Arthroscopic capsular release is an effective means of treating stiffness that is the result of capsular contractures, such as in the case of a tight Bankart repair. Open release allows lengthening of a surgically shortened subscapularis, such as after a tight Putti-Platt repair. Additional physical therapy is unlikely to be effective because 8 months of treatment has failed to result in improvement. Accepting this degree of asymptomatic limited motion is not advisable because of the functional limitations for the patient and the increased risk of postoperative degenerative arthritis. Warner JJ, Allen AA, Marks PH, Wong P: Arthroscopic release of postoperative capsular contracture of the shoulder. J Bone Joint Surg Am 1997;79:1151-1158.

Question 2659

Topic: 5. Sports Medicine

Figure 49 shows an acute axial MRI scan of a left knee. What is the most likely diagnosis?

Anatomy Board Review 2008: High-Yield MCQs (Set 4) - Figure 15

. Patellar tendon rupture
. Lateral dislocation of the patella
. Quadriceps tendon rupture
. Anterior cruciate ligament rupture
. Posterior cruciate ligament rupture

Correct Answer & Explanation

. Lateral dislocation of the patella

Explanation

The MRI scan shows bone bruises in the medial aspect of the patella and the lateral aspect of the lateral femoral condyle. Both of these signs are typical for a lateral dislocation of the patella with spontaneous reduction. In addition, there may be associated tearing of the medial retinaculum or distal aspect of the vastus medialis. Elias DA, White LM, Fithian DC: Acute lateral patellar dislocation at MR imaging: Injury patterns of medial patellar soft-tissue restraints and osteochondral injuries of the inferomedial patella. Radiology 2002;225:736-743. 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 2660

Topic: 5. Sports Medicine

A 19-year-old college football player reports persistent weakness, tingling, and numbness of both upper extremities at half time. He states that these symptoms initially occurred after tackling an opposing player with his head early in the game. History reveals that he has had "burners" in the past that typically resolved within 15 to 30 minutes. Examination reveals pain-free cervical motion, weakness to shoulder abduction testing bilaterally, normal upper extremity reflexes, and decreased sensation over both shoulders and the upper arms. Appropriate initial management should consist of

. no treatment, the athlete may return to play.
. modification of the shoulder pads and a return to play.
. shoulder rehabilitation exercises and a return to play when strength is normal.
. MRI of the cervical spine.
. CT of the brain.

Correct Answer & Explanation

. MRI of the cervical spine.

Explanation

The player's symptoms represent more than the mere "burner syndrome," which leads to unilateral symptoms that typically last less than 1 minute. Return to play following a burner is allowed following nonsurgical management and once the symptoms have subsided and the player exhibits normal strength and motion of the neck and upper extremities. This player has the history, symptoms, and examination findings that are consistent with cervical neurapraxia. Return to play in contact sports is contraindicated with bilateral symptoms prior to MRI evaluation of the cervical spine. CT of the brain is indicated with a history of loss of consciousness or other symptoms suggestive of a concussion. Torg JS, Sennett B, Pavlov H, et al: Spear tackler's spine: An entity precluding participation in tackle football and collision activities that expose the cervical spine to axial energy inputs. Am J Sports Med 1993;21:640-649. Torg JS: Cervical spinal stenosis with cord neurapraxia and transient quadriplegia. Sports Med 1995;20:429-434.

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