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5. Sports Medicine MCQs

Practice Set 134 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 2661

Topic: 5. Sports Medicine

A 68-year-old man embarks on a 24-week strength training program. He trains at 80% of his single repetition maximum for both the upper and lower extremities. Which of the following changes can be anticipated?

. An absolute decrease in aerobic capacity
. A decrease in capillary density in the trained muscles
. A significant increase in strength
. A significant improvement in Vo2max
. No change in the cross-sectional area of the trained muscles

Correct Answer & Explanation

. A significant increase in strength

Explanation

Consistent, long-term exercise training in older athletes has proven very beneficial in reversing both endurance and strength losses that traditionally have been seen with aging. This patient's program will lead to a significant increase in the strength, cross-sectional area, and capillary density of the trained muscles. No major changes in aerobic capacity are anticipated. Strength improvements of up to 5% per day, similar to those for younger athletes, have been identified in this population in one study. Kirkendall DT, Garrett WE Jr: The effects of aging and training on skeletal muscle. Am J Sports Med 1998;26:598-602.

Question 2662

Topic: Shoulder & Hip Sports

A 21-year-old patient has had pain and a marked decrease in active and passive shoulder motion after having had a seizure 2 months ago as the result of alcohol abuse. Current AP and axillary radiographs and a CT scan are shown in Figures 26a through 26c. Management should consist of

. closed reduction under sedation.
. total shoulder arthroplasty.
. open reduction and subscapularis and lesser tuberosity transfer.
. open reduction and disimpaction with bone grafting.
. hemiarthroplasty with the humeral component placed in less than 20 degrees of retroversion.

Correct Answer & Explanation

. open reduction and subscapularis and lesser tuberosity transfer.

Explanation

Open reduction and subscapularis and lesser tuberosity transfer into the defect is the treatment of choice in young individuals who have defects that involve between 20% to 45% of the head. Disimpaction and bone grafting is an option in injuries that are less than 3 weeks old. Closed reduction 2 to 3 months after injury usually is unsuccessful and increases the risk of fracture or neurovascular injury. Total shoulder arthroplasty is reserved for defects of greater than 50% or with associated glenoid surface damage. Hemiarthroplasty should be avoided in young individuals unless 50% or more of the head is involved. Gerber C: Chronic locked anterior and posterior dislocations, in Warner JJ, Iannotti JP, Gerber C (eds): Complex and Revision Problems in Shoulder Surgery. Philadelphia, PA, Lippincott-Raven, 1997, pp 99-113.

Question 2663

Topic: Shoulder & Hip Sports

Figures 26a through 26c show the MRI scans of a 47-year-old man who underwent arthroscopic shoulder surgery 6 months ago and continues to have pain despite a prolonged course of rehabilitation. Management should now consist of

. rotator cuff repair.
. revision acromioplasty.
. fragment excision.
. open reduction and internal fixation.
. continued rehabilitation.

Correct Answer & Explanation

. open reduction and internal fixation.

Explanation

The MRI scans show an os acromiale of the mesoacromion type. This represents an unfused acromial apophysis. Pain is thought to be caused by either motion at the site or downward displacement of the anterior aspect of the acromion onto the rotator cuff, causing impingement. Most patients can be treated nonsurgically as they are usually asymptomatic. In those patients with persistent symptoms of pain and tenderness over the acromion, surgery consisting of rigid internal fixation and bone grafting has yielded satisfactory results. Excision may be a viable treatment option for the preacromion type. Herzog RJ: Magnetic resonance imaging of the shoulder. Instr Course Lect 1998;47:3-20. Warner JP, Beim GM, Higgins L: The treatment of symptomatic os acromiale. J Bone Joint Surg Am 1998;80:1320-1326.

Question 2664

Topic: 5. Sports Medicine

A 23-year-old man who is a competitive overhead athlete has shoulder pain. Based on the pathology shown in Figure 47, what treatment option would yield the highest satisfaction and return to overhead sports?

Upper Extremity Board Review 2008: High-Yield MCQs (Set 4) - Figure 20

. Biceps tenodesis
. Biceps tenotomy
. Labral debridement
. Labral repair
. Rotator cuff debridement

Correct Answer & Explanation

. Labral repair

Explanation

The patient has a classic type II SLAP tear that will respond best to arthroscopic repair. Labral debridement has been shown to lead to predictably poor results, and biceps tenodesis and tenotomy may be appropriate for an older patient who is not a competitive overhead athlete. Snyder SJ, Karzel RP, Del Pizzo W, et al: SLAP lesions of the shoulder. Arthroscopy 1990;6:274-279.

Question 2665

Topic: Knee Sports

A 26-year-old man has recurrent right knee pain. Figures 9a and 9b show consecutive sagittal T2-weighted MRI scans, and Figure 9c shows a coronal T1-weighted MRI scan. What is the most likely diagnosis?

. Bucket-handle tear of the lateral meniscus
. Medial meniscus tear
. Discoid lateral meniscus
. Posterior cruciate ligament tear
. Normal MRI of the knee

Correct Answer & Explanation

. Discoid lateral meniscus

Explanation

A discoid meniscus is a large disk-like meniscus. It is seen in the lateral meniscus in 3% of the population; a discoid medial meniscus is much less common. It can be identified on the coronal view by noting meniscal tissue extending into the tibial spine at the intercondylar notch. The average width of a normal meniscus is less than 11 mm. A bow-tie appearance should not be seen on more than two consecutive sagittal images because the conventional thickness of the sagittal slices is 3 mm and the interval between two consecutive slices is 1.5 mm. Two sagittal slices will cover a 9-mm thickness. A discoid meniscus can be diagnosed on the sagittal views by noting a bow-tie appearance on more than two consecutive images. Helms CA: MR image of the knee, in Fundamentals of Skeletal Radiology, ed 2. Philadelphia, PA, WB Saunders, 1995, pp 172-191.

Question 2666

Topic: 5. Sports Medicine

A 20-year-old man reports painless snapping about the lateral aspect of the right hip. He denies any history of trauma. Examination reveals no limp or tenderness. Hip range of motion is full, and there is good strength. Radiographs are normal. What anatomic structure is most likely causing these symptoms?

. Acetabular labrum
. Iliopsoas
. Loose body
. Piriformis
. Iliotibial band

Correct Answer & Explanation

. Iliotibial band

Explanation

Coxa saltans (snapping hip syndrome) can occur in two forms: external/lateral or interior/medial/anterior. This patient has the external/lateral form. The external/lateral form involves the iliotibial band, tensor fascia, or gluteus medius, which snaps over the greater trochanter. The external form usually can be treated with physical therapy alone; however, several recent studies report satisfactory results with surgical treatment. Faraj and associates reported good results from surgical Z-plasty in a series of 10 patients. White and associates reported good results in a series of 16 patients with 17 hips who underwent surgical release of an external snapping hip. The interior/medial/anterior form can involve the iliopsoas tendon, acetabular labrum, subluxation of the hip, and loose bodies. White RA, Hughes MS, Burd T, et al: A new operative approach in the correction of external coxa saltans: The snapping hip. Am J Sports Med 2004;32:1504-1508. Faraj AA, Moulton A, Sirivastava VM: Snapping iliotibial band: Report of ten cases and review of the literature. Acta Orthop Belg 2001;67:19-23.

Question 2667

Topic: Shoulder & Hip Sports

Figures 36a and 36b show the MRI scans of a patient who has shoulder weakness. What is the most likely diagnosis?

. Suprascapular nerve entrapment
. Supraspinatus and infraspinatus tendon tear
. Muscular dystrophy
. Thoracic outlet syndrome
. Spinal accessory nerve disruption

Correct Answer & Explanation

. Suprascapular nerve entrapment

Explanation

The sagittal image reveals increased signal and decreased size of the supraspinatus and infraspinatus muscles, indicating muscle atrophy. The rotator cuff tendon signal is normal. The subscapularis and teres minor muscles are unaffected. Muscular dystrophy and thoracic outlet syndrome would be expected to have a more global effect. Although muscular atrophy can occur in the setting of a rotator cuff tear, the coronal image shows an intact supraspinatus. The suprascapular nerve supplies the supraspinatus and infraspinatus muscles. Therefore, suprascapular nerve entrapment would result in atrophy of these muscles with sparing of the surrounding musculature. Any lesion within the suprascapular notch, including neoplastic disease, a venous varix, or neuroma, can place pressure on the suprascapular nerve. Suprascapular nerve entrapment most commonly results from extension of a paralabral cyst or ganglion, often with associated labral pathology. Spinal accessory nerve disruption would show trapezius muscle atrophy. Resnick D, Kang HS (eds): Internal Derangement of Joints: Emphasis on MR Imaging. Philadelphia, PA, WB Saunders, 1997, pp 308-317.

Question 2668

Topic: Shoulder & Hip Sports

Figure 1 shows the radiograph of a 71-year-old man who has had increasing pain and weakness in his shoulder for the past 3 years. Nonsurgical management has failed to provide relief. Examination shows 130 degrees of active forward flexion and intact external rotation strength. During surgery, a 1- x 1-cm rotator cuff tear involving the supraspinatus is encountered. Treatment should include

Shoulder 2002 Practice Questions: Set 1 (Solved) - Figure 2

. humeral head replacement with rotator cuff repair.
. humeral head replacement without rotator cuff repair.
. arthrodesis of the shoulder.
. total shoulder replacement with rotator cuff repair.
. total shoulder replacement without rotator cuff repair.

Correct Answer & Explanation

. total shoulder replacement with rotator cuff repair.

Explanation

Given the size of the rotator cuff tear, it is likely to be repaired; therefore, the treatment of choice is a total shoulder replacement with rotator cuff repair. Severe rotator cuff insufficiency can lead to early glenoid failure because of superior instability, and glenoid resurfacing should be avoided in those instances. Boyd AD Jr, Thomas WH, Scott RD, Sledge CB, Thornhill TS: Total shoulder arthroplasty versus hemiarthroplasty: Indications for glenoid resurfacing. J Arthroplasty 1990;5:329-336.

Question 2669

Topic: Shoulder & Hip Sports

A patient reports pain in the hip with functional positioning. With the patient supine, pain in which of the following positions would be typical for femoral acetabular impingement?

Hip & Knee Reconstruction Board Review 2007: High-Yield MCQs (Set 2) - Figure 10

. Hip is internally rotated, passively flexed to 90 degrees, and adducted
. Hip is internally rotated, passively flexed to 90 degrees, and abducted
. Hip is externally rotated, maximally flexed to 90 degrees, and adducted
. Hip is externally rotated, passively flexed to 90 degrees, and abducted
. Hip is externally rotated, maximally flexed, and abducted

Correct Answer & Explanation

. Hip is internally rotated, passively flexed to 90 degrees, and adducted

Explanation

Patients with dysplasia often have a hypertrophic labrum. Abnormal contact between the femoral neck and the acetabular rim leads to labral injury, especially in the anterior-superior acetabular zone. Typically, young patients with the condition report pain with activity or long periods of sitting or driving. The hips often have limited motion, in particular in internal rotation and flexion. Forceful adduction with the maneuver causes pain. Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 411-424. Beck M, Leunig M, Parvizi J, et al: Anterior femoroacetabular impingement: Part II. Midterm results of surgical treatment. Clin Orthop 2004;418:67-73.

Question 2670

Topic: 5. Sports Medicine

A 20-year-old woman with a history of subtotal meniscectomy has a painful knee. What associated condition is a contraindication to proceeding with a meniscal allograft?

Basic Science 2006 Practice Questions: Set 1 (Solved) - Figure 1

. Grade I posterior cruciate ligament tear
. Grade II medial collateral ligament tear
. Lateral meniscal tear
. 5 degrees of genu varum
. 5- x 5-mm patellar chondral lesion

Correct Answer & Explanation

. 5 degrees of genu varum

Explanation

Patients with significant joint malalignment place increased stresses on the allograft, and this malalignment must be corrected to decrease the likelihood of meniscal allograft failure. None of the other options would lead to failure of the allograft.

Question 2671

Topic: Shoulder & Hip Sports

A 22-year-old professional baseball pitcher has had pain in the axillary region of his dominant shoulder for the past several weeks. While throwing a pitch during a game, he notes a sharp pulling sensation with a "pop" in his shoulder. Examination the following day reveals tenderness along the posterior axillary fold and pain and weakness with resisted extension of the shoulder. What is the most likely cause of his symptoms?

. Type 2 tear of the superior labrum anterior and posterior
. Tear of the anterior labrum
. Tear of the subscapularis tendon
. Tear of the latissimus dorsi tendon
. Tear of the supraspinatus tendon

Correct Answer & Explanation

. Tear of the latissimus dorsi tendon

Explanation

Injury to the latissimus dorsi tendon recently has been reported as a cause of pain in the thrower's shoulder. The etiology of this injury is felt to be eccentric overload during the follow-through of the throwing motion. Recommended management for this unusual injury consists of a short period of rest, followed by physical therapy to restore shoulder motion and strength. Throwing is allowed when the athlete demonstrates full, pain-free motion and good strength and balance of the rotator cuff and scapular rotator muscles. Currently there are no defined indications for surgical repair. Schickendantz MS, Ho CP, Keppler L, et al: MR imaging of the thrower's shoulder: Internal impingement, latissimus dorsi/subscapularis strains and related injuries. Magn Reson Imaging Clin N Am 1999;7:39-49.

Question 2672

Topic: 5. Sports Medicine

A 17-year-old girl has multidirectional instability of the shoulder. What is the most appropriate initial management?

. Immobilization in a sling and swathe
. Open capsular shift
. Arthroscopic capsular plication
. Thermal capsulorrhaphy
. Physical therapy and home exercises

Correct Answer & Explanation

. Physical therapy and home exercises

Explanation

Multidirectional instability of the shoulder is defined as symptomatic instability in two or more directions (anterior, posterior) but must include a component of inferior instability. Initial treatment should always include physical therapy and instruction in a home exercise program that emphasizes periscapular and rotator cuff strengthening to improve the dynamic stability of the glenohumeral joint. Immobilization has not been shown to be effective. Open capsular shift and arthroscopic capsular plication remain the surgical options when appropriate nonsurgical management fails (typically a minimum of 6 months of dedicated therapy and home program). Thermal capsulorrhaphy remains controversial but is not recommended by many clinicians because of reported complications including recurrent instability, axillary nerve injury, chondrolysis, and capsular injury. 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. D'Alessandro DF, Bradley JP, Fleischli JE, et al: Prospective evaluation of thermal capsulorrhaphy for shoulder instability: Indications and results, two- to five-year follow-up. Am J Sports Med 2004;32:21-33. Levine WN, Clark AM Jr, D'Alessandro DF, et al: Chondrolysis following arthroscopic thermal capsulorrhaphy to treat shoulder instability: A report of two cases. J Bone Joint Surg Am 2005;87:616-621.

Question 2673

Topic: 5. Sports Medicine

A 70-year-old golfer has pain in her dominant shoulder. She reports that initially the pain was at night but now she is unable to play. Examination reveals weakness in external rotation and shoulder abduction. Radiographs reveal the humeral head articulating with a thin acromion. Management should consist of

Sports Medicine 2004 Practice Questions: Set 1 (Solved) - Figure 12

. a scapular and rotator cuff strengthening program.
. arthroscopy.
. review of her golf technique.
. humeral head replacement.
. an erythrocyte sedimentation rate.

Correct Answer & Explanation

. a scapular and rotator cuff strengthening program.

Explanation

Chronic rotator cuff tears should be nonsurgically managed initially with a strengthening program. A cortisone injection may reduce inflammation. Surgery is reserved for patients who continue to have pain and lose sleep despite the use of physical therapy. Blood tests for infection or inflammation are nonspecific. Arthroscopy may play a role, but surgical replacement is reserved for advanced cases. Bokor DJ, Hawkins RJ, Huckell GH, et al: Results of nonoperative management of full-thickness tears of the rotator cuff. Clin Orthop 1993;294:103-110.

Question 2674

Topic: 5. Sports Medicine
Human tendons are made up primarily of what collagen type (~95%)?
. I
. II
. III
. IV
. V

Correct Answer & Explanation

. I

Explanation

Tendons are dense, primarily collagenous tissues that attach muscle to bone. Collagen content of the dry weight is slightly greater than that found in ligaments and is predominantly type I. Type III collagen makes up the remaining ~5% of total collagen content.

Question 2675

Topic: 5. Sports Medicine

A 29-year-old ultramarathoner, who is halfway into a 50-mile race, is sweating profusely. He suddenly collapses, is unresponsive, and has violent muscle contractions. Prior to these symptoms, he had been drinking water at every water stop (every 1 mile). What is the most likely diagnosis?

. Hypernatremia
. Hyponatremia
. Hyperkalemia
. Hypokalemia
. Hyperuremia

Correct Answer & Explanation

. Hyponatremia

Explanation

Hyponatremia ("water intoxication") can occur in endurance athletes such as ultramarathoners who are sweating profusely and drinking only water as fluid replacement. Sports drinks which contain electrolytes are a better replacement in this group of athletes. Sodium is the mineral most commonly affected by physical exercise. Sodium concentration in sweat depends on diet, hydration, and heat acclimation. In most cases, sodium lost in sweat can be replaced by regular diet. Potassium plays an important role in nerve conduction and muscle contraction but is not lost in excessive amounts in sweat during exercise. The most frequent loss of potassium is through gastrointestinal disorders or excessive loss from the kidneys. Rehrer reported that overhydrating during very long-lasting exercise in the heat with low or negligible sodium intake can result in reduced performance and hyponatremia. With hyponatremia, the serum sodium is abnormally low, resulting in brain swelling, seizures, coma, and potentially death. Interestingly, hyponatremia is rarely seen in adolescent athletes and young children. Griffin LY: Emergency preparedness: Things to consider before the game starts. J Bone Joint Surg Am 2005;87:894-902.

Question 2676

Topic: 5. Sports Medicine

A 13-year-old boy sustains a valgus stress injury to the knee while playing football, and he is unable to bear weight after the injury. Examination reveals tenderness medially superior to the joint line. The knee is held in flexion, and he has a large effusion and localized medial swelling. Plain radiographs show no obvious fracture. What is the next diagnostic step?

. Arthroscopy
. MRI scan
. Stress radiographs
. Tomogram
. Arthrogram

Correct Answer & Explanation

. Stress radiographs

Explanation

In the skeletally mature individual, this mechanism of injury will often result in a sprain of the medial collateral ligament. In skeletally immature patients, the same mechanism can cause a fracture of the distal femoral physis. If the fracture is nondisplaced, the plain radiographs may show only soft-tissue swelling or effusion. While the MRI scan may show edema in the soft tissues on the medial side of the knee and even an abnormality of the physis, stress radiographs provide a quicker and less expensive means of making the diagnosis. Arthroscopy and arthrography would not be helpful in making the diagnosis. Arthroscopy may result in further displacement of the injury. Smith L: Concealed injury to the knee. J Bone Joint Surg Am 1962;44:1659-1660.

Question 2677

Topic: 5. Sports Medicine

Figure 50 shows the MRI scan of a 20-year-old female college soccer player with knee pain. What is the most likely diagnosis?

Anatomy Board Review 2002: High-Yield MCQs (Set 4) - Figure 13

. Normal knee
. Posterior cruciate ligament tear
. Quadriceps tendon rupture
. Proximal tibia fracture
. Femoral subchondral contusion

Correct Answer & Explanation

. Posterior cruciate ligament tear

Explanation

The MRI scan shows an acute complete tear of the posterior cruciate ligament. No evidence is seen of a quadriceps tendon rupture, a tibia fracture, or a bone contusion. Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 533-557.

Question 2678

Topic: 5. Sports Medicine

A professional baseball player has had intermittent, mild shoulder pain for the past 2 years. Nonsurgical management has consisted of anti-inflammatory drugs. Examination reveals atrophy of the infraspinatus muscle but not the supraspinatus. There is weakness in external rotation with the arm at his side but not at 90 degrees of abduction. He has no weakness or pain with resisted abduction. Electromyography confirms an isolated lesion of the suprascapular nerve branch to the infraspinatus. He is otherwise neurologically intact. An MRI scan of the shoulder shows no cysts but confirms atrophy of the infraspinatus muscle. What is the next most appropriate step in management?

Upper Extremity Board Review 2005: High-Yield MCQs (Set 2) - Figure 9

. Immediate MRI of the brain
. Physical therapy and observation
. Subacromial injection
. Decompression of the suprascapular nerve at the suprascapular notch
. Decompression of the infraspinatus branch of the suprascapular nerve at the spinoglenoid notch

Correct Answer & Explanation

. Physical therapy and observation

Explanation

Suprascapular nerve injuries are more commonly seen in athletes who participate in overhead activities. When a patient is evaluated for posterior shoulder pain and infraspinatus muscle weakness or atrophy, electrodiagnostic studies are an essential part of the evaluation. In addition, imaging studies are indicated to exclude other diagnoses that can mimic a suprascapular nerve injury. Initial management should consist of cessation of the aggravating activity along with an organized shoulder rehabilitation program. If nonsurgical management fails to provide relief within 6 months to 1 year, surgical exploration of the suprascapular nerve should be considered. Release of the spinoglenoid ligament with resultant suprascapular nerve decompression may result in pain relief and a return of normal shoulder function. In this patient, who has a chronic neuropathy and mild symptoms, surgery is indicated only if nonsurgical management fails to provide relief and he is unable to perform at his position. Cummins CA, Bowen M, Anderson K, et al: Suprascapular nerve entrapment at the spinoglenoid notch in a professional baseball pitcher. Am J Sports Med 1999;27:810-812. Cummins CA, Messer TM, Nuber GW: Suprascapular nerve entrapment. J Bone Joint Surg Am 2000;82:415-424.

Question 2679

Topic: 5. Sports Medicine

A 19-year-old college cross-country runner is amenorrheic and has recurrent stress fractures. Long-term management should consist of

. cross training with swimming and cycling.
. a complete cessation of running.
. vitamin D and calcium supplements.
. increased caloric intake.
. oral contraceptives, vitamin D, and calcium supplements.

Correct Answer & Explanation

. oral contraceptives, vitamin D, and calcium supplements.

Explanation

The triad of menstrual dysfunction, disordered eating, and stress fracture is well recognized in women who participate in endurance sports. The best treatment remains to be determined, but at present, the combination of oral contraceptives to regulate menses, an increased intake of calcium and vitamin D, as well as nutritional counseling, is the recommended treatment for decreased bone mass related to exercise-induced amenorrhea. Nattiv A, Armsey TD Jr: Stress injury to bone in the female athlete. Clin Sports Med 1997;16:197-224.

Question 2680

Topic: Shoulder & Hip Sports

A 58-year-old man has persistent pain and weakness of his right shoulder after undergoing primary rotator cuff repair 1 year ago. A clinical photograph is shown in Figure 11. Which of the following factors might make functional improvement problematic with revision rotator cuff surgery?

Upper Extremity 2005 Practice Questions: Set 1 (Solved) - Figure 29

. Patient's age
. Patient's gender
. Number of prior surgical procedures
. Detachment of the deltoid
. Duration of the rotator cuff tear

Correct Answer & Explanation

. Detachment of the deltoid

Explanation

Functional improvement after revision rotator cuff surgery is most likely to occur in patients with an intact deltoid, good-quality rotator cuff tissue, preoperative active elevation alone to 90 degrees, and only one prior rotator cuff repair. In this patient, the compromised deltoid origin might make functional improvement less likely. Djurasovic M, Marra G, Arroyo JS, et al: Revision rotator cuff repair: Factors influencing results. J Bone Joint Surg Am 2001;83:1849-1855. Bigliani LU, Cordasco FA, McIlveen SJ, et al: Operative treatment of failed repairs of the rotator cuff. J Bone Joint Surg Am 1992;74:1505-1515.

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