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 2681
Topic: Knee Sports
Figures 28a and 28b show AP and lateral radiographs of the knee. Based on these findings, which of the following structures has most likely been injured?
Correct Answer & Explanation
. Popliteal artery
Explanation
The radiographs show a posterior knee dislocation. Knee dislocations almost always involve rupture of both the anterior and posterior cruciate ligaments. Collateral ligament injuries also are common. Arterial, nerve, and tendon injuries each occur in less than half of knee dislocations. Schenck RC Jr, Hunter RE, Ostrum RF, et al: Knee dislocations. Instr Course Lect 1999;48:515-522.
Question 2682
Topic: 5. Sports Medicine
Figure 1 shows the radiograph of a 68-year-old man who underwent revision hip arthroplasty with impaction grafting of the femur and cementing of a tapered component into the graft 2 years ago. The patient remains symptom-free. Which of the following best describes the most likely histologic appearance of the proximal femur if a biopsy was performed?
Correct Answer & Explanation
. Viable trabecular bone resulting from incorporation and remodeling of allograft
Explanation
The radiograph shows three zones: an outer regenerated cortical layer, an interface zone consisting of viable trabecular bone and occasional particles of bone cement, and an inner layer of necrotic bone embedded in cement. No fibrous membrane is noted, and there is no direct contact of cement with native bone. Based on these findings, it is believed that the middle layer is the result of incorporation of the allograft with further remodeling. Nelissen RG, Bauer TW, Weidenhielm LR, LeGolvan DP, Mikhail WE: Revision hip arthroplasty with the use of cement and impaction grafting: Histological analysis of four cases. J Bone Joint Surg Am 1995;77:412-422.
Question 2683
Topic: Shoulder & Hip Sports
A 52-year-old man underwent arthroscopic repair of a 1-cm supraspinatus tendon tear 3 weeks ago. He was doing well until he fell down three stairs. One week after the fall he continues to report pain similar to his preoperative pain. An MRI scan reveals a minimally retracted 1-cm supraspinatus tendon tear in the same location as his original tear. Management should now consist of
Correct Answer & Explanation
. revision rotator cuff repair.
Explanation
The patient has retorn his rotator cuff repair. This traumatic retear is different from a chronic tear and should be treated similar to an acute rotator cuff tear. Because the patient is younger than age 65 and has a small, single tendon tear, a revision rotation cuff repair is indicated with an expected tendon healing rate of greater than 95%. A physical therapy program is not indicated, and further delay in repair compromises his functional recovery. A cortisone injection is not indicated for this repairable tendon tear. Immobilization will not allow the tendon to heal once it has retorn. A debridement procedure is not indicated on this repairable tendon tear; this procedure is indicated in painful, chronic, irreparable tendon tears. Boileau P, Brassart N, Watkinson DJ, et al: Arthroscopic repair of full-thickness tears of the supraspinatus: Does the tendon really heal? J Bone Joint Surg Am 2005;87:1229-1240. Jost B, Zumstein M, Pfirrmann CWA, et al: Long-term outcome after structural failure of rotator cuff repairs. J Bone Joint Surg Am 2006;88:472-479.
Question 2684
Topic: 5. Sports Medicine
What is the single most important nutritional factor affecting athletic performance?
Correct Answer & Explanation
. Maintenance of adequate hydration
Explanation
Maintenance of adequate hydration is the single most important factor affecting athletic performance. While carbohydrate loading may be beneficial for some endurance athletes, the consumption of carbohydrates during exercise does not appear to be beneficial for athletes engaged in events that last less than 1 hour. In general, athletes consuming a balanced diet do not need electrolyte supplementation. Maughan RJ, Noakes TD: Fluid replacement and exercise stress: A brief review of studies on fluid replacement and some guidelines for the athlete. Sports Med 1991;12:16-31.
Question 2685
Topic: Shoulder & Hip Sports
A 39-year-old man has anterior shoulder pain after landing on his abducted left shoulder while playing softball. Examination reveals a stable glenohumeral joint, pain on passive external rotation of greater than 25 degrees, and pain and weakness on belly press (Napoleon's) test. An MRI scan is shown in Figure 32. To provide maximum pain relief and return of function, management should include
Correct Answer & Explanation
. repair of the subscapularis and biceps tenodesis.
Explanation
The examination and MRI scan confirm a subscapularis rupture and dislocation of the long head of the biceps tendon. The greatest return of function will result from repair of the subscapularis and tenodesis of the biceps tendon. Physical therapy alone will result in inadequate healing of the subscapularis and will not address the biceps tendon. While biceps tenotomy is an option, it will not provide the same level of pain relief and return of function as a tenodesis in a young, active man. There is no evidence for a supraspinatus tear. Deutsch A, Altchek DW, Veltri DM, Potter HG, Warren RF: Traumatic tears of the subscapularis tendon: Clinical diagnosis, magnetic resonance imaging findings, and operative treatment. Am J Sports Med 1997;25:13-22.
Question 2686
Topic: 5. Sports Medicine
A 21-year-old collegiate track athlete increased her training 4 months ago in anticipation of starting the season. Two months into her training program, she reported pain followed by a 1-month history of diffuse pain in the first metatarsophalangeal joint that was aggravated by weight bearing. A removable walker boot partially relieved the pain, and she was able to complete the season. Her pain has now returned; however, she denies any history of injury. Examination reveals tenderness over the medial sesamoid but no deformities. A radiograph and bone scan are shown in Figures 22a and 22b. What is the best treatment option at this time?
Correct Answer & Explanation
. Medial sesamoidectomy
Explanation
The radiograph reveals either a fractured or bipartite sesamoid. The bone scan shows asymmetrically increased uptake over the medial sesamoid. Given the history and physical examination, a stress fracture is the most likely diagnosis. Medial sesamoidectomy reliably improves pain, and athletes return to sports on an average of 7 weeks after excision. Immobilization typically requires more than 4 to 8 weeks and is not always successful; however, it would be appropriate management for a patient who is not an elite athlete. Sanders R: Fractures of the midfoot and forefoot, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 1601-1603.
Question 2687
Topic: Shoulder & Hip Sports
A previously asymptomatic 40-year-old man injures his shoulder in a fall. Examination shows that he is unable to lift the hand away from his back while maximally internally rotated. An axial MRI scan of the shoulder is shown in Figure 14. What is the most likely diagnosis?
Correct Answer & Explanation
. Subscapularis rupture
Explanation
The MRI scan shows detachment of the subscapularis from its insertion on the lesser tuberosity. The examination finding is consistent with a positive lift-off test, also indicating a tear of the subscapularis. Lyons RP, Green A: Subscapularis tendon tears. J Am Acad Orthop Surg 2005;13:353-363.
Question 2688
Topic: Shoulder & Hip Sports
A 70-year-old man who underwent an uncomplicated large rotator cuff repair 6 months ago is now seeking a second opinion regarding persistent pain and weakness in his shoulder. Examination reveals that his incision is well healed and unreactive. The surgical report suggests that the tendons were secured back to bone with sutures through the greater tuberosity. Figure 28 shows a radiograph that was obtained 1 week ago. What is the most likely diagnosis?
Correct Answer & Explanation
. Failed rotator cuff repair
Explanation
Symptoms can persist following a rotator cuff repair for a variety of reasons. In the early postoperative period, infection is the primary concern. Stiffness and loss of motion can occur because of postoperative scarring. Complex regional pain syndrome can occur but is rare, and the diagnosis is not made with a plain radiograph. This radiograph shows a superiorly migrated humeral head that articulates with the acromion, indicating that the repair has failed. While large to massive tears may fail more commonly than once thought, the clinical outcome may be satisfactory in many patients. Mansat P, Cofield RH, Kersten TE, Rowland CM: Complications of rotator cuff repair. Orthop Clin North Am 1997;28:205-213.
Question 2689
Topic: 5. Sports Medicine
A 20-year-old football player has repeated episodes of heat cramps during summer training sessions. A deficiency of what electrolyte is most responsible for heat cramps?
Correct Answer & Explanation
. Sodium
Explanation
Sodium deficiency is the cause of heat cramps. It is the principle electrolyte of sweat and is readily lost during training, especially in warmer temperatures. The condition can be avoided by adding extra table salt to food and maintaining good hydration before and after sports activities. Salt tablets are to be avoided when a patient has heat cramps because the high soluble load will cause gastric irritation. Bergeron MF, Armstrong LE, Maresh CM: Fluid and electrolyte losses during tennis in the heat. Clin Sports Med 1995;14:23-32.
Question 2690
Topic: Shoulder & Hip Sports
A 50-year-old electrician who is right-hand dominant has had right shoulder pain and stiffness after sustaining an electric shock 2 months ago. An AP radiograph obtained at the time of injury was considered negative, and the patient was diagnosed with a shoulder sprain. The patient now reports continued shoulder pain and restricted motion. AP and axillary radiographs and a CT scan are shown in Figures 41a through 41c. Management should consist of
Correct Answer & Explanation
. open reduction and transfer of the subscapularis and lesser tuberosity into the anteromedial humeral head defect.
Explanation
Open reduction and transfer of the subscapularis and lesser tuberosity into the humeral head defect is the treatment of choice for chronic posterior dislocations in which the articular defect consists of 20% to 40% of the articular surfaces. Closed reduction can be used if the dislocation is recognized early and the articular defect is less than 20% of the articular surface. Humeral arthroplasty is reserved for patients with an articular defect that is greater than 45% to 50% of the head. Hawkins RJ, Neer CS II, Pianta RM, Mendoza FX: Locked posterior dislocation of the shoulder. J Bone Joint Surg Am 1987;69:9-18.
Question 2691
Topic: 5. Sports Medicine
A 39-year-old man has had persistent right shoulder pain for the past 6 months. A formal physical therapy program has failed to provide relief, and an injection several months ago provided only short-term relief. Examination reveals a positive Neer and Hawkins test. There is no instability and the neurovascular examination is normal. Arthroscopy reveals a partial rotator cuff tear on the bursal side measuring 60% of the tendon thickness. What is the next most appropriate step in management?
Correct Answer & Explanation
. Repair of the partial rotator cuff tear and subacromial decompression
Explanation
Although arthroscopic debridement with or without subacromial decompression is a reasonable response, the patient has positive impingement signs. Several recent studies regarding the surgical treatment of partial rotator cuff tears have demonstrated good to excellent results after repair of tears involving more than 50% of the tendon thickness. This was shown specifically for bursal-sided tears and joint-side tears. Biceps tenotomy is not indicated in a young patient. Matava MJ, Purcell DB, Rudzki JR: Partial-thickness rotator cuff tears. Am J Sports Med 2005;33:1405-1417.
Question 2692
Topic: Shoulder & Hip Sports
A 59-year-old construction worker who is right-hand dominant has had right shoulder pain for the past 9 months with no history of injury. Nonsurgical management consisting of two cortisone injections, physical therapy for 3 months, and nonsteroidal anti-inflammatory drugs has failed to provide lasting relief. Examination reveals tenderness over the acromioclavicular (AC) joint and over the subacromial bursa. He has positive Neer and Hawkins impingement signs and AC joint pain with adduction of the shoulder. Radiographs are shown in Figures 36a and 36b. An MRI scan reveals an intact rotator cuff. Management should now consist of
Correct Answer & Explanation
. anterior acromioplasty and distal clavicle excision.
Explanation
Because the patient has clinical and radiographic signs of AC arthritis and subacromial impingement, the treatment of choice is anterior acromioplasty and distal clavicle excision. Arthroscopic acromioplasty alone would not address the AC arthritis. The rotator cuff is intact; therefore, rotator cuff repair is not indicated. An open Mumford procedure would address the AC arthritis only and not the impingement symptoms. Immobilization might lead to stiffness of the shoulder and is not recommended for treating impingement.
Question 2693
Topic: 5. Sports Medicine
Figures 10a and 10b show the radiographs of an athletic 9-year-old boy who has activity-related anterior knee pain with intact active knee extension. Examination reveals tenderness to palpation over the inferior pole of the patella. There is no effusion or ligamentous instability. Initial management should consist of
Correct Answer & Explanation
. activity restrictions and nonsteroidal anti-inflammatory drugs.
Explanation
The radiographs show fragmentation of the inferior pole of the patella. This finding, along with the clinical presentation, is most consistent with Sindig-Larsen-Johansson disease. This is an overuse syndrome commonly seen in boys ages 9 to 11 years. The differential diagnosis includes bipartite patella and patellar sleeve fracture. Like most overuse syndromes, Sindig-Larsen-Johansson disease responds to activity modification and nonsteroidal anti-inflammatory drugs. While symptoms usually resolve with short periods of activity restriction, radiographic findings may persist. Stanitski CL: Anterior knee pain syndromes in the adolescent. J Bone Joint Surg Am 1993;75:1407-1416.
Question 2694
Topic: 5. Sports Medicine
A 30-year-old patient reports chronic medial knee pain and swelling. Figure 9a shows an articular cartilage lesion observed during arthroscopy. The surgeon decides to treat the lesion with the microfracture technique seen in Figure 9b. A biopsy of the repaired tissue 1 year after treatment is likely to show which of the following findings?
Correct Answer & Explanation
. Fibrocartilage
Explanation
Microfracture is a marrow stimulation technique where stem cells from the underlying subchondral bone marrow can form at the base of the lesion. The rationale for this technique is based on these cells differentiating into cells that will produce an articular cartilage repair. Biopsy findings in animals and humans have demonstrated primarily a fibrocartilagenous repair tissue and not articular cartilage. The collagen type found in hyaline or articular cartilage is of the type II variety. Fibrocartilage possesses mostly type I and III cartilage.
Question 2695
Topic: 5. Sports Medicine
A 37-year-old racquet player had dominant shoulder pain for 1 year, and cortisone injections provided only temporary relief. Because MRI findings did not reveal a rotator cuff tear, he underwent arthroscopic treatment including subacromial decompression and spur removal below the distal clavicle. Three years following surgery, he now reports that the pain has returned. What is the most likely cause of his pain?
Correct Answer & Explanation
. Acromioclavicular joint pathology
Explanation
Co-planing the distal clavicle may lead to painful acromioclavicular joints in up to 35% of patients; this is felt to be related to destabilizing the distal clavicle. Intra-articular diagnosis of synovitis, degenerative joint disease, and superior labrum anterior and posterior lesions would have been identified at initial arthroscopy (not necessarily seen in open surgery). Ganglions are seen on MRI. Fischer BW, Gross RM, McCarthy JA: Incidence of acromioclavicular joint complications after arthroscopic subacromial decompression. Arthroscopy 1999;15:241-248. Hazel RM, Tasto JP, Klassen J: Arthroscopic subacromial decompression: A 9-year follow-up. Arthroscopy 1998;14:419.
Question 2696
Topic: Shoulder & Hip Sports
A 25-year-old tennis player has shoulder pain and weakness to external rotation. MRI scans are shown in Figures 16a and 16b. What is the most likely cause of his weakness?
Correct Answer & Explanation
. Suprascapular nerve compression
Explanation
The MRI scans show a paralabral cyst, which is most commonly associated with labral tears. Compression of the suprascapular nerve results in weakness of the supraspinatus and/or infraspinatus depending on the level of compression. Piatt BE, Hawkins RJ, Fritz RC, et al: Clinical evaluation and treatment of spinoglenoid notch ganglion cysts. J Shoulder Elbow Surg 2002;11:600-604.
Question 2697
Topic: 5. Sports Medicine
A sagittal T1-weighted MRI scan of the knee joint is shown in Figure 23. What structure is identified by the arrow?
Correct Answer & Explanation
. Posterior cruciate ligament
Explanation
On T1-weighted images, the posterior cruciate ligament is a low-signal (black) structure that courses from the posterior aspect of the tibia to the medial femoral condyle. The posterior cruciate ligament can appear as arcuate, U-shaped, or kinked. The other structures have similar signal but different anatomic locations. Gross ML, Grover JS, Bassett LW, Seeger LL, Finerman GA: Magnetic resonance imaging of the posterior cruciate ligament: Clinical use to improve diagnostic accuracy. Am J Sports Med 1992;20:732-737.
Question 2698
Topic: 5. Sports Medicine
A player on a professional football team sustains a knee injury and is diagnosed with an anterior cruciate ligament rupture. When employed as the team physician, your ethical obligation is to inform
Correct Answer & Explanation
. both the team and the player.
Explanation
When you are employed as a team physician, you are obligated to inform the players and the team organization of all athletically relevant medical issues. This differs significantly from the normal rule of patient confidentiality. If the player came to see you and you were not the team physician, you may not inform the team unless the player so desires. As the team physician, you are not obligated to inform the media. Tucker AM: Ethics and the professional team physician. Clin Sports Med 2004;23:227-241.
Question 2699
Topic: 5. Sports Medicine
A 22-year-old college football player reports shortness of breath and dyspnea after a tackle. Examination reveals tachypnea, tachycardia, the trachea is shifted to the right, and there are decreased breath sounds on the left lung fields. The first line of treatment on the field should be
Correct Answer & Explanation
. insertion of a large gauge needle into the second intercostal space.
Explanation
The patient has a tension pneumothorax. This is a life-threatening emergency where air is trapped between the pleura and the lung, which prevents expansion of the lung. This causes hypoxia and cardiopulmonary compromise. The first line of treatment is to place a needle into the second intercostal space in the midclavicular line. The athlete should then be transported to the emergency department for chest tube placement. The athlete cannot return to play, and resuscitation is not necessary because he has not gone into cardiopulmonary arrest. Amaral JF: Thoracoabdominal injuries in the athlete. Clin Sports Med 1997;16:739-753.
Question 2700
Topic: 5. Sports Medicine
A collegiate football player who sustained a blow to the head during the first quarter of a game is confused for several minutes after the hit but does not lose consciousness. He had two similar episodes in games earlier in the season. When should he be allowed to return to play?
Correct Answer & Explanation
. Next season
Explanation
Using the traditional concussion grading scale, the patient sustained a grade I concussion because he did not lose consciousness and his abnormal cognitive level lasted less than 1 hour. If this was the player's first concussion, theoretically he could return to play later in the game provided that he had no confusion, headache, or associated symptoms. However, because it was the third concussion for the year, participation in contact sports should be terminated for the season. Guskiewwicz KM, Barth JT: Head injuries, in Schenk RC Jr (ed): Athletic Training and Sports Medicine. Rosemont, IL, American Academy of Orthopedic Surgeons, 1999, pp 143-167.
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