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5. Sports Medicine MCQs

Practice Set 136 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 2701

Topic: Shoulder & Hip Sports

A 60-year-old right hand-dominant women fell on her outstretched arm and sustained an anterior shoulder dislocation. The shoulder is reduced in the emergency department and she is seen for follow-up 1 week later wearing a sling. Examination reveals that she has significant difficulty raising her arm in forward elevation and has excessive external rotation compared to the contralateral shoulder. What is the next most appropriate step in management?

Upper Extremity Board Review 2008: High-Yield MCQs (Set 2) - Figure 1

. MRI
. Electromyography
. Open repair of the supraspinatus
. Arthrography
. Arthroscopic labral repair

Correct Answer & Explanation

. MRI

Explanation

In patients older than age 40 years, a high suspicion of a rotator cuff tear should be kept in those patients with weakness after shoulder dislocation. Both posterior rotator cuff and subscapularis injuries have been documented. The next most appropriate step in management should be MRI. If the findings are negative, suspicion of nerve injury should lead to electromyography. Stayner LR, Cumming J, Andersen J, et al: Shoulder dislocations in patients older than 40 years of age. Orthop Clin North Am 2000;31:231-239.

Question 2702

Topic: 5. Sports Medicine

As a baseball player dives to catch a line drive in the outfield, the ball strikes the tip of the player's finger when extended, causing forcible flexion to avulse the extensor tendon from the distal phalanx. Following evaluation and normal radiographic findings, initial management should include

. continuous extension splinting to the distal interphalangeal (DIP) joint for 6 weeks, followed by night splinting for an additional 6 weeks.
. splinting at the DIP joint in 20 degrees of flexion.
. percutaneous pinning.
. buddy taping.
. dynamic splinting for 8 weeks.

Correct Answer & Explanation

. continuous extension splinting to the distal interphalangeal (DIP) joint for 6 weeks, followed by night splinting for an additional 6 weeks.

Explanation

Avulsion of the terminal extensor tendon from the distal phalanx (mallet or baseball finger) may or may not be associated with a bony avulsion. The injury is caused by forcible flexion of the DIP joint while catching a ball or hitting an object with the finger extended. Most authorities recommend continuous extension splinting to the DIP joint for 6 weeks, followed by nighttime splinting for an additional 6 weeks. It must be emphasized to the patient that at no time during the initial 6 weeks of treatment should the DIP joint be allowed to fall into flexion or an additional 6 weeks of continuous splinting is required. Miller MD, Cooper DE, Warner JP (eds): Review of Sports Medicine and Arthroscopy. Philadelphia, PA, WB Saunders, 1995, p 255. Rettig AC: Closed tendon injuries of the hand and wrist in the athlete. Clin Sports Med 1992;11:77-99.

Question 2703

Topic: Shoulder & Hip Sports

A patient underwent anterior stabilization of the shoulder 6 months ago, and examination now reveals lack of external rotation beyond 0 degrees. The patient has a normal apprehension sign and normal strength, and the radiographs are normal. Based on these findings, the patient is at greater risk for the development of

Sports Medicine Board Review 2001: High-Yield MCQs (Set 2) - Figure 16

. recurring instability.
. osteoarthritis.
. osteonecrosis.
. a tear of the rotator cuff.
. internal impingement.

Correct Answer & Explanation

. osteoarthritis.

Explanation

Because the patient's shoulders are overtensioned anteriorly, premature osteoarthritis may develop. This may create obligate translation posteriorly and increase the interarticular pressure of the humeral head against the glenoid. Patients should achieve 20 degrees to 30 degrees of external rotation with the elbow at the side. Late degenerative arthritis following a Putti-Platt procedure is associated with significant restriction of external rotation. This patient's shoulder has a reduced risk of anterior instability, rotator cuff tear, and internal impingement because of the limitation of motion. Hawkins RJ, Angelo RL: Glenohumeral osteoarthritis: A late complication of the Putti-Platt repair. J Bone Joint Surg Am 1990;72:1193-1197.

Question 2704

Topic: 5. Sports Medicine

An 18-year-old woman sustains a twisting injury of the knee while skiing. Figures 7a and 7b show the radiograph and coronal MRI scan of the knee. In addition to the injury shown, what is the most likely associated injury?

. Medial collateral ligament rupture
. Patellar dislocation
. Patellar tendon rupture
. Anterior cruciate ligament rupture
. Posterior cruciate ligament rupture

Correct Answer & Explanation

. Anterior cruciate ligament rupture

Explanation

The MRI scan shows a Segond fracture, which is a small avulsion of the lateral joint capsule from the anterolateral aspect of the proximal tibia. It is almost always associated with anterior cruciate ligament rupture and often with a tear of either the medial or lateral meniscus. Goldman AB, Pavlov H, Rubenstein D: The Segond fracture of the proximal tibia: A small avulsion that reflects major ligamentous damage. Am J Roentgenol 1988;151:1163-1167. 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 2705

Topic: 5. Sports Medicine

A 21-year-old collegiate scholarship football player has an episode of transient quadriplegia. An MRI scan of the cervical spine reveals cord edema and severe congenital spinal stenosis. The athlete has aspirations of playing on a professional level and demands that he be allowed to play. The team physician should give what recommendation to the college?

. Do not allow the athlete to return to football.
. Allow the athlete to participate.
. Allow the athlete to play only if he signs a waiver.
. Suggest that the college and athlete enter binding arbitration.
. Allow the athlete to play with special equipment.

Correct Answer & Explanation

. Do not allow the athlete to return to football.

Explanation

Federal courts have ruled that a student-athlete does not have a constitutional right to participate in athletics against medical advice. As long as the student retains his scholarship, the college is under no legal or ethical obligation to allow the student to participate in sports. A waiver would not hold up in court and would not indemnify the college or the team physician against suit. No equipment has been shown to be effective in preventing transient quadriplegia. Mathias MB: The competing demands of sport and health: An essay on the history of ethics in sports medicine. Clin Sports Med 2004;23:195-214.

Question 2706

Topic: Knee Sports
A 36-year-old skier sustains a grade III posterior cruciate ligament (PCL) tear. Where will increased contact pressures develop over time?
. Ligament of Humphrey
. Patellar ligament
. Quadriceps tendon
. Lateral compartment
. Medial compartment

Correct Answer & Explanation

. Medial compartment

Explanation

Complete rupture of the PCL leads to increased contact pressures in the patellofemoral and medial compartments of the knee. However, whether degenerative arthritis will develop and in which compartments still remains controversial.

Question 2707

Topic: Knee Sports

An 18-year-old football player lands on a flexed knee and ankle after being tackled. Examination reveals increased external rotation and posterior translation and varus at 30 degrees of flexion, which decreases as the knee is flexed to 90 degrees. What is the most likely diagnosis?

Sports Medicine 2001 Practice Questions: Set 1 (Solved) - Figure 16

. Torn posterolateral corner
. Torn posterior cruciate ligament (PCL) and posterolateral corner
. Torn PCL
. Rupture of the quadriceps tendon
. Rupture of the lateral collateral ligament

Correct Answer & Explanation

. Torn posterolateral corner

Explanation

The flexed knee and ankle mechanism of injury can result in a PCL and/or posterolateral corner injury. The examination reveals an isolated injury to the posterolateral corner (arcuate, popliteus, posterolateral capsule). This results in increased posterior translation and external rotation, as well as varus that is most notable at 30 degrees of flexion and decreases as the knee is further flexed to 90 degrees. Combined PCL and posterolateral corner injuries are characterized by increasing instability as the knee is flexed to 90 degrees from 30 degrees, while isolated PCL tears show the greatest degree of instability at 90 degrees of flexion. A rupture of the quadriceps tendon would not affect anterior or posterior stability, whereas an isolated rupture of the lateral collateral ligament, which is a rare injury, is characterized by varus instability at 30 degrees of knee flexion without posterior translation. Harner CD, Hoher J: Evaluation and treatment of posterior cruciate ligament injuries. Am J Sports Med 1998;26:471-482.

Question 2708

Topic: 5. Sports Medicine

Figure 23 shows the postoperative radiograph of a patient who underwent an anterior cruciate ligament (ACL) reconstruction (with bone-patella tendon-bone autograft) that failed. He initially had loss of flexion postoperatively. What is the most likely cause of this failure?

Sports Medicine Board Review 2007: High-Yield MCQs (Set 4) - Figure 4

. Fixation in the tibial tunnel
. Fixation in the femoral tunnel
. Posterior placement of the tibial tunnel
. Anterior placement of the femoral tunnel
. Size of the patellar autograft

Correct Answer & Explanation

. Anterior placement of the femoral tunnel

Explanation

The key to this question is the fact that the patient initially lost flexion postoperatively and this relates to anterior placement of the femoral tunnel, thus capturing the knee. The bone plug seen on the radiograph is actually from the tibial tunnel, but this occurred as the patient forced flexion until failure of the ACL graft and pullout of the plug from the tunnel. Although it could be argued that better tibial fixation would have prevented this failure, poor placement of the femoral tunnel led to the failure of this ACL reconstruction. Fu FH, Bennett CH, Latterman C, et al: Current trends in anterior cruciate ligament reconstruction: Part 1. Biology and biomechanics of reconstruction. Am J Sports Med 1999;27:821-830.

Question 2709

Topic: Shoulder & Hip Sports

A 22-year-old volleyball player reports the insidious onset of superior and posterior shoulder pain. Radiographs are normal. An MRI scan is shown in Figure 25. What is the most specific physical examination finding?

Sports Medicine Board Review 2007: High-Yield MCQs (Set 4) - Figure 6

. Positive impingement sign
. Positive apprehension
. Positive active compression
. Weakness of external rotation
. Weakness of abduction

Correct Answer & Explanation

. Weakness of external rotation

Explanation

Overhead athletes are prone to a number of problems involving the shoulder. Pitchers and volleyball players are susceptible to posterior superior labral tears and internal impingement. These patients will have posterior superior shoulder pain, a positive relocation sign, and a positive active compression test. Occasionally, these posterior superior labral tears are associated with a spinoglenoid cyst as seen in the MRI scan. These cysts cause compression of the suprascapular nerve which manifests primarily as weakness of the infraspinatus, resulting in weakness of external rotation. Romeo AA, Rotenberg DD, Bach BR Jr: Suprascapular neuropathy. J Am Acad Orthop Surg 1999;7:358-367.

Question 2710

Topic: 5. Sports Medicine

Figure 13 shows the radiographs of a 20-year-old intercollegiate basketball player who was injured 6 weeks prior to the start of the season. What is the most appropriate treatment?

Sports Medicine Board Review 2007: High-Yield MCQs (Set 2) - Figure 12

. Intramedullary screw fixation
. Immobilizing orthotic/boot
. Walking cast
. Physical therapy
. Rest for 2 weeks and return to play

Correct Answer & Explanation

. Intramedullary screw fixation

Explanation

A Jones fracture occurs at the metaphyseal-diaphyseal junction of the fifth metatarsal. It is often an acute fracture in conjunction with a chronic stress-related injury. It requires either a short leg cast with strict non-weight-bearing or surgical fixation. In the high performance athlete, the need for rapid return to sport activity usually requires surgical intervention, most commonly with an intramedullary screw. Brodsky JW, Krause JO: Stress fractures of the foot and ankle, in Delee JC, Drez D (eds): Orthopaedic Sports Medicine, ed 2. Philadelphia, PA, Saunders, 2003, vol 2, pp 2391-2409.

Question 2711

Topic: 5. Sports Medicine

A 23-year-old professional baseball pitcher reports shoulder pain and decreased velocity while pitching. Physical examination reveals a side-to-side internal rotation deficit of 25 degrees. The O'Brien sign is negative; Neer and Hawkins signs are negative. Rotator cuff strength is full. Radiographs are unremarkable. What is the next step in management?

Upper Extremity 2008 Practice Questions: Set 3 (Solved) - Figure 8

. MRI-arthrogram to evaluate the rotator cuff
. Rotator cuff strengthening program
. Posterior capsular stretching program
. Shoulder arthroscopy with SLAP repair
. Shoulder arthroscopy with posterior capsular release

Correct Answer & Explanation

. Posterior capsular stretching program

Explanation

Throwing athletes with symptomatic internal rotation deficits often benefit from an intensive posterior capsular stretching program. Patients that fail to respond to nonsurgical management may benefit from an arthroscopic posterior capsular release. Wilk KE, Meister K, Andrews JR: Current concepts in rehabilitation of the overhead throwing athlete. Am J Sports Med 2002;30:136-151.

Question 2712

Topic: 5. Sports Medicine

A patient undergoes hip arthroscopy, and the pathology is seen in Figure 18. What is the most likely diagnosis?

Anatomy Board Review 2002: High-Yield MCQs (Set 2) - Figure 10

. Femoral head articular defect
. Acetabular articular defect
. Haversian fat pad hypertrophy
. Labral tear
. Loose body

Correct Answer & Explanation

. Labral tear

Explanation

The motorized shaver is adjacent to the acetabular labrum, which is torn. The femoral head and acetabulum are normal in appearance. Neither the fat pad nor a loose body is identified.

Question 2713

Topic: 5. Sports Medicine

A 42-year-old woman has cervical stenosis and radicular deficits at the C5-6 and C6-7 levels. History reveals that she has smoked one pack of cigarettes a day for 25 years. Because nonsurgical management has failed to provide relief, she is now seeking surgical treatment. After preoperative counseling, it becomes clear that she is not likely to stop smoking. Which of the following surgical procedures should be used?

. Anterior diskectomy and interbody fusion with autograft at C5-6 and C6-7
. Anterior diskectomy at C5-6 and C6-7, subtotal corpectomy at C6, and iliac strut autograft at C5 to C7
. Anterior diskectomy at C5-6 and C6-7 without fusion
. Anterior diskectomy at C5-6 and C6-7, subtotal corpectomy at C6, and allograft strut at C5 to C7
. Multilevel diskectomy and allograft interbody fusion

Correct Answer & Explanation

. Anterior diskectomy at C5-6 and C6-7, subtotal corpectomy at C6, and iliac strut autograft at C5 to C7

Explanation

In a review of 190 anterior cervical fusions, Hilibrand and associates reported that only 20 of 40 patients who smoked had solid fusion at all levels, whereas 64 of 91 nonsmokers had solid fusions at all levels when treated with multilevel interbody technique (Smith-Robinson). When fused with strut grafts, 14 of 15 smokers and 41 of 44 nonsmokers had solid fusions with a fusion rate of 93% in the same series. Multilevel allografts have a lower fusion rate than autografts, and diskectomy without fusion has an increased rate of residual neck pain. Hilibrand AS, Fye MA, Emery SE, et al: Impact of smoking on the outcome of anterior cervical arthrodesis with interbody or strut-grafting. J Bone Joint Surg Am 2001;83:668-673.

Question 2714

Topic: Shoulder & Hip Sports

Figure 52 shows the MRI scan of a 28-year-old baseball pitcher. Examination will most likely reveal which of the following findings?

Anatomy Board Review 2005: High-Yield MCQs (Set 4) - Figure 16

. Weakness of the deltoid
. Numbness in the C7 dermatomal distribution
. Winging of the scapula
. A positive lift-off test
. Clinical findings similar to a large rotator cuff tear

Correct Answer & Explanation

. Weakness of the deltoid

Explanation

A ganglion cyst compressing the suprascapular nerve results in poorly localized pain in the shoulder girdle. Sensation is intact, with weakness of external rotation and abduction. Supraspinatus and infraspinatus atrophy is often noted when viewed from behind. These cysts are typically associated with labral tears. Deltoid weakness is associated with an axillary nerve injury, and scapular winging results from injury to the long thoracic nerve. 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 2715

Topic: 5. Sports Medicine

A 12-year-old boy who pitches on two "select" baseball teams has had pain in his dominant right shoulder for the past 6 weeks. The pain is present only with throwing and is associated with decreased throwing velocity and control. He has no radiation of pain or paraesthesias of the upper extremity. An AP radiograph and MRI scan are shown in Figures 19a and 19b, respectively. Management should consist of

. rest from throwing activities.
. a subacromial corticosteroid injection.
. open reduction and internal fixation.
. arthroscopic labral repair.
. biopsy of the proximal humerus.

Correct Answer & Explanation

. rest from throwing activities.

Explanation

The imaging study demonstrates characteristics of Little Leaguer's shoulder, including physeal widening. This condition is secondary to overuse (typically throwing) and responds well to rest from the inciting activity. There is no evidence from the patient's history or examination that he has an impingement syndrome, nor is there any indication of labral pathology on the MRI scan. The changes in the proximal humerus are classic for this condition and are not suggestive of a neoplastic process requiring biopsy for definitive diagnosis. Lipscomb AB: Baseball pitching injuries in growing athletes. J Sports Med 1975;3:25-34. Cahill BR, Tullos HS, Fain RH: Little league shoulder: Lesions of the proximal humeral epiphyseal plate. J Sports Med 1974;2:150-152.

Question 2716

Topic: Shoulder & Hip Sports

A 40-year-old woman who is an avid tennis player reports the insidious onset of progressive left shoulder pain for the past 2 months. Examination reveals full range of motion with a positive impingement sign. Strength in the supraspinatus and infraspinatus muscles is normal, although stress testing is painful. An earlier subacromial cortisone injection provided good, but only temporary relief. An AP radiograph of the left shoulder is shown in Figure 10. Management should now consist of

Sports Medicine 2001 Practice Questions: Set 1 (Solved) - Figure 30

. a rotator cuff exercise program and anti-inflammatory drugs.
. repeat subacromial cortisone injections as necessary.
. open subacromial decompression.
. arthroscopic evacuation of calcium deposits.
. open rotator cuff repair.

Correct Answer & Explanation

. arthroscopic evacuation of calcium deposits.

Explanation

The radiograph shows calcific deposits within the substance of the supraspinatus tendon. Patients with this condition are prone to recurrent bouts of acute inflammation in the shoulder. While the response to cortisone injection is often dramatic, repeated injections are not recommended because of injury to the collagen fibers. Good results have been obtained with arthroscopic evacuation of the calcium deposits. In one study, the addition of a subacromial decompression did not improve the results. Jerosch J, Strauss JM, Schmiel S: Arthroscopic treatment of calcific tendinitis of the shoulder. J Shoulder Elbow Surg 1998;7:30-37.

Question 2717

Topic: Shoulder & Hip Sports

Figures 25a and 25b show the clinical photographs of a 19-year-old baseball outfielder who has shoulder pain after sliding headfirst into second base. He reports pain while batting, sliding, and catching. Examination reveals a posterior prominence during midranges of forward elevation, which then disappears with a palpable clunk during terminal elevation and abduction. What is the most likely diagnosis?

. Superior labrum anterior and posterior (SLAP) lesion
. Bankart lesion
. Rotator cuff interval tear
. Rotator cuff tendinitis
. Posterior glenohumeral subluxation

Correct Answer & Explanation

. Posterior glenohumeral subluxation

Explanation

A headfirst slide with the arm extended can injure the posterior shoulder. Winging of the scapula is dynamic and is considered a compensatory effort to prevent subluxation; it is not related to nerve injury. Posterior glenohumeral subluxation can be present during the initiation of a bat swing. Rotator cuff function, interval tears, and superior labrum tears can be painful but do not produce winging. Kuhn JE, Plancher KD, Hawkins RJ: Scapular winging. J Am Acad Orthop Surg 1995;3:319-325.

Question 2718

Topic: Shoulder & Hip Sports

Figure 30 shows an axial T1-weighted MRI scan of a patient's right shoulder. The arrows are pointing to what normal structure?

Anatomy 2005 Practice Questions: Set 3 (Solved) - Figure 6

. Deltoid insertion
. Subscapularis tendon
. Latissimus dorsi tendon
. Short head of the biceps tendon
. Pectoralis major tendon

Correct Answer & Explanation

. Pectoralis major tendon

Explanation

Tears of the pectoralis major tendon are frequently missed during examination. MRI provides excellent visualization of the tendon if the study extends low enough down the arm. The pectoralis major tendon inserts on the crest of the greater tubercle of the humerus, just lateral to the long head of the biceps tendon. The latissimus dorsi tendon inserts medial to the long head of the biceps tendon on the lesser tubercle. The subscapularis tendon inserts on the lesser tuberosity more proximally. The deltoid insertion is more distal. Connell DA, Potter HG, Sherman MF, et al: Injuries of the pectoralis major muscle: Evaluation with MR imaging. Radiology 1999;210:785-791. Carrino JA, Chandnanni VP, Mitchell DB, et al: Pectoralis major muscle and tendon tears: Diagnosis and grading using magnetic resonance imaging. Skeletal Radiol 2000;29:305-313.

Question 2719

Topic: 5. Sports Medicine

Figure 16 shows the lateral radiograph of a patient who is scheduled to undergo an anterior cruciate ligament (ACL) reconstruction. If the graft is tensioned at 20 degrees of flexion and the femoral tunnel is created by passing a reamer over the guide wire marked "A," the resulting ligament reconstruction will excessively

Sports Medicine Board Review 2001: High-Yield MCQs (Set 2) - Figure 13

. tighten as the knee extends past 10 degrees of flexion.
. tighten as the knee flexes past 90 degrees.
. loosen as the knee extends past 10 degrees of flexion.
. loosen as the knee flexes past 30 degrees.
. loosen as the knee flexes past 90 degrees.

Correct Answer & Explanation

. tighten as the knee flexes past 90 degrees.

Explanation

If the femoral tunnel is created using guide wire A, it will be too far anterior in the intercondylar notch. The distance between a central tibial insertion for the ACL and an anterior femoral tunnel will progressively increase as the knee is flexed. Therefore, if the graft is tensioned near extension, the ligament will excessively tighten as the knee flexes past 90 degrees. This will result in restricted knee flexion or failure of the graft as full flexion is gained. There will be little effect on the ligament as it extends from 20 degrees to 0 degrees of flexion. If the graft is tensioned in significant flexion (greater than 60 degrees), it will be excessively loose as the knee fully extends. Daniel DM, Fritschy D: Anterior cruciate ligament injuries, in DeLee JC, Drez D Jr (eds): Orthopaedic Sports Medicine: Principles and Practice. Philadelphia, PA, WB Saunders, 1994, pp 1313-1360.

Question 2720

Topic: Knee Sports

What is the most anatomic location for placement of the femoral tunnel in anterior cruciate ligament reconstruction?

Anatomy Board Review 2002: High-Yield MCQs (Set 2) - Figure 20

. As far superior in the notch as possible
. As far posterior as possible on the lateral femoral condyle
. As far posterior as possible on the medial femoral condyle
. Directly across from the posterior cruciate femoral insertion
. At resident's ridge

Correct Answer & Explanation

. As far posterior as possible on the lateral femoral condyle

Explanation

It is critical for graft isometry and knee stability that the femoral tunnel be placed as far posterior as possible on the lateral femoral condyle. Superiorly, the graft should be at the one o'clock position on the left knee. Resident's ridge is a false posterior shelf that often seems like the extreme posterior cortex. Abnormal tunnel placement results in a variety of complications, including an unstable knee, early graft failure, and joint stiffness. Johnson RJ, Beynnon BD, Nichols CE, Renstrom PA: The treatment of injuries of the anterior cruciate ligament. J Bone Joint Surg Am 1992;74:140-151.

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