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 2841
Topic: Knee Sports
A 25-year-old male undergoes an isolated posterior cruciate ligament (PCL) reconstruction using an anterolateral bundle (ALB) single-bundle technique. At what degree of knee flexion should the ALB graft be tensioned and fixed to best replicate native biomechanics?
Correct Answer & Explanation
. 90 degrees
Explanation
The native PCL consists of the anterolateral bundle (ALB) and posteromedial bundle (PMB). The ALB is tightest in flexion, and the PMB is tightest in extension. During a single-bundle PCL reconstruction targeting the ALB, the graft is typically tensioned and fixed at 90 degrees of flexion while an anterior drawer force is applied to restore the normal tibial step-off.
Question 2842
Topic: 5. Sports Medicine
A 22-year-old collegiate athlete undergoes an anterior cruciate ligament (ACL) reconstruction using a bone-patellar tendon-bone autograft. During the biological process of 'ligamentization', at approximately what postoperative time frame does the graft reach its nadir of mechanical strength, placing the patient at highest risk for traumatic rupture?
Correct Answer & Explanation
. 6-12 weeks
Explanation
The 'ligamentization' of a tendon autograft used for ACL reconstruction consists of three phases: necrosis, proliferation/revascularization, and remodeling/maturation. During the proliferation phase, which occurs approximately 6 to 12 weeks postoperatively, there is intense cellular activity, revascularization, and collagen degradation/resynthesis. Because the original collagen architecture is being broken down before the new organized matrix matures, the graft is mechanically at its weakest during this 6 to 12 week window.
Question 2843
Topic: 5. Sports Medicine
A 28-year-old athlete undergoes evaluation for a knee injury. MRI confirms an isolated tear of the posterior cruciate ligament (PCL). Which of the following statements regarding the biomechanics of the PCL is correct?
Correct Answer & Explanation
. The anterolateral bundle is tight in flexion and loose in extension.
Explanation
The PCL consists of two main bundles: the larger anterolateral (AL) bundle and the smaller posteromedial (PM) bundle. Biomechanically, the AL bundle is tight in flexion and loose in extension, making it the primary restraint to posterior translation at 90 degrees of flexion. The PM bundle is tight in extension and loose in flexion.
Question 2844
Topic: 5. Sports Medicine
When performing an anterior cruciate ligament (ACL) reconstruction using a bone-patellar tendon-bone autograft, placement of the femoral tunnel too anteriorly (shallow) will most likely result in:
Correct Answer & Explanation
. Increased laxity in extension and tightness in flexion
Explanation
If the femoral tunnel is placed too anteriorly, the graft will be tight in flexion and loose in extension. Conversely, if it is placed too posteriorly (deep), it will be tight in extension and loose in flexion.
Question 2845
Topic: Shoulder & Hip Sports
A 22-year-old football player sustains a recurrent anterior shoulder dislocation. An MRI arthrogram reveals a Bankart tear and a large Hill-Sachs lesion that engages the anterior glenoid rim. What is the best surgical option to address the engaging Hill-Sachs lesion?
Correct Answer & Explanation
. Remplissage procedure with Bankart repair
Explanation
An engaging Hill-Sachs lesion is a defect on the posterolateral humeral head that engages the anterior glenoid during abduction and external rotation, predisposing to recurrent dislocation. The Remplissage procedure (infilling the defect with the infraspinatus tendon and capsule) combined with a Bankart repair is an effective treatment.
Question 2846
Topic: Knee Sports
A 19-year-old female undergoes MPFL reconstruction for recurrent patellar instability. To ensure proper isometry, the femoral attachment (Schöttle's point) must be accurately identified on a true lateral radiograph. Where is this point located?
Correct Answer & Explanation
. 1 mm anterior to the posterior femoral cortical line, 2.5 mm distal to the posterior origin of the medial femoral condyle, and proximal to Blumensaat's line
Explanation
Schöttle's point is a radiographic landmark for the femoral origin of the medial patellofemoral ligament (MPFL). On a strict lateral radiograph, it is defined as 1 mm anterior to the posterior femoral cortical line, 2.5 mm distal to the posterior articular border of the medial femoral condyle, and proximal to the level of the posterior point of Blumensaat's line. Placing the graft at this point helps achieve near-isometric behavior.
Question 2847
Topic: 5. Sports Medicine
A 45-year-old recreational athlete presents with anterior shoulder pain. MRI arthrogram demonstrates a Type II SLAP tear.
In patients over the age of 40, comparing primary biceps tenodesis to arthroscopic SLAP repair, literature shows that primary tenodesis generally results in:
Correct Answer & Explanation
. Equivalent or superior patient-reported outcomes with lower complication rates
Explanation
In patients over 40 years old with symptomatic SLAP tears, primary biceps tenodesis has been shown to yield equivalent or superior clinical outcomes, higher rates of return to activity, and significantly lower rates of reoperation and postoperative stiffness compared to arthroscopic SLAP repair. Therefore, tenodesis is often favored in this age group.
Question 2848
Topic: Knee Sports
During an anatomic double-bundle Anterior Cruciate Ligament (ACL) reconstruction, the surgeon aims to replicate native knee kinematics. Which of the following accurately describes the tensioning pattern of the native ACL bundles during knee range of motion?
Correct Answer & Explanation
. The AM bundle is tightest in flexion and the PL bundle is tightest in extension
Explanation
The native ACL consists of two primary bundles: the anteromedial (AM) bundle and the posterolateral (PL) bundle. Biomechanically, the AM bundle is tightest in flexion (providing primary anterior stability at 90 degrees), while the PL bundle is tightest in extension (providing primary rotatory stability near full extension).
Question 2849
Topic: Knee Sports
A 25-year-old male sustains a severe knee dislocation resulting in an injury to the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), and posterolateral corner (PLC). Following acute multiligament reconstruction, including the PLC, which of the following post-operative rehabilitation parameters is most critical to protect the PLC repair?
Correct Answer & Explanation
. Avoiding active isolated knee flexion against gravity for 6 weeks
Explanation
Active knee flexion against gravity isolates and activates the hamstrings. Hamstring contraction exerts a posterior and external rotatory force on the proximal tibia, placing severe stress on the newly reconstructed posterolateral corner (and PCL). Therefore, active hamstring contraction/knee flexion is typically avoided for the first 6 weeks postoperatively.
Question 2850
Topic: 5. Sports Medicine
When comparing bone-patellar tendon-bone (BPTB) autograft to quadrupled hamstring autograft for anterior cruciate ligament (ACL) reconstruction, BPTB autograft is generally associated with a higher incidence of which of the following postoperative complications?
Correct Answer & Explanation
. Anterior knee pain and kneeling pain
Explanation
Both BPTB and hamstring autografts are excellent choices for ACL reconstruction with comparable long-term knee stability and graft survival rates. However, harvest site morbidity differs. BPTB autograft is notoriously associated with a higher incidence of anterior knee pain and discomfort while kneeling, largely due to the harvest of the central third of the patellar tendon and the creation of bone defects in the patella and tibial tubercle. Hamstring harvest may result in temporary or mild permanent loss of deep flexion strength, but anterior knee pain is specifically a hallmark risk of BPTB.
Question 2851
Topic: Shoulder & Hip Sports
A 22-year-old collegiate baseball pitcher presents with vague, deep shoulder pain and clicking during the late cocking phase of throwing. Magnetic resonance arthrography demonstrates a superior labral tear from anterior to posterior (SLAP tear) with detachment of the biceps anchor from the superior glenoid tubercle. This represents which type of SLAP tear?
Correct Answer & Explanation
. Type II
Explanation
According to the Snyder classification of SLAP tears: Type I involves fraying of the superior labrum but the biceps anchor is intact. Type II (the most common type, especially in throwers) involves detachment of the superior labrum and the origin of the long head of the biceps tendon from the glenoid. Type III is a bucket-handle tear of the superior labrum with an intact biceps anchor. Type IV is a bucket-handle tear that extends into the biceps tendon. Therefore, a detached biceps anchor signifies a Type II SLAP lesion.
Question 2852
Topic: 5. Sports Medicine
A 45-year-old weekend warrior sustains an acute Achilles tendon rupture while playing tennis. He opts for non-operative management with a functional rehabilitation protocol. Compared to acute operative repair, current literature suggests this management approach is associated with:
Correct Answer & Explanation
. An equivalent re-rupture rate when early functional rehabilitation is employed
Explanation
Historically, non-operative treatment of Achilles tendon ruptures was associated with higher re-rupture rates compared to surgery. However, modern high-quality randomized controlled trials (such as the Willits study) have demonstrated that when non-operative treatment is combined with an early dynamic functional rehabilitation protocol (weight-bearing in an orthosis), the re-rupture rates are equivalent to those of operative repair. Non-operative management eliminates surgical risks like infection, wound breakdown, and iatrogenic sural nerve injury, though some patients may have slightly reduced peak plantar flexion strength compared to the surgical cohort.
Question 2853
Topic: Knee Sports
During arthroscopic posterior cruciate ligament (PCL) reconstruction, a surgeon is preparing the tibial tunnel. To prevent iatrogenic injury to the popliteal artery, it is critical to understand its anatomical relationship to the PCL. Where is the popliteal artery located in relation to the PCL tibial footprint?
Correct Answer & Explanation
. Directly posterior to the PCL tibial attachment
Explanation
The popliteal artery is at significant risk during tibial tunnel drilling for PCL reconstruction. It is located directly posterior to the PCL tibial attachment (the "facies poplitea"), separated only by the posterior capsule. Studies have shown the distance from the posterior capsule to the artery can be as little as 5 to 10 mm.
Question 2854
Topic: 5. Sports Medicine
Figures 8a through 8c show the lateral radiograph and T1- and T2-weighted MRI scans of a 14-year-old soccer player who reports aching thigh pain. The next most appropriate step in management should consist of
Correct Answer & Explanation
. a repeat radiograph in 6 to 8 weeks.
Explanation
Although the MRI findings could be misinterpreted as an aggressive soft-tissue process, the periosteal-based ossification on the radiograph in an athlete most likely suggests myositis ossificans. The radiograph should be repeated to see further maturation of the ossification with a typical "zoning" pattern. The zoning pattern is one of peripheral ossification. This is often best seen on a CT scan. King JB: Post-traumatic ectopic calcification in the muscles of athletes: A review. Br J Sports Med 1998;32:287-290.
Question 2855
Topic: 5. Sports Medicine
A 21-year-old football player reports increasing pain and a deformity involving his chest after colliding with another player during a scrimmage. Imaging studies confirm an anterior sternoclavicular dislocation. Management should consist of:
Correct Answer & Explanation
. symptomatic nonsurgical treatment.
Explanation
For the patient with an anterior sternoclavicular dislocation, the most appropriate initial treatment should be symptomatic. Surgical options are usually contraindicated because the incidence of intraoperative and postoperative complications is high. A deformity from an anterior sternoclavicular dislocation is usually well tolerated. Return to play is allowed when symptoms resolve.
Question 2856
Topic: 5. Sports Medicine
A 20-year-old minor league baseball pitcher is diagnosed with a symptomatic torn ulnar collateral ligament (UCL) in his pitching elbow. Nonsurgical management consisting of rest and physical therapy aimed at elbow strengthening has failed to provide relief. He has concomitant cubital tunnel symptoms that worsen while throwing. What is his best surgical option?
Correct Answer & Explanation
. Autograft UCL reconstruction with ulnar nerve transposition
Explanation
High-level pitchers with symptomatic UCL tears require reconstruction, with autograft being the best studied graft selection. With concomitant ulnar nerve symptoms, a simultaneous ulnar nerve transposition provides good results. Ligament "repairs" and allograft reconstructions have not shown good long-term results. Azar FM, Andrews JR, Wilk KE, et al: Operative treatment of ulnar collateral ligament injuries of the elbow in athletes. Am J Sports Med 2000;28:16-23.
Question 2857
Topic: Shoulder & Hip Sports
Figure 14 shows an intra-articular gadolinium-enhanced MRI scan of a 52-year-old woman who has stopped playing tennis because of pain in her left shoulder while serving. What is the most likely diagnosis?
Correct Answer & Explanation
. Partial-thickness rotator cuff tear on the articular side
Explanation
The MRI scan shows increased signal intensity along the deep fibers of the supraspinatus near its insertion. This is typical of tendinosis and a probable partial-thickness rotator cuff tear. Herzog RJ: Magnetic resonance imaging of the shoulder. Instr Course Lect 1998;47:3-20.
Question 2858
Topic: 5. Sports Medicine
A 38-year-old man sustains a complete avulsion with retraction of the ischial attachment of the hamstring muscles in a fall while water skiing. He indicates that he is an aggressive athlete who participates regularly in multiple running and cutting-type sports, and he strongly desires to continue his athletic competition. Management should consist of
Correct Answer & Explanation
. early surgical repair, prolonged rehabilitation, and a return to sports.
Explanation
Several studies have identified a complete proximal avulsion of the hamstring muscles as an injury that leads to significant long-term disability, with a high percentage of athletes who must permanently restrict their activities following nonsurgical management. Early surgical repair and prolonged rehabilitation have yielded consistently better results than nonsurgical management. Orava S, Kujala UM: Rupture of the ischial origin of the hamstring muscles. Am J Sports Med 1995;23:702-705.
Question 2859
Topic: Shoulder & Hip Sports
A 28-year-old professional dancer presents with chronic groin pain, particularly with deep flexion and internal rotation. MRI with arthrogram reveals a large cam lesion with an alpha angle of 80 degrees, a pincer lesion with acetabular retroversion, and a superior labral tear with chondral delamination. Diagnostic injection provides temporary relief.
Given these findings, what is the most appropriate definitive management strategy?
Correct Answer & Explanation
. Arthroscopic acetabuloplasty, femoral osteochondroplasty, and labral repair.
Explanation
This patient presents with a classic picture of mixed-type femoroacetabular impingement (FAI) characterized by both cam and pincer lesions, a labral tear, and associated chondral damage. The 'gold standard' for surgical management of FAI with articular damage and a reparable labrum is arthroscopic hip surgery. This approach allows for assessment and treatment of all impingement components: femoral osteochondroplasty to address the cam lesion, acetabuloplasty to correct the pincer lesion, and labral repair (or reconstruction if irreparable) to restore the suction seal and biomechanics of the hip. Chondral delamination can also be addressed with debridement or microfracture if indicated.Option A (arthroscopic labral debridement and cam osteoplasty only) is insufficient as it fails to address the pincer lesion and the possibility of labral repair instead of debridement.Option B (open surgical dislocation with acetabular osteotomy, femoral osteochondroplasty, and labral repair) is a more invasive option usually reserved for very complex deformities, severe articular damage requiring direct access, or cases where arthroscopic treatment has failed. For an active dancer with chronic but treatable FAI, arthroscopy is generally preferred as the first-line surgical treatment due to lower morbidity and faster recovery if successful.Option D (conservative management) has already failed, and given the significant mechanical impingement and structural damage (chondral delamination), it is unlikely to provide long-term relief or prevent progression of arthritis.Option E (Periacetabular osteotomy - PAO) is indicated for developmental dysplasia of the hip (DDH) to improve acetabular coverage, not typically for isolated FAI with acetabular retroversion. Acetabular retroversion is addressed by rim trimming (acetabuloplasty), not a PAO.
Question 2860
Topic: Knee Sports
A 35-year-old male sustained a high-energy knee injury in a motor vehicle collision. Clinical examination reveals a gross posterolateral rotatory instability, a positive dial test at 30 and 90 degrees, a grade III posterior sag, and an absent posterior drawer. Foot drop is noted. MRI confirms avulsion of the PCL from the tibia, rupture of the fibular collateral ligament (FCL), and injury to the popliteus tendon. What is the most critical immediate concern that dictates the timing and approach to surgical management?
Correct Answer & Explanation
. Presence of a foot drop indicating common peroneal nerve injury.
Explanation
This patient has a multi-ligamentous knee injury involving the PCL and the posterolateral corner (PLC), a highly unstable injury. The key additional finding is 'foot drop,' which signifies injury to the common peroneal nerve. The common peroneal nerve courses superficially around the fibular head and is highly susceptible to injury in PLC disruptions and fibular head fractures. While all listed options represent valid concerns in multi-ligamentous knee injuries: Option A (post-traumatic arthritis) is a long-term complication but not an immediate concern dictating surgical timing. Option B (common peroneal nerve injury) is critical. Foot drop indicates significant nerve dysfunction, which needs to be addressed promptly. Surgical exploration and nerve repair or neurolysis may be necessary, and the presence of this neurological deficit often influences the timing and urgency of surgical intervention. Early diagnosis and management of nerve injuries are crucial for potential recovery. Option C (severity of PCL avulsion) is significant for surgical planning, but the nerve injury adds another layer of complexity and urgency. Option D (early mobilization to prevent stiffness) is important post-surgery but is not the most critical immediate concern pre-operatively, especially when compared to acute nerve injury. Option E (neurovascular compromise and compartment syndrome) is a critical immediate concern in any high-energy knee injury, especially dislocations. However, the question specifically states 'foot drop is noted,' identifying a definite neurological injury rather than just a potential for neurovascular compromise. If a popliteal artery injury was present, it would be the absolute highest priority, but a peroneal nerve injury is also very high priority. Given the options, the presence of an already identified foot drop makes the nerve injury the most critical factor listed that dictates the immediate approach to surgical management, potentially requiring specific nerve interventions concurrently with or preceding ligamentous reconstruction.
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