5. Sports Medicine MCQs

If the femoral tunnel is placed too anterior (shallow) in the intercondylar notch, the distance between the femoral and tibial tunnels increases as the knee extends, causing the graft to become excessively tight in extension (resulting in an extension block) and loose in flexion. A graft placed too vertical (12 o'clock) controls anterior translation but fails to control rotational stability (positive pivot shift).

Internal impingement in overhead throwing athletes occurs during the late cocking phase (maximum abduction and external rotation). In this position, the articular surface of the posterior rotator cuff (supraspinatus/infraspinatus junction) becomes pinched or rubs directly against the posterosuperior glenoid rim and labrum. This is completely distinct from classic subacromial (external) impingement, which involves the bursal surface of the cuff and the undersurface of the acromion or coracoacromial ligament.

Bone-patellar tendon-bone (BTB) autograft is considered the gold standard for ACL reconstruction in high-demand athletes due to its rigid bone-to-bone healing and strength. However, its most significant and frequently reported donor-site morbidity is anterior knee pain, particularly pain when kneeling. Hamstring autografts, conversely, are associated with a temporary decrease in deep hamstring flexion strength and potential iatrogenic injury to the infrapatellar branch of the saphenous nerve during graft harvest.

In a skeletally immature patient with significant remaining growth (e.g., Tanner stage I or II, open physes), ACL reconstruction techniques must minimize the risk of iatrogenic physeal injury. An all-epiphyseal (epiphyseal-sparing) ACL reconstruction or an entirely physeal-sparing technique is indicated to avoid drilling across the femoral and tibial physes. Transphyseal techniques may be considered in older adolescents (Tanner III/IV) but should use soft tissue grafts (not bone plugs). Bone-patellar tendon-bone grafts are contraindicated due to the risk of bone blocks bridging the physis, leading to premature arrest.

Recent high-level evidence demonstrates that when acute Achilles tendon ruptures are managed nonoperatively with early functional rehabilitation (early weight-bearing and mobilization in a functional orthosis), the re-rupture rates are equivalent to those of operative repair. Operative repair has a higher rate of overall complications (such as infection and sural nerve injury) but historically had a lower re-rupture rate when compared to prolonged rigid immobilization. With modern functional bracing protocols, the difference in re-rupture rates is no longer statistically significant.

Bone-patellar tendon-bone (BTB) autografts have historically been associated with a higher incidence of donor site morbidity, specifically anterior knee pain and pain with kneeling, compared to hamstring autografts. Rates of graft failure are generally comparable or slightly lower for BTB grafts, and postoperative laxity is often slightly less with BTB grafts due to bone-to-bone healing.

In ACL reconstruction, an anteriorly (shallow) placed femoral tunnel creates a length mismatch where the graft becomes tight in flexion and loose in extension. Conversely, a posteriorly (deep) placed femoral tunnel results in a graft that is tight in extension and loose in flexion. Optimal isometric placement or anatomic placement avoids these extremes, allowing normal range of motion without over-constraining the joint or leaving it unstable.

Early controlled mobilization following a flexor tendon repair stimulates intrinsic tendon healing, increases the overall tensile strength of the repair, and significantly decreases the formation of restrictive peritendinous adhesions. It does not decrease the risk of rupture (which remains a risk during early motion if overloaded) and has no bearing on sensory nerve recovery or osteoarthritis.

Historically, nonoperative treatment of Achilles tendon ruptures was associated with higher rerupture rates. However, modern Level I randomized controlled trials (such as the Willits study) have demonstrated that when an accelerated functional rehabilitation protocol with early mobilization and weight-bearing is utilized, the rerupture rate is equivalent to surgical repair. Furthermore, nonoperative management completely avoids surgical risks, leading to a definitively lower rate of wound complications.

Biomechanical studies have demonstrated that the quadrupled hamstring autograft (semitendinosus and gracilis) has an ultimate tensile load of approximately 4140 N, which is significantly higher than a 10-mm BPTB graft (~2977 N), quadriceps tendon (~2185-2352 N), and the native ACL (~2160 N). However, it is important to note that despite the high ultimate tensile load, factors such as fixation strength, graft incorporation, and stiffness also dictate the ultimate clinical success.

The MRI scans show a large paralabral ganglion cyst in the spinoglenoid notch that communicates with an extensive tear of the glenoid labrum. Snyder and associates have classified superior labral tears into several subtypes that reflect the location and extent of the injury. Arthroscopic repair of the labral tear and aspiration of the ganglion cyst is the treatment of choice. Open excision of the cyst does not address the underlying problem of the labral tear. Snyder SJ, Karzel RP, Delpizzo W: SLAP lesions of the shoulder. Arthroscopy 1990;6:274-279. Piatt BE, Hawkins RJ, Fritz RC, et al: Clinical evaluation and treatment of spinoglenoid notch cysts. J Shoulder Elbow Surg 2002;11:600-604. McFarland EG, Kim TK, Savino RM: Clinical assessment of three common tests for superior labral anterior-posterior lesions. Am J Sports Med 2002;30:810-815.

Transfer of the latissimus dorsi and teres major to the posterior rotator cuff will restore external rotation and some abduction. The procedure should be performed in children who are approximately age 4 years, following spontaneous recovery and prior to significant stiffness. External rotation osteotomy is more appropriate for an older child. Fusion should not be performed until skeletal maturity. Distal biceps rerouting restores pronation for a supination deformity. Latissimus dorsi and teres major transfer to the subscapularis would accentuate the internal rotation. In younger patients without significant bony deformity, a subscapularis slide or lengthening can restore external rotation. Strecker WB, McAllister JW, Manske PR, Schoenecker PL, Dailey LA: Sever-L'Episcopo transfers in obstetrical palsy: A retrospective review of twenty cases. J Pediatr Orthop 1990;10:442-444.

The most reliable test for a relatively isolated posterolateral complex (PLC) injury is the asymmetric tibial external rotation or "dial test." It can be performed with the patient prone or supine. When greater than 10 degrees of external rotation at 30 degrees of flexion is present when compared with the opposite knee, it indicates significant damage to the posterolateral structures. Asymmetric external rotation, which is also present at 90 degrees of flexion, indicates injury to the posterior cruciate ligament (PCL) as well. Varus laxity may indicate significant damage to both the PLC and PCL. Approximately 35% of the normal population may have a reverse pivot shift when examined under anesthesia; therefore, it is considered a less specific test. The external rotation/recurvatum and posterolateral drawer tests are adjunctive in assessing isolated posterolateral laxity but are not thought to be as reliable. Veltri DM, Warren RF: Isolated and combined posterior cruciate injuries. J Am Acad Orthop Surg 1993;1:67-75.

The lateral cord terminates as the musculocutaneous nerve and also contributes sensory fibers to the median nerve. Involvement of the C6 root or upper trunk could potentially cause weakness of the infraspinatus and the brachioradialis. The middle trunk and the posterior cord do not contribute motor fibers to the thumb or sensory fibers to the thumb.

An avulsion fracture from the lateral tibial margin carries the eponym Segond fracture and is pathognomonic for an anterior cruciate ligament (ACL) tear. The fragment is located posterior to Gerdy's tubercle and is superior and anterior to the fibular head. It represents an avulsion of the lateral capsular ligament of the knee and is caused by the same mechanism that causes the ACL tear. The pes anserinus is the insertion point of the medial hamstrings and would not be affected in a lateral avulsion injury. The posterior cruciate ligament may be seen on a lateral view if associated with an avulsion fragment, but a tear of the PCL generally cannot be diagnosed on an AP view. The insertion of the iliotibial band is broad and is unlikely to produce an avulsion injury such as that seen in the radiograph. This view is not consistent with the appearance of a lateral collateral ligament injury. Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 533-557.

Throwing athletes, particularly pitchers, have a high incidence of shoulder pain. Recent evidence suggests that posteroinferior capsular tightness and scapular dyskinesis may play a substantial role in the pathologic cascade, culminating in the development of articular surface rotator cuff tears and tearing of the posterosuperior labrum. These patients have posterosuperior shoulder pain primarily. Furthermore, these athletes are susceptible to a muscular fatigue syndrome, the SICK (Scapular malposition, Inferior medial border prominence, Coracoid pain and malposition, and dysKinesis of scapular movement) scapula syndrome. This patient has an internal rotation deficit and tenderness over the coracoid. The internal rotation deficit is addressed by stretching the posterior capsule. The tenderness over the coracoid has been attributed to a contracture of the pectoralis minor tendon secondary to scapular malposition. The initial phase of the rehabilitation regimen is directed at stretching the posterior capsule and pectoralis minor tendon. Burkhart SS, Morgan CD, Kibler WB: The disabled throwing shoulder: Spectrum of pathology. Part III. Arthroscopy 2003;19:641-661.

Isolated palsy of the infraspinatus portion of the suprascapular nerve is common in volleyball players and is seen frequently in the throwing arm of baseball players. The exact cause is not known, but it may be the result of either tethering or traction on the nerve at the spinoglenoid notch. Synovial cysts in the spinoglenoid notch also can be a cause, but the patient's negative MRI findings rule out that entity. Because many isolated nerve palsies of the infraspinatus branch are asymptomatic, initial management should always be nonsurgical. Surprisingly, many athletes with this injury can participate fully in sports. Surgical treatment with decompression at the notch is unpredictable and generally is indicated only if nonsurgical management fails. Ferretti A, Cerullo G, Russo G: Suprascapular neuropathy in volleyball players. J Bone Joint Surg Am 1987;69:260-263.

The patient needs to immediately begin an active assisted range-of-motion program emphasizing forward elevation and external rotation to the side. Sling immobilization without stretching for either 3 or 6 weeks will result in severe stiffness that will compromise her ultimate range of motion. Since she has a good quality subscapularis tendon, there is no need to avoid beginning external rotation to the side. However, starting a strengthening program at 3 weeks risks tearing the subscapularis tendon repair. Active strengthening should not begin for 6 weeks postoperatively to allow the subscapularis tendon repair time to heal. Boardman ND III, Cofield RH, Bengston KA, et al: Rehabilitation after total shoulder arthroplasty. J Arthroplasty 2001;16:483-486.

The MRI scan demonstrates a grade III MCL tear. Basic science and clinical studies have shown that nonsurgical management is preferred for MCL tears. Functional rehabilitation and early motion have led to consistently better results than has surgical repair.

Recent evidence has shown that the position of immobilization of the shoulder after a dislocation influences the reduction of the Bankart lesion. In an MRI study in patients who sustained an anterior dislocation, the Bankart lesion was reduced to the glenoid anatomically with the arm in 30 degrees of external rotation. Subsequently, a clinical follow-up study has shown a reduction in recurrence rates when the arm is immobilized in external rotation compared to internal rotation. Itoi E, Hatakeyama Y, Kido T, et al: A new method of immobilization after traumatic anterior dislocation of the shoulder: A preliminary study. J Shoulder Elbow Surg 2003;12:413-415.