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5. Sports Medicine MCQs

Practice Set 226 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 4501

Topic: 5. Sports Medicine

A 26-year-old female reports persistent anteromedial ankle pain 6 months after an inversion injury. MRI demonstrates a 1.2 cm by 1.0 cm osteochondral lesion on the medial talar dome with intact overlying cartilage but deep subchondral edema. Conservative management has failed. What is the most appropriate initial surgical treatment?

. Arthroscopic bone marrow stimulation (microfracture)
. Osteochondral autograft transfer system (OATS)
. Autologous chondrocyte implantation (ACI)
. Open medial malleolar osteotomy and retrograde drilling
. Total ankle arthroplasty

Correct Answer & Explanation

. Arthroscopic bone marrow stimulation (microfracture)

Explanation

For primary symptomatic osteochondral lesions of the talus (OCDs) smaller than 1.5 cm in diameter, arthroscopic bone marrow stimulation (microfracture) is the gold standard initial surgical treatment. This technique prompts bleeding and marrow element release, stimulating fibrocartilage (Type I collagen) formation to fill the defect.

Question 4502

Topic: 5. Sports Medicine

A 24-year-old professional rugby player sustains a severe hyperextension injury to his first metatarsophalangeal (MTP) joint. MRI confirms a complete tear of the plantar plate and proximal migration of the sesamoids (Grade 3 Turf Toe). What is the recommended management?

. Taping and immediate return to play
. Stiff-soled shoe with carbon fiber insert for 2 weeks
. Corticosteroid injection into the MTP joint
. Operative repair of the plantar plate and sesamoid complex
. First MTP joint arthrodesis

Correct Answer & Explanation

. Taping and immediate return to play

Explanation

Grade 3 turf toe injuries involve a complete tear of the plantar plate and sesamoid complex. Operative repair is recommended for high-level athletes to restore push-off strength and normal joint kinematics.

Question 4503

Topic: Knee Sports

A 25-year-old woman presents with deep, chronic anterior ankle pain 1 year after a severe inversion sprain. MRI shows a 1.2 cm^2 (10 mm diameter) primary osteochondral lesion of the medial talar dome. Nonoperative management has failed. What is the most appropriate next step?

. Arthroscopic bone marrow stimulation (microfracture)
. Osteochondral autograft transfer (OATS)
. Matrix-induced autologous chondrocyte implantation (MACI)
. Ankle arthrodesis
. Distal tibial osteotomy

Correct Answer & Explanation

. Arthroscopic bone marrow stimulation (microfracture)

Explanation

For symptomatic primary osteochondral lesions of the talus that are less than 1.5 cm^2 (or <15 mm in diameter), arthroscopic debridement and bone marrow stimulation (microfracture) is the first-line surgical treatment.

Question 4504

Topic: 5. Sports Medicine

A 28-year-old male runner presents with chronic, deep ankle pain following an inversion injury 1 year ago. MRI reveals an osteochondral lesion of the medial talar dome measuring 1.8 square centimeters. Non-operative management has failed. Which of the following is the most appropriate surgical intervention for this lesion?

. Arthroscopic bone marrow stimulation (microfracture)
. Osteochondral autograft transfer (OATS)
. Subtalar arthrodesis
. Arthroscopic debridement without osseous intervention
. Total ankle arthroplasty

Correct Answer & Explanation

. Arthroscopic bone marrow stimulation (microfracture)

Explanation

The management of osteochondral lesions of the talus (OLT) depends on the size of the lesion. Arthroscopic bone marrow stimulation (microfracture) is generally indicated for primary, smaller lesions (typically < 1.5 cm^2). For larger lesions (> 1.5 cm^2), structural restoration of the subchondral bone and cartilage is required to achieve a durable clinical outcome. Therefore, osteochondral autograft transfer (OATS) or allograft transplantation is the most appropriate treatment for an OLT measuring 1.8 cm^2.

Question 4505

Topic: 5. Sports Medicine

A 42-year-old recreational basketball player presents with an acute, midsubstance Achilles tendon rupture. The surgeon and patient are discussing operative versus non-operative management, planning to utilize an early functional rehabilitation protocol. Based on Level 1 evidence, the patient should be counseled that non-operative management is associated with which of the following when compared to operative management?

. A significantly higher rate of re-rupture
. Decreased plantarflexion strength at 2-year follow-up
. Similar re-rupture rates but significantly fewer wound complications
. Increased risk of deep vein thrombosis
. A significantly faster return to competitive sports

Correct Answer & Explanation

. A significantly higher rate of re-rupture

Explanation

High-quality Level 1 evidence (such as the landmark Willits et al. trial) demonstrates that when an early functional rehabilitation protocol (early weight-bearing and range of motion) is utilized, the re-rupture rates between operative and non-operative management of acute Achilles tendon ruptures are statistically similar. However, operative management is associated with a significantly higher risk of soft-tissue and wound complications, including infection and sural nerve injury.

Question 4506

Topic: 5. Sports Medicine

A 35-year-old male recreational athlete sustains an acute Achilles tendon rupture. He is discussing operative repair versus non-operative management utilizing a strict early functional rehabilitation protocol. Based on current randomized controlled trials (e.g., Willits et al.), what is the expected difference in outcomes between these two treatment strategies?

. Similar rerupture rates, but a higher rate of wound complications with operative management
. Significantly higher rerupture rate with non-operative management
. Significantly decreased plantarflexion strength with non-operative management
. Better validated patient-reported outcome scores with operative management
. Lower risk of sural nerve injury with operative management

Correct Answer & Explanation

. Similar rerupture rates, but a higher rate of wound complications with operative management

Explanation

Current high-level evidence, including the landmark study by Willits et al., demonstrates that when an early functional rehabilitation protocol (early weight-bearing and range of motion) is employed, there is no statistically significant difference in rerupture rates, functional outcomes, or plantarflexion strength between operative and non-operative management of acute Achilles tendon ruptures. However, operative management carries a significantly higher risk of complications, primarily related to wound healing and infection.

Question 4507

Topic: 5. Sports Medicine

A 28-year-old woman presents with persistent anterolateral ankle pain 1 year after a severe inversion injury. MRI demonstrates a 1.8 cm^2 osteochondral lesion of the anterolateral talar dome with deep subchondral cystic changes. She has failed a 6-month trial of conservative management. What is the most appropriate surgical treatment?

. Arthroscopic debridement and marrow stimulation (microfracture)
. Conservative management with prolonged cast immobilization
. Retrograde drilling of the talus
. Osteochondral autograft transfer (OATS)
. Ankle arthrodesis

Correct Answer & Explanation

. Arthroscopic debridement and marrow stimulation (microfracture)

Explanation

Osteochondral lesions of the talus (OLT) that are large (> 1.5 cm^2) or associated with significant subchondral cystic changes have a high failure rate with marrow stimulation techniques like microfracture. For large or cystic lesions, structural bone grafting and cartilage restoration via an osteochondral autograft transfer system (OATS) or fresh osteochondral allograft is indicated to restore the articular contour and provide structural support.

Question 4508

Topic: 5. Sports Medicine

A 28-year-old woman presents with persistent deep ankle pain following an inversion ankle sprain 6 months ago. MRI reveals an osteochondral lesion on the posteromedial aspect of the talar dome measuring 8 mm x 8 mm (64 mm^2), with intact overlying cartilage and no significant subchondral cystic changes. Conservative management has failed. What is the most appropriate next step in management?

. Osteochondral autograft transfer system (OATS)
. Arthroscopic bone marrow stimulation (microfracture)
. Fresh osteochondral allograft
. Matrix-induced autologous chondrocyte implantation (MACI)
. Conservative management with a CAM boot for an additional 6 months

Correct Answer & Explanation

. Osteochondral autograft transfer system (OATS)

Explanation

For symptomatic osteochondral lesions of the talus (OLT) that are less than 1.5 cm^2 (150 mm^2) and lack extensive subchondral cysts, arthroscopic bone marrow stimulation (microfracture) is the gold standard first-line surgical treatment. OATS or structural allografts are typically reserved for larger lesions (>1.5 cm^2), lesions with large cysts, or those that have failed prior microfracture.

Question 4509

Topic: 5. Sports Medicine

A 35-year-old male weekend warrior sustained an acute Achilles tendon rupture 2 days ago. He prefers nonoperative management but asks about the risks compared to surgery. According to recent high-level evidence, what is the most significant difference between operative and nonoperative management when an early functional rehabilitation protocol is employed?

. Increased rate of re-rupture with nonoperative management
. Decreased rates of deep vein thrombosis with operative management
. Increased risk of soft tissue complications with operative management
. Earlier return to baseline sports with operative management
. Significantly higher patient-reported outcome measures at 2 years with operative management

Correct Answer & Explanation

. Increased rate of re-rupture with nonoperative management

Explanation

According to multiple randomized controlled trials (e.g., Willits et al.), when early functional rehabilitation protocols are utilized, the re-rupture rates between operative and nonoperative management of acute Achilles tendon ruptures are statistically similar. However, operative management is associated with a significantly higher risk of soft-tissue complications, including infection and wound breakdown. Functional outcomes and return to sports rates are generally equivalent when early motion is instituted.

Question 4510

Topic: 5. Sports Medicine

A 26-year-old professional football player presents after a severe hyperextension injury to his great toe. He has significant plantar ecchymosis, swelling, and gross instability with resisted plantarflexion of the first MTP joint. MRI confirms a complete tear of the plantar plate with proximal retraction of the sesamoids. Which of the following is the most appropriate management?

. Short leg cast with toe spica for 3 weeks
. Stiff-soled shoe and immediate weight-bearing
. Corticosteroid injection into the MTP joint and taping
. Surgical repair of the plantar plate
. Excision of the bipartite sesamoid

Correct Answer & Explanation

. Short leg cast with toe spica for 3 weeks

Explanation

Turf toe is a sprain of the first MTP joint plantar plate, typically resulting from a severe hyperextension injury. Grade 3 injuries involve a complete disruption of the plantar plate complex, manifesting with gross instability, weakness in push-off, and proximal retraction of the sesamoids on imaging. In competitive athletes, surgical repair of the plantar plate is indicated to restore function, push-off strength, and prevent chronic MTP joint instability, progressive deformity, and early osteoarthritis.

Question 4511

Topic: Knee Sports

A 28-year-old male runner presents with chronic, deep anterolateral ankle pain following a severe inversion injury 18 months ago. Non-operative management, including immobilization and physical therapy, has failed. MRI reveals a 1.8 square centimeter osteochondral lesion on the lateral talar dome with underlying subchondral cysts measuring 5 mm in depth. Which of the following is the most appropriate surgical treatment?

. Arthroscopic bone marrow stimulation (microfracture)
. Osteochondral autograft transfer (OATS)
. Arthroscopic debridement alone
. Retrograde drilling
. Matrix-induced autologous chondrocyte implantation (MACI) without bone grafting

Correct Answer & Explanation

. Arthroscopic bone marrow stimulation (microfracture)

Explanation

The management of osteochondral lesions of the talus (OLT) depends on the size of the lesion and the presence of subchondral cysts. While arthroscopic bone marrow stimulation (microfracture) is the first-line surgical treatment for lesions smaller than 1.5 square centimeters without significant cystic changes, larger lesions (> 1.5 square centimeters) and those with deep subchondral cysts are better treated with structural bone grafting to restore the subchondral architecture. Osteochondral autograft transfer (OATS) provides a viable hyaline cartilage surface and addresses the subchondral bony defect simultaneously.

Question 4512

Topic: 5. Sports Medicine

A 35-year-old woman presents with deep, aching, posteromedial ankle pain. She denies any specific traumatic event. MRI demonstrates an osteochondral lesion of the posteromedial talar dome measuring 1.8 square centimeters with underlying cystic changes. She has failed 6 months of non-operative management including immobilization and physical therapy. What is the most appropriate surgical intervention?

. Arthroscopic bone marrow stimulation (microfracture)
. Arthroscopic retrograde drilling
. Osteochondral autograft transfer (OATS)
. Arthroscopic debridement and platelet-rich plasma (PRP) injection
. Subchondroplasty without articular debridement

Correct Answer & Explanation

. Arthroscopic bone marrow stimulation (microfracture)

Explanation

The management of osteochondral lesions of the talus (OLT) depends significantly on the size and characteristics of the lesion. Arthroscopic bone marrow stimulation (microfracture) is generally indicated as first-line surgical treatment for lesions smaller than 1.5 square centimeters. For larger lesions (> 1.5 square centimeters) or those with significant subchondral cystic changes, structural restoration is required because microfracture has a high failure rate in this scenario. Osteochondral autograft transfer (OATS) or structural allograft provides viable hyaline cartilage and structural bone to fill the defect. Retrograde drilling is reserved for intact cartilage with underlying cysts.

Question 4513

Topic: Shoulder & Hip Sports

A 28-year-old competitive swimmer presents with recurrent anterior shoulder dislocations. He has failed a supervised physical therapy program. On examination, he has generalized ligamentous laxity (Beighton score 6/9) and full external rotation with the arm abducted 90 degrees (apprehension test negative in this position). He is concerned about his long-term ability to return to swimming. Which of the following surgical interventions is MOST appropriate to recommend?

. Arthroscopic Bankart repair
. Open Bankart repair with capsular shift
. Latarjet procedure
. Remplissage procedure with Bankart repair
. Inferior capsular shift alone

Correct Answer & Explanation

. Arthroscopic Bankart repair

Explanation

The patient's generalized ligamentous laxity and failure of conservative management for recurrent anterior shoulder dislocations suggest a need for bony augmentation, especially in a high-demand athlete. The negative apprehension test in abduction and external rotation despite recurrent dislocations is a red flag for significant bony loss (either glenoid or humeral). While Bankart repair addresses soft tissue, it has higher failure rates in patients with significant bone loss or hyperlaxity. The Latarjet procedure provides a bone block that increases the anterior-inferior glenoid articular arc, thereby augmenting the "inverted pear" glenoid deficiency and creating a conjoint tendon sling effect. This is particularly effective in cases with significant glenoid bone loss (>20%) or engaging Hill-Sachs lesions, and in hyperlax patients or those involved in high-impact overhead sports, where standard soft-tissue repairs are prone to failure. Remplissage addresses Hill-Sachs, but without addressing potential glenoid bone loss it may not be sufficient for a high-demand, hyperlax individual. Open Bankart with capsular shift is good for multidirectional instability, but recurrent anterior dislocations with hyperlaxity often benefit more from bony stabilization.

Question 4514

Topic: Shoulder & Hip Sports

A 22-year-old female presents with bilateral, atraumatic shoulder instability. She describes a sensation of the shoulder "slipping out" in multiple directions, often spontaneously or with minimal provocation. On examination, she exhibits a positive sulcus sign, hyperlaxity, and pain with posterior and inferior loading. She has failed a comprehensive rotator cuff and periscapular strengthening program. What is the MOST appropriate surgical intervention?

. Anterior Bankart repair
. Posterior Bankart repair
. Thermal capsulorrhaphy
. Inferior capsular shift (open or arthroscopic)
. Latarjet procedure

Correct Answer & Explanation

. Anterior Bankart repair

Explanation

The patient's presentation of atraumatic, bilateral instability with a positive sulcus sign and generalized hyperlaxity, refractory to conservative management, is characteristic of multidirectional instability (MDI). The primary pathology in MDI is capsular laxity. The goal of surgical intervention for MDI is to reduce capsular volume and tighten the capsule. An inferior capsular shift (either open or arthroscopic) is the gold standard procedure for MDI, as it effectively addresses the redundant capsule in all directions, particularly inferiorly and posteriorly, depending on the shift's direction. Isolated anterior or posterior Bankart repairs are for unidirectional instability. Thermal capsulorrhaphy has largely been abandoned due to poor long-term outcomes and potential for nerve damage and capsular necrosis. The Latarjet procedure is for anterior instability with significant glenoid bone loss.

Question 4515

Topic: Shoulder & Hip Sports

A 35-year-old volleyball player complains of chronic, deep, dull posterior shoulder pain and weakness with overhead activity. He denies any acute injury. Examination reveals atrophy of the infraspinatus muscle and weakness with external rotation. Sensory examination is normal. What is the MOST likely diagnosis?

. Rotator cuff tear
. Adhesive capsulitis
. Long thoracic nerve palsy
. Suprascapular nerve entrapment
. Axillary nerve palsy

Correct Answer & Explanation

. Rotator cuff tear

Explanation

The patient's symptoms of chronic posterior shoulder pain, infraspinatus atrophy, and weakness with external rotation (and often abduction) are classic for suprascapular nerve entrapment. The suprascapular nerve supplies both the supraspinatus (abduction and external rotation) and infraspinatus (external rotation) muscles. Entrapment can occur at the suprascapular notch or spinoglenoid notch. Atrophy of the infraspinatus specifically points to distal entrapment at the spinoglenoid notch (sparing the supraspinatus if proximal to its innervation), but overall, it's a strong indicator. A rotator cuff tear could cause similar pain and weakness, but atrophy might be less pronounced early on, and nerve conduction studies would differentiate. Adhesive capsulitis involves global stiffness. Long thoracic nerve palsy affects the serratus anterior (winging scapula). Axillary nerve palsy affects the deltoid and teres minor (loss of abduction beyond 15 degrees and external rotation), leading to deltoid atrophy, not infraspinatus.

Question 4516

Topic: Knee Sports

A 14-year-old male baseball pitcher presents with chronic lateral elbow pain, clicking, and occasional locking. Radiographs show a lesion on the capitellum with an intact overlying articular cartilage. MRI confirms an osteochondritis dissecans (OCD) lesion of the capitellum, demonstrating a stable fragment. He has failed conservative management. What is the MOST appropriate surgical intervention?

. Loose body removal
. Debridement and microfracture
. Open reduction and internal fixation of the fragment
. Drilling of the lesion
. Total elbow arthroplasty

Correct Answer & Explanation

. Loose body removal

Explanation

For a stable osteochondritis dissecans (OCD) lesion of the capitellum in an adolescent athlete that has failed conservative management, surgical drilling (arthroscopic or open) is often the initial intervention. Drilling aims to stimulate revascularization and healing of the subchondral bone, facilitating integration of the fragment. Debridement and microfracture are typically for unstable or fragmented lesions where the cartilage is damaged or detached. Loose body removal is indicated if the fragment has completely detached and is causing locking. ORIF is reserved for large, unstable, but salvageable fragments. Total elbow arthroplasty is not indicated in a young patient with an OCD lesion.

Question 4517

Topic: 5. Sports Medicine

A 40-year-old active construction worker presents with chronic pain and instability of his right acromioclavicular (AC) joint following a Rockwood Type III injury 6 months ago. He complains of inability to perform overhead tasks and persistent deformity. He has failed extensive physical therapy. Which of the following surgical procedures is MOST likely to provide durable stability and improve function?

. Distal clavicle excision (Mumford procedure)
. Arthroscopic debridement of the AC joint
. Coracoclavicular (CC) ligament reconstruction with autograft or allograft
. AC joint arthrodesis
. Subacromial decompression

Correct Answer & Explanation

. Distal clavicle excision (Mumford procedure)

Explanation

While some Rockwood Type III AC joint injuries can be managed non-operatively, chronic symptomatic instability and deformity, especially in a high-demand individual, warrants surgical intervention. Distal clavicle excision (Mumford procedure) addresses AC joint pain by removing the arthritic joint surfaces but does not restore stability. For chronic symptomatic instability of a Type III (or higher) injury, particularly if functional deficits persist, reconstruction of the coracoclavicular (CC) ligaments using autograft (e.g., semitendinosus) or allograft is the most common and effective procedure to restore horizontal and vertical stability of the AC joint. Arthroscopic debridement is insufficient. AC joint arthrodesis provides stability but sacrifices motion. Subacromial decompression is for impingement, not AC joint instability.

Question 4518

Topic: Shoulder & Hip Sports

A 16-year-old male presents with recurrent anterior shoulder dislocations. He has a history of a seizure disorder, which is poorly controlled. After his most recent seizure, he sustained another dislocation. Radiographs show a large bony Bankart lesion and a significant Hill-Sachs lesion. Given his history, which surgical intervention is MOST appropriate?

. Arthroscopic Bankart repair
. Open Bankart repair with capsular shift
. Latarjet procedure
. Remplissage procedure with Bankart repair
. Conservative management with seizure control

Correct Answer & Explanation

. Arthroscopic Bankart repair

Explanation

Recurrent anterior shoulder dislocations in a patient with a seizure disorder are particularly challenging because the powerful, uncontrolled muscle contractions during seizures place extreme stress on the shoulder, often leading to large bony defects (Bankart and Hill-Sachs). Soft tissue repairs (arthroscopic or open Bankart) have a very high failure rate in this population. The Latarjet procedure, which involves transferring the coracoid process with its attached conjoined tendon to the anterior-inferior glenoid, provides significant bony augmentation to the glenoid, thus preventing engagement of the Hill-Sachs lesion and creating a dynamic sling effect. This bony stabilization is crucial for patients with seizure disorders who are at very high risk for recurrence. Remplissage addresses Hill-Sachs but does not augment the glenoid directly. Conservative management alone is unlikely to be effective given recurrent dislocations.

Question 4519

Topic: Shoulder & Hip Sports

A 65-year-old male presents with a massive, retracted rotator cuff tear (supraspinatus, infraspinatus, partial subscapularis). MRI shows significant fatty infiltration (Goutallier Grade 3-4) in the retracted muscles. He has pain and weakness, but no significant glenohumeral arthritis. He is otherwise healthy. Which of the following is considered a relative contraindication to primary rotator cuff repair?

. Patient age greater than 60
. Partial tear of the subscapularis
. Significant retraction of the rotator cuff
. Goutallier Grade 3 or 4 fatty infiltration
. Presence of a concomitant biceps tendon lesion

Correct Answer & Explanation

. Patient age greater than 60

Explanation

While all options can influence surgical decision-making, Goutallier Grade 3 or 4 fatty infiltration (meaning greater than 50% fat within the muscle belly) is considered a strong predictor of poor healing and a relative contraindication to primary rotator cuff repair. Significant fatty infiltration indicates muscle degeneration and atrophy, which severely compromises the ability of the muscle to heal and function, even if the tear can be physically repaired. Patient age alone is not a contraindication. Partial subscapularis tears are often addressed. Significant retraction makes repair more challenging but not impossible. A biceps lesion is often addressed concurrently (tenotomy/tenodesis).

Question 4520

Topic: 5. Sports Medicine

A 28-year-old professional football player sustains an acute Grade III acromioclavicular (AC) joint separation. He desires to return to play as soon as possible. On examination, he has significant pain, deformity, and tenderness over the AC joint. What is the MOST appropriate treatment approach for this athlete?

. Conservative management with sling immobilization and early physical therapy
. Distal clavicle excision
. Open reduction and internal fixation with CC screw fixation
. Coracoclavicular ligament reconstruction (arthroscopic or open)
. AC joint arthrodesis

Correct Answer & Explanation

. Conservative management with sling immobilization and early physical therapy

Explanation

A Rockwood Type III AC joint separation involves complete disruption of the AC ligaments and partial disruption of the CC ligaments. While non-operative management is often successful for Type III injuries in the general population, for a high-demand overhead athlete who desires early return to competition, surgical intervention is often favored to restore anatomical stability and prevent chronic symptoms (pain, weakness, fatigue, apprehension). Coracoclavicular ligament reconstruction (either arthroscopic or open, using allograft or autograft, often combined with AC ligament repair) is the most common surgical approach for acute Type III (and higher) injuries in this specific population. Distal clavicle excision is for chronic pain/arthritis. ORIF with CC screw fixation is less common now due to hardware complications and superior reconstruction techniques. AC joint arthrodesis is a salvage procedure.

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