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5. Sports Medicine MCQs

Practice Set 66 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 1301

Topic: 5. Sports Medicine
A 35-year-old woman who is a recreational runner reports posterior knee pain and tightness in the knee with flexion during running. She denies any history of trauma. Examination reveals normal patellar glide and tilt and no patellar apprehension. Range of motion is 5 degrees to 120 degrees, and quadriceps function and knee ligamentous examination are normal. Radiographs are normal. What is the most likely diagnosis?
. Baker’s cyst
. Torn medial meniscus
. Patellofemoral pain syndrome
. Lipoma
. Ganglion cyst of the cruciates

Correct Answer & Explanation

. Ganglion cyst of the cruciates

Explanation

DISCUSSION: Ganglia involving the cruciate ligaments have been recently reported as a cause of knee pain that interferes with knee flexion and extension. The symptoms are poorly localized in this patient and not along the medial joint line, making the diagnosis of a torn medial meniscus less likely. A Baker’s cyst is usually posteromedial and extends posterior to the interval between the medial head of the gastrocnemius and semimembranosus.

Question 1302

Topic: Shoulder & Hip Sports

.A patient is unable to actively externally rotate the shoulder when the arm is placed into 90 degrees of abduction and neutral rotation. This finding is most consistent with a tear of the

. biceps tendon.
. isolated subscapularis.
. isolated supraspinatus.
. superior and anterior labrum.
. infraspinatus and teres minor.

Correct Answer & Explanation

. biceps tendon.

Explanation

Question 1303

Topic: 5. Sports Medicine
The parents of a 14-year-old female soccer player are concerned about any future injury. They have been advised that she has the potential to play for the US Olympic team. They are especially concerned about the anterior cruciate ligament (ACL). What should you advise them?
. ACL injuries are more common in men younger than 30 years of age.
. ACL injuries are more common in women younger than 30 years of age.
. ACL injuries are usually the result of contact sports.
. The incidence of ACL injuries can be decreased by a neuromuscular training program.
. ACL injuries are rarely associated with meniscal injury.

Correct Answer & Explanation

. ACL injuries are more common in women younger than 30 years of age.

Explanation

DISCUSSION: ACL injuries are five to eight times more common in young women. The highest incidence is associated with basketball and soccer. These sports require rapid directional and rotational changes. Use of neuromuscular training programs has not been associated with a decrease in ACL injuries. It is recommended that there be more frequent rests. ACL injuries are commonly associated with meniscal injury.

Question 1304

Topic: 5. Sports Medicine
A 17-year-old male soccer player sustains repeated lateral patellar dislocations refractory to physical therapy, bracing, and taping. After a workup including radiographs and MRI, the orthopaedic surgeon considers an isolated tibial tubercle osteotomy (TTO). He plans a 60-degree anteromedialization to address instability and to unload the patellofemoral joint. What is a relative contraindication to this procedure?
. Grade III chondrosis of the proximal patella
. Caton-Deschamps ratio of 1:1
. Tibial tubercle-trochlear groove (TT-TG) distance of 21 mm
. Q angle of 17 degrees

Correct Answer & Explanation

. Grade III chondrosis of the proximal patella

Explanation

DISCUSSION: TTO is a common treatment for patellofemoral instability. The angle of correction must be customized to each patient’s anatomy. For this patient, the orthopaedic surgeon plans an osteotomy that will both anteriorize and medialize the tubercle. This will consistently result in a change of patellofemoral kinematics and contact pressures. Medialization decreases lateral and increases medial patellofemoral contact pressures, and anteriorization shifts contact pressures from distal to proximal. Significant anteriorization may not be desired in a patient with proximal patellar chondrosis unless a concomitant chondral procedure is performed as well. The patellar height (Caton-Deschamps ratio) is normal, precluding the need for distalization but not medialization. The TT-TG distance, at more than 20 mm, is a strong indication for osteotomy. The Q angle, although a less precise indicator of malalignment, is also elevated and would be considered an indication for osteotomy.

Question 1305

Topic: 5. Sports Medicine

A 23-year-old woman has had a 3-year history of snapping and pain in her left hip. She notes that the snapping started while marathon training and is only problematic about 15 minutes into a run. Examination is consistent with a negative Stinchfield, negative logroll, negative flexion abduction/external rotation test (FABER) of the hip; however, she has a positive Ober test as she has difficulty adducting her hip across the midline in the lateral decubitus position. Management consisting of nonsteroidal anti-inflammatory drugs and stretching has failed to improve her snapping. What is the most reliable surgical treatment? Review Topic

. Hip arthroscopy with labral debridement
. Hip arthroscopy with femoral acetabular impingement lesion debridement
. Release of the iliopsoas tendon
. Z-plasty of the iliotibial band
. Release of the iliotibial band at Gerdy's tubercle

Correct Answer & Explanation

. Hip arthroscopy with labral debridement

Explanation

The patient has external-type snapping hip (coxa saltans). It is not uncommon for patients to have a very long duration of symptoms that limit running or other sporting activities, and commonly affects the downward leg (usually the left leg when running on the left side of the road). The snapping causes a profound bursitis at the greater trochanter, and occasionally corticosteroid injections may be helpful. Her physical examination does not suggest an intra-articular process, and is not consistent with an internal-type snapping hip, usually caused by the iliopsoas tendon as it moves over the iliopectineal eminence. Stretching is the mainstay of treatment, as testing with a positive Ober signifies a tight iliotibial band as the thigh has difficulty crossing the midline with adduction. Various iliotibial band lengthening procedures have been described, including a Z-plasty near the proximal origin of the iliotibial band. Release at Gerdy's tubercle has not been described.

Question 1306

Topic: Shoulder & Hip Sports

Figure 1 is the T2 axial MRI scan of a 21-year-old man who was injured while playing for his college football team. His pain was aggravated with blocking maneuvers and alleviated with rest, and he had to stop playing because of the pain. What examination maneuver most likely will reproduce his pain?

. Forward elevation in the scapular plane
. External rotation and abduction
. Flexion, adduction, and internal rotation
. Flexion and abduction

Correct Answer & Explanation

. Forward elevation in the scapular plane

Explanation

This patient has a mechanism of injury and MRI scan consistent with a posterior labral tear and posterior instability. Flexion, adduction, and internal rotation produce a net posterior vector on the glenohumeral joint and should reproduce this patient's symptoms. Pain or instability with the arm elevated in the scapular plane describes an impingement sign. Pain or instability with the arm in external rotation and abduction describes the apprehension sign. Pain or instability with the arm in flexion and abduction is anonspecific finding.

Question 1307

Topic: 5. Sports Medicine
Accurate evaluation of the upper portion of the subscapularis muscle is best accomplished with active internal rotation:
. in adduction and the arm in external rotation.
. in adduction and the arm in neutral rotation.
. with the dorsum of the hand on the buttocks.
. with the dorsum of the hand on the midlumbar level.
. with the palm of the hand pressing against the belly.

Correct Answer & Explanation

. with the palm of the hand pressing against the belly.

Explanation

DISCUSSION: The two tests commonly performed to isolate the internal rotation to the subscapularis muscle are the lift-off test and the belly press test. Electromyographic findings have shown the lift-off test to be more accurate for the lower portion of the subscapularis and the belly press test to be more sensitive for the upper portion.

Question 1308

Topic: 5. Sports Medicine
Figures 5a and 5b show the radiographs of a 21-year-old wrestler who reports that his leg was rolled over while wrestling. The patient has decreased sensation and function in the distribution of the peroneal nerve, and he has absent pulses. What is the most appropriate initial management at this time?
. Acute reconstruction of all ligamentous structures
. Emergency MRI and reconstruction of all ligamentous structures
. Emergency arteriogram followed by MRI
. Emergency surgery with open reduction and repair of all torn structures with vascular surgery available
. Closed reduction in the emergency room and reevaluation of the vascular status

Correct Answer & Explanation

. Closed reduction in the emergency room and reevaluation of the vascular status

Explanation

DISCUSSION: The patient has an acute traumatic anteromedial dislocation of the knee with occlusion of the popliteal artery with a possible tear. Treatment should include reduction and reevaluation of the vascular status. At this time, if pulses are symmetric, observation may be appropriate without surgical intervention of the artery, but documentation with studies would be appropriate. Delayed reconstruction of injured structures is appropriate. REFERENCES: Fanelli GC, Orcutt DR, Edson CJ: The multiple-ligament injured knee: Evaluation, treatment, and results. Arthroscopy 2005;21:471-486. McDonough EB Jr, Wojtys EM: Multiligamentous injuries of the knee and associated vascular injuries. Am J Sports Med 2009;37:156-159. Wascher DC: High-velocity knee dislocation with vascular injury: Treatment principles. Clin Sports Med 2000;19:457-477.

Question 1309

Topic: Knee Sports

A football player injures his knee when he is tackled and falls awkwardly. He does not note any discreet “pop,” but pain prevents him from returning to the game. An effusion is noted the following day and an MRI scan is ordered. Selected images are shown in Figures 1 through 3. Based on these images, physical examination findings likely include

. positive Lachman test, normal posterior drawer, positive pivot shift.
. positive Lachman test, positive posterior drawer, negative pivot shift.
. normal Lachman test, positive posterior drawer, positive pivot shift.
. normal Lachman test, positive posterior drawer, negative pivot shift.

Correct Answer & Explanation

. positive Lachman test, normal posterior drawer, positive pivot shift.

Explanation

The images provided reveal a posterior cruciate ligament (PCL) disruption with an intact anterior cruciate ligament (ACL). Common diagnostic findings for a PCL tear include a positive posterior drawer test, positive reverse pivot shift, positive quadriceps active test, and positive posterior sag. A positive Lachman test, which would indicate a torn ACL, would not be expected to be positive. A false-positive result for a Lachman test can arise with a torn PCL because of the overall increased anterior-posterior translation;this must be avoided by careful attention to initial resting position and station of the knee.

Question 1310

Topic: 5. Sports Medicine
An 18-year-old hockey player sustains an acute anterior shoulder dislocation that requires manual reduction. At arthroscopy, the lesion shown in Figure 24 will be observed in what percent of patients?
. 20% to 30%
. 35% to 45%
. 50% to 60%
. 80% to 95%
. 100%

Correct Answer & Explanation

. 80% to 95%

Explanation

DISCUSSION: The clinical photograph shows an acute capsulolabral avulsion from the anterior glenoid, also referred to as a Perthes-Bankart lesion. In patients who sustain an acute dislocation that requires a manual reduction, this pathologic lesion is observed with high frequency. In several research studies, it has been visualized in 80% to 95% of patients at arthroscopy. REFERENCES: Taylor DC, Arciero RA: Pathologic changes associated with shoulder dislocations: Arthroscopic and physical examination findings in first-time, traumatic anterior dislocations. Am J Sports Med 1997;25:306-311. Baker CL, Uribe JW, Whitman C: Arthroscopic evaluation of acute initial anterior shoulder dislocations. Am J Sports Med 1990;18:25-28.

Question 1311

Topic: Shoulder & Hip Sports

A 41-year-old male truck driver fell off his truck and tried to break his fall by holding on to the side of the door with his left arm. His MRI is depicted in Figures A. Which of the following special tests would most likely be positive on physical examination? Review Topic

. Empty can test
. Hornblower's test
. Belly press test
. External rotation lag sign
. Relocation test

Correct Answer & Explanation

. Empty can test

Explanation

Based on this patient's MRI he has sustained a full-thickness tear of his subscapularis tendon. As a result, he will likely have a positive belly press test on physical exam.While the subscapularis is the largest of the rotator cuff muscles, the relativeprevalence of injuries to the subscapularis tendon has only recently been recognized. The primary function of the subscapularis is to internally rotate the humerus. Patients with such injury often present with anterior shoulder pain, and increased external rotation compared to the contralateral limb. It is often associated with medial subluxation of the long head of biceps. A number of special tests have been developed to help aid in the clinical diagnosis of this injury including the belly press, lift off and bear hug tests.Gerber et al. demonstrated the efficacy of a simple clinical maneuver called the ‘lift-off test’ to reliably diagnose or exclude clinically relevant rupture of the subscapularis tendon in 16 patients.Barth et al. evaluated the diagnostic value of three clinical tests commonly used to diagnose subscapularis tendon tears; the lift-off test, belly-press test, and bear-hug test. They found that the lift-off test was the most difficult for patients to perform. However, when it was performed and found to be positive, it was 74% sensitive of very severe tears. They also found that the bear hug test was the most sensitive of all tests (82%).Figures A shows an axial MRI arthrogram showing a subscapularis tear with dislocation of the biceps tendon. Illustration A demonstrates how to perform the bear hug test.Incorrect Answers:

Question 1312

Topic: 5. Sports Medicine
Which of the following best characterizes the antigenicity of allograft bone?
. Cell surface glycoproteins are primarily responsible for the antigenicity of the graft.
. Fresh grafts have less antigenicity than cryopreserved grafts.
. Immunosupression provides little difference in response to allogenic bone.
. Hematopoietic elements are the primary cells causing antigenic response.
. Lyophilization (freeze-drying) or chemical sterilization does not change the antigenicity of the graft.

Correct Answer & Explanation

. Cell surface glycoproteins are primarily responsible for the antigenicity of the graft.

Explanation

DISCUSSION: Cell surface glycoproteins present in the heterogeneous population of the cells within the graft are primarily responsible for the antigenicity. Macromolecules of the matrix have also been implicated. Cryopreserved grafts have less antigenicity than fresh. Freezing, freeze-drying, or chemical sterilization and antigen extraction of the bone allograft have all been shown to reduce the antigenicity of the graft. Freeze-drying of retroviral-infected cortical bone and tendon does not inactivate retrovirus. Immunosuppression has been shown to decrease response. Hematopoietic elements along with osteogenic, chondrogenic, fibrous, and vascular cells have been shown to be antigenic. REFERENCES: Crawford MJ, Swenson CL, Arnoczky SP, et al: Lyophilization does not inactivate infectious retrovirus in systemically infected bone and tendon allografts. Am J Sports Med 2004;32:580-586. Stevenson S, Li XQ, Davy DT, et al: Critical biological determinants of incorporation of non-vascularized cortical bone grafts: Quantification of a complex process and structure. J Bone Joint Surg Am 1997;79:1-16. Simon SR (eds): Orthopaedic Basic Science. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 277-320.

Question 1313

Topic: Shoulder & Hip Sports

An active 68-year-old woman undergoes an uncomplicated rotator cuff repair with a double-row construct using biocomposite knotless anchors. At her two month follow up, she is noted to have increased shoulder pain, weakness and limited motion. Imaging reveals failure of the rotator cuff repair. What is the most likely mechanism of failure? Review Topic

. Anchor fatigue and breakage
. Anchor pull out from bone
. Suture rupture secondary to anchor eyelet abrasion
. Suture pull out from the repaired tissue
. Infection

Correct Answer & Explanation

. Anchor fatigue and breakage

Explanation

Rotator cuff repair (RCR) failure most commonly occurs from a failure of the repaired tissue to heal with suture anchor pull out from the repaired tissue.The overall complication rate of arthroscopic RCR is roughly 10%. Failed RCR most commonly results from failure to heal (19-94%) secondary to poor rotator cuff tissue, insufficient vascularity or poor bone quality. Other causes of RCR failure include surgical complications (deltoid disruption, infection, foreign body reaction, stiffness, neurologic injury), diagnostic errors (missed lesions of the rotator interval, long head of biceps or subscapularis tear), and technical errors (excessive tension due to lack of proper tissue mobilization, anchor pull out secondary to improper anchor placement).George et al evaluated the causes of failed RCR and results of revision RCR. While results of revision RCR are inferior to primary RCR, arthroscopic repair yields > 60% good or excellent results. Risk factors for poor results following revision RCR include poor tissue quality, detachment of the deltoid origin and multiple previous surgeries.Diduch et al reviewed the design and composition of various anchors used in arthroscopic shoulder surgery. Current advancements in the field include high-strength polyethylene sutures, new biocompatible anchor materials (PEEK, biocomposite) and modified designs including knotless systems. With improved strength of the current anchors and repair constructs, the most common mode of arthroscopic RCR failure is now related to tissue failure occurring at the tissue-anchor interface.Cole et al discussed the different primary rotator cuff repair constructs, including single row, double row, transosseous and transosseous equivalent. The authors concluded that construct selection depends on tear acuity, size and tissue quality. For acute tears < 12mm in anteroposterior length, single-row configuration likely has sufficient strength to maintain the repair and promote healing. For more chronic tears, poor tissue quality, or tears > 12-15mm in the anteroposterior dimension, the authors recommend double-row or transosseous-equivalent repair to better restore the anatomic footprint and provide optimal mechanical stability to achieve healing.Illustration A is an algorithm from George et al detailing the decision-making process when considering revision RCR for a symptomatic failed RCR.Incorrect Responses

Question 1314

Topic: Shoulder & Hip Sports
A 15-year-old wrestler sustains an abduction, hyperextension, and external rotation injury to his right shoulder. The MRI scan findings shown in Figures 27a and 27b are most consistent with
. an avulsion of the lesser tuberosity.
. a midsubstance tear of the capsule.
. a tear of the anterior inferior labrum.
. a tear of the subscapularis.
. a tear of the humeral insertion of the inferior glenohumeral ligament.

Correct Answer & Explanation

. a tear of the humeral insertion of the inferior glenohumeral ligament.

Explanation

DISCUSSION: An isolated avulsion of the lesser tuberosity occurs very rarely and usually is found in 12- and 13-year-old adolescents. The MRI scans reveal a tear of the humeral attachment of the inferior glenohumeral ligament, a so-called HAGL lesion. This injury to the inferior glenohumeral ligament occurs much less commonly than the classic Bankart lesion (anterior inferior labral tear). A tear of the subscapularis occurs with a similar mechanism of injury but generally occurs in older individuals. REFERENCES: Bokor DJ, Conboy VB, Olson C: Anterior instability of the glenohumeral joint with humeral avulsion of the glenohumeral ligament: A review of 41 cases. J Bone Joint Surg Br 1999;81:93-96. Wolf EM, Cheng JC, Dickson K: Humeral avulsion of the inferior glenohumeral ligaments as a cause of anterior shoulder instability. Arthroscopy 1995;11:600-607.

Question 1315

Topic: Knee Sports
A 48-year-old man has recurrent right knee pain. Figure 52a shows the sagittal proton density T2-weighted MRI scan, and Figure 52b shows the sagittal T2-weighted MRI scan at the same level. The arrow is pointing to a
. popliteal cyst.
. posterior cruciate ligament tear.
. torn and displaced posterior horn of the medial meniscus.
. normal meniscofemoral ligament of Humphry.
. normal meniscofemoral ligament of Wrisberg.

Correct Answer & Explanation

. torn and displaced posterior horn of the medial meniscus.

Explanation

DISCUSSION: Meniscal tears have many configurations and locations. The normal medial meniscus has a bow-tie configuration on the two most medial consecutive sagittal views. Toward the center of the joint the anterior and posterior horns have a triangular shape. These images show an abnormal intra-articular low-signal structure located anterior to the intact posterior cruciate ligament. This most likely represents a torn and displaced posterior horn of the medial meniscus, sometimes called “double PCL sign.” A popliteal cyst and ligaments of Wrisberg and Humphry are not visible on these figures. REFERENCES: Helms CA: MR image of the knee, in Fundamentals of Skeletal Radiology, ed 2. Philadelphia, PA, WB Saunders, 1995, pp 172-191. Mink JH, Deutsch AL: The knee, in MRI of the Musculoskeletal System, ed 1. New York, NY, Raven Press, 1990, pp 251-387.

Question 1316

Topic: 5. Sports Medicine
Commotio cordis is best treated with
. immediate cardiac defibrillation.
. the chest thump maneuver.
. IV fluids and hydration.
. epinephrine.
. albuterol inhalers.

Correct Answer & Explanation

. immediate cardiac defibrillation.

Explanation

DISCUSSION: Commotio cordis is a rare but catastrophic condition that is caused by blunt chest trauma. It results in cardiac fibrillation and is universally fatal unless immediate defibrillation is performed. Although case reports of successful use of the chest thump maneuver exist, the best method of treatment is cardiac defibrillation. IV fluids, epinephrine, and albuterol inhalers are used to treat dehydration, anaphylactic shock, and bronchospasm respectively, and are not effective in the treatment of commotio cordis.

Question 1317

Topic: 5. Sports Medicine
When comparing arthroscopic lavage and knee debridement with placebo in patients with chronic symptomatic osteoarthritis, what outcome has been demonstrated?
. Reliable and durable pain relief
. No significant benefit for chronic osteoarthritis
. Up to 75% pain relief for 2 months, then variable response
. Three-month measurable pain relief, followed by recurrence

Correct Answer & Explanation

. No significant benefit for chronic osteoarthritis

Explanation

DISCUSSION: Excluding a diagnosis of meniscal tear, loose body, or mechanical derangement, treating knee osteoarthritis of indeterminate cause with arthroscopic lavage and debridement has been found to provide no discernable benefit to offset the risk of surgery. The effects of arthroscopy have not been clinically significant in the vast majority of patient-oriented outcomes measures for pain and function at multiple times between 1 week and 2 years after surgery.

Question 1318

Topic: 5. Sports Medicine

A 29-year-old man sustained an injury when he was playing basketball, landing on his left knee while jumping for a rebound. He had vague pain in the anterior aspect of the knee for several weeks. The initial radiographs were negative with the exception of a large traumatic effusion. Examination reveals no apparent ligament instability but a significant extension lag of 30 degrees. There was a palpable defect above the superior pole of the patella. What is the most appropriate management? Review Topic

. MRI scan
. Diagnostic arthroscopy
. Surgical repair of a ruptured quadriceps tendon
. Knee immobilizer for 6 weeks, followed by a sport brace
. Limited weight bearing for 3 weeks, followed by physical therapy

Correct Answer & Explanation

. MRI scan

Explanation

This is the classic presentation of a tendon disruption in an active athlete that may represent chronic strain or weakening of the tendon insertion. The factors that lead to this condition are multitude, including biomechanic and cytologic, but there is little evidence that inflammation is an active factor. Surgical treatment is straightforward and logical. Suture anchors have been compared with simple holes made in the patella for suturing the tendon, with no apparent biomechanic advantage.

Question 1319

Topic: Shoulder & Hip Sports
Figures 26a through 26c show the MRI scans of a 47-year-old man who underwent arthroscopic shoulder surgery 6 months ago and continues to have pain despite a prolonged course of rehabilitation. Management should now consist of
. rotator cuff repair.
. revision acromioplasty.
. fragment excision.
. open reduction and internal fixation.
. continued rehabilitation.

Correct Answer & Explanation

. open reduction and internal fixation.

Explanation

The MRI scans show an os acromiale of the mesoacromion type. This represents an unfused acromial apophysis. Pain is thought to be caused by either motion at the site or downward displacement of the anterior aspect of the acromion onto the rotator cuff, causing impingement. Most patients can be treated nonsurgically as they are usually asymptomatic. In those patients with persistent symptoms of pain and tenderness over the acromion, surgery consisting of rigid internal fixation and bone grafting has yielded satisfactory results. Excision may be a viable treatment option for the preacromion type.

Question 1320

Topic: 5. Sports Medicine
The best initial treatment for calcific tendinitis of the shoulder would entail
. physical therapy and nonsteroidal anti-inflammatory medications.
. open biopsy of the lesion for permanent section.
. manipulation under anesthesia.
. shoulder arthroscopy.

Correct Answer & Explanation

. physical therapy and nonsteroidal anti-inflammatory medications.

Explanation

Calcific tendinitis of the shoulder is a deposition of calcium carbonate apatite crystals into the structure of the rotator cuff tendon. The crystalline form appears to progress throughout the clinical disease process, demonstrating increasing matured stoichiometric apatite deposition during the resorptive phase. MRI can be difficult to interpret because the signal of the calcific lesion is frequently similar to that seen in normal supraspinatus tendon. Plain radiographs remain the gold standard for diagnosis. Ultrasound can be a useful ancillary study to determine the location and size of the lesion. Primary management of calcific tendinitis starts with nonsurgical treatment including physiotherapy and injections, if indicated. Mixed results have been reported with extracorporeal shock wave therapy. Surgical removal with repair of the tendon in larger lesions remains the definitive treatment when nonsurgical modalities fail. Subacromial decompression may improve pain relief in patients who require surgery; however, patients with decompression may take longer to fully recover.

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