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 1321
Topic: Knee Sports
Figure 51 shows an arthroscopic view of the patellofemoral joint from an inferolateral portal. The arrow points to which of the following structures?
Correct Answer & Explanation
. Plica
Explanation
Synovial folds or plicae are the result of incomplete or partial resorption of the synovial membranes during fetal development of the knee. The arthroscopic view shows a medial patellar plica, which has been noted in 5% to 55% of all individuals but becomes symptomatic in only a small number of patients. Symptoms may include crepitus, pain, snapping, and swelling and often respond to nonsurgical management.
Question 1322
Topic: Shoulder & Hip Sports
Based on the injury shown on the axial MRI scan of the shoulder in Figure 1, what other pathology should be closely examined for during surgery?
Correct Answer & Explanation
. Subscapularis tear
Explanation
The axial MRI scan reveals a subluxated biceps tendon. In the study by Koh and associates, 85% of patients with a biceps subluxation on MRI were found to have a subscapularis tear at the time of arthroscopy. These are not always obvious on the MRI, and close inspection of the leading edge/upper border of the subscapularis tendon at the time of arthroscopy is necessary.
Question 1323
Topic: Shoulder & Hip Sports
A 52-year-old man has had right shoulder pain in the deltoid region that increases at night for the past 2 months. He denies any history of trauma. Examination reveals mild tenderness over the greater tuberosity, and the Neer and Hawkins impingement signs are positive. AP and outlet lateral radiographs are shown in Figures 24a and 24b. Initial management should consist of
Correct Answer & Explanation
. a program of stretching exercises and rotator cuff strengthening exercises.
Explanation
The patient has the findings of classic subacromial impingement. Initial management should consist of stretching exercises directed at the posterior capsule and a program of rotator cuff and deltoid strengthening exercises performed below the horizontal in a “safe” plane. The judicious use of subacromial cortisone injections (one or two) may be helpful. Anterior acromioplasty is reserved for patients who have failed to respond to nonsurgical management.
Question 1324
Topic: Shoulder & Hip Sports
Which of the following patients has the highest risk of developing recurrent instability after an arthroscopic Bankart procedure for anterior shoulder instability? Review Topic
Correct Answer & Explanation
. year old female, recreational soccer player with ligamentous laxity and an x-ray showing a Hill-Sachs lesion and loss of glenoid contour
Explanation
The 18-year old competitive tennis player with no ligamentous laxity and x-ray findings consistent with a Hill-Sachs lesion and loss of glenoid contour has an instability severity index score (ISIS) of 9, which is associated with a >70% chance of recurrent instability after a arthroscopic Bankart procedure.The surgical management of anterior shoulder instability consists of both arthroscopic and open approaches. The guiding principles for treatment are the restoration of the normal glenoid labrum anatomy and retensioning of the inferior glenohumeral ligament which is achieved via soft-tissue reconstructions (repair of any labral detachment +/- capsular shift) or bony procedures (such as transfer of the coracoid process).Ahmed et al. reviewed 302 patients who had undergone arthroscopic Bankart repair and capsular shift for the treatment of recurrent anterior glenohumeral instability. The prevalence of patient and injury-related risk factors for recurrence was assessed. The rate of recurrent glenohumeral instability after arthroscopic Bankart repair and capsular shift was 13.2%. The risk of recurrence was independently predicted by the patient’s age at surgery, the severity of glenoid bone loss, and the presence of an engaging Hill-Sachs lesion.Balg et al. identified risk factors for recurrent instability after arthroscopic Bankart procedure in 131 consecutive patients. Age under 20 years at the time of surgery; involvement in competitive or contact sports or those involving forced overhead activity; shoulder hyperlaxity; a Hill-Sachs lesion present on an AP radiograph of the shoulder in external rotation and/or loss of the sclerotic inferior glenoid contour were all identified as risk factors. These factors were integrated into a 10-point preoperative instability severity index score (ISIS). Patients with a score over 6 points had an unacceptable recurrence risk of 70%.Illustration A summarizes the components of the ISIS as developed by Balg and Boileau.Incorrect Answers:
Question 1325
Topic: 5. Sports Medicine
An 18-year-old high school football player exits the field after making a tackle on the opening kickoff. He reports “feeling out of it” and states that he has a headache. He does not recall any loss of consciousness and has no amnesia. He is unable to list the months of the year in reverse order on questioning. He does not return to the game and feels normal at the completion of the game. What is the most sensitive test in assessing deficits after mild traumatic brain injury?
Correct Answer & Explanation
. Neuropsychologic testing
Explanation
Most imaging studies in mild traumatic brain injury will be normal. Neuropsychologic testing is the most sensitive test in assessing mild deficits after traumatic brain injury. Sideline assessment is important but less sensitive in assessing deficits. The precise role of neuropsychologic testing in determining return to play has not been fully defined.
Question 1326
Topic: Knee Sports
A 12.5-year-old boy reports intermittent knee pain and limping that interferes with his ability to participate in sports. He actively participates in football, basketball, and baseball. He denies any history of injury. Examination shows full range of motion without effusion. Radiographs reveal an osteochondritis dissecans (OCD) lesion on the lateral aspect of the medial femoral condyle. MRI scans are shown in Figures 14a and 14b. Initial treatment should consist of:
Correct Answer & Explanation
. Activity modification
Explanation
This skeletally immature patient has a small OCD lesion that appears stable, and he has not undergone any treatment. Therefore, a trial of activity modification and limited weight bearing until pain resolves is the best initial choice. Cessation of sport activities for 4 to 6 months may allow healing of the lesion. Surgical treatment of juvenile OCD lesions is reserved for unstable lesions, patients who have not shown radiographic evidence of healing and are still symptomatic after 6 months of nonsurgical management, or patients who are approaching skeletal maturity.
Question 1327
Topic: 5. Sports Medicine
When obtaining grafts from a trochlear donor site during an osteochondral autograft transplantation procedure, where on the trochlea are the lowest contact pressures found? Review Topic
Correct Answer & Explanation
. Distal/medial
Explanation
Patellofemoral contact pressure studies have shown that the lowest contact pressures during a functional range of motion of the knee (0 degrees to 110 degrees) are located on the distal/medial surface of the trochlea. However, before a final donor site location is chosen, additional considerations include the size of the defect (the distal/medial location may not provide sufficient surface area for larger lesions) and the curvature of the recipient surface (the distal/medial surface is convex whereas the intercondylar notch is saddle-shaped).
Question 1328
Topic: Shoulder & Hip Sports
A 21-year-old patient has had pain and a marked decrease in active and passive shoulder motion after having had a seizure 2 months ago as the result of alcohol abuse. Current AP and axillary radiographs and a CT scan are shown in Figures 26a through 26c. Management should consist of:
Correct Answer & Explanation
. open reduction and subscapularis and lesser tuberosity transfer.
Explanation
Open reduction and subscapularis and lesser tuberosity transfer into the defect is the treatment of choice in young individuals who have defects that involve between 20% to 45% of the head. Disimpaction and bone grafting is an option in injuries that are less than 3 weeks old. Closed reduction 2 to 3 months after injury usually is unsuccessful and increases the risk of fracture or neurovascular injury. Total shoulder arthroplasty is reserved for defects of greater than 50% or with associated glenoid surface damage. Hemiarthroplasty should be avoided in young individuals unless 50% or more of the head is involved.
Question 1329
Topic: Shoulder & Hip Sports
What procedure can eliminate a sulcus sign? Review Topic
Correct Answer & Explanation
. Rotator interval closure
Explanation
A sulcus sign represents inferior subluxation of the shoulder. The elimination of this sign and correction of the inferior subluxation is best achieved through either an open or arthroscopic rotator interval closure. A SLAP repair stabilizes the biceps anchor but does not affect the sulcus sign. A Bankart repair, which corrects anterior-inferior laxity, is not sufficient to eliminate a sulcus sign. Subacromial decompression and supraspinatus repairs have no effect on inferior subluxation.
Question 1330
Topic: 5. Sports Medicine
Figure 41 shows the MRI scan of a 38-year-old weightlifter. What does the arrow on the MRI scan indicate?
Correct Answer & Explanation
. Pectoralis major tear
Explanation
Pectoralis major ruptures typically occur in avid weightlifters (often on supplements) and typically while bench-pressing. Clinically there is significant discoloration/bruising over the pectoralis and into the axilla. MRI helps confirm the diagnosis and may help determine if the tear is in the muscle belly or at the bone-tendon junction.
Question 1331
Topic: 5. Sports Medicine
A 22-year-old man reports anterior knee pain, swelling, and is unable to perform a straight leg raise after undergoing endoscopic anterior cruciate ligament (ACL) reconstruction with a bone-patellar tendon-bone autograft 1 week ago. He is afebrile. Examination reveals a clean incision, moderate effusion, a weak isometric quadriceps contraction, active knee range of motion of 5 degrees to 45 degrees, and the patella is ballottable. Knee radiographs show postoperative changes with good femoral and tibial tunnel placements, and normal patellar height. What is the next most appropriate step in management?
Correct Answer & Explanation
. Knee aspiration
Explanation
DISCUSSION: Knee pain and swelling in the first week after ACL reconstruction is usually related to a postoperative hemarthrosis. A large hemarthrosis creates capsular distension, which inhibits active quadriceps contraction by a neurologic reflex, the H. reflex. Kennedy and associates reported that an experimentally induced knee effusion at 60 mL was found to result in profound inhibition of reflexly evoked quadriceps contraction. Removal of the hemarthrosis by aspiration will improve strength and often instantaneously restore the ability to contract the quadriceps muscle. A large effusion will also limit knee flexion. EMG and NCVS are not necessary unless there is a high index of suspicion of a femoral neuropathy. Diagnostic ultrasonography is not necessary in this patient but can be useful in the assessment of patellar tendon integrity. MRI is not indicated and would most likely be limited by artifact and postoperative changes. Continuous passive motion is not indicated and would most likely worsen the patient’s symptoms. REFERENCES: Kennedy JC, Alexander IJ, Hayes KC: Nerve supply of the human knee and its functional importance. Am J Sports Med 1982;10:329-335. Fahrer H, Rentsch HU, Gerber NJ, et al: Knee effusion and reflex inhibition of the quadriceps: A bar to effective retraining. J Bone Joint Surg Br 1988;70:635-638.
Question 1332
Topic: 5. Sports Medicine
Which of the following is not considered to be a part of the constellation of the clinical entities known as the female athlete triad? Review Topic
Correct Answer & Explanation
. Thyroid dysfunction
Explanation
Thyroid dysfunction is not one of the clinical entities included in the female athlete triad.The female athlete triad was coined in 1992 by the American College of Sports Medicine as a complex disorder more prevalent in the adolescent and young femaleathlete population including decreased bone mineral density (BMD), menstrual dysfunction, and low energy availability with or without a concomitant eating disorder. Treatment should involve a multidisciplinary approach, including psychological and nutritional counseling for eating behaviors and dietary management, reduction of training intensity to decrease risk of stress fractures, and initiating calcium and vitamin D supplements for osteoporosis.Nazem et al performed a systematic review of articles containing the female athlete triad, reviewing diagnosis via screening during physical examinations as well as laboratory and imaging evaluation for menstrual dysfunction, low energy availability, and low bone mineral density. They state that potential complications including possible infertility, decreased immune function, cardiovascular disease, and irreversible loss of bone mineral density. They concluded that prevention, early recognition, and a multidisciplinary treatment team with a focus on proper nutrition and natural return of menses is vital.Nattiv et al review the position of the American College of Sports Medicine regarding the female athlete triad, including screening for the triad at the pre-participation physical, discouragement of unhealthy weight loss practices. Essential members of the multidisciplinary treatment team include a health-care professional, a registered dietitian, and a mental health practitioner. They endorse that the first aim of treatment for any triad component is to increase energy availability by increasing energy intake and reducing exercise energy expenditure.
Question 1333
Topic: Knee Sports
A 20-year-old basketball player sustains a knee injury during a game and is seen in the orthopaedic clinic 3 days after injury. Examination reveals a positive Lachman, pivot shift, joint line tenderness, and moderate effusion. Which of the following tissue injuries is most likely causing the jointline tenderness? Review Topic
Correct Answer & Explanation
. Lateral meniscus tear
Explanation
The physical examination findings are consistent with an acute anterior cruciate ligament tear. In the acute setting, a lateral meniscus tear is a more common secondary injury than a medial meniscus tear. In one study of acute anterior cruciate ligament tears in alpine skiers, the incidence of lateral meniscus tears was over four times that of medial meniscus tears. Medial meniscus tears are more common in the chronic setting, most likely secondary to its role as a secondary restraint.
Question 1334
Topic: 5. Sports Medicine
A radiologist's report of a lateral knee radiograph comments that the height of the patella is 4 cm, and the length of the patellar tendon is 3 cm. Which of the following may lead to this measurement? Review Topic
Correct Answer & Explanation
. Quadriceps tendon rupture
Explanation
The question describes a knee with patella baja, which would likely be seen in the presence of a quadriceps tendon rupture.The measurements described allow you measure an Insall-Salvati Index (ISI). The ISI is the ratio of the patellar tendon length to the patellar height (distance from the superior pole to the inferior pole). These measurements give a ratio of 0.75 which indicates the presence of patella baja. Normal values range from 0.8 to 1.2. A lower ratio is diagnostic of patella baja, while a higher ratio is diagnostic of patella alta. The ISI as well as some other measures of the patella's position within the trochlea are important when evaluating conditions such as patellar instability or patellofemoralpain.Insall and Salvati present their original paper describing the anatomy of the knee with respect to patellar positioning. They note that previous methods of determining patellar positioning was either too complicated, or too subjective. They found the length of the patellar tendon and the height of the patella to be approximately equal, and saw no variations greater than 20%. Thus they proposed the ISI with "normal" values ranging from 0.8 to 1.2.Shabshin et al. present a study making similar calculations as the ISI but done on sagittal MRI rather than lateral radiographs. They found a slightly higher degree of variation, and defined "normal" as ranging from 0.79 to 1.52. They also noted females tended to have higher ratios on average compared to males.Aglietti et al. compared various measurements of the patellofemoral joint in a group of asymptomatic knees compared to knees with recurrent patellar subluxation. The normal knees were found to have an ISI of about 1, average congruence angle of -8, and an average Q angle of 15°. The subluxating knees had higher ISIs (average 1.23), higher congruence angles (average +16), and a higher Q angles (average 20°).Illustration A shows how to measure and calculate the ISI. Illustration B shows measurements of the patellofemoral joint that may help identify presence of trochlear dysplasia and patellar maltracking.Incorrect Answers:
Question 1335
Topic: 5. Sports Medicine
What is the etiology of this patient’s problem?
Correct Answer & Explanation
. Overuse condition
Explanation
Little leaguer’s shoulder is an overuse condition of the proximal humeral physis. Patients report diffuse pain that is worse with throwing. Factors that contribute to the condition include excessive throwing, improper throwing mechanics, and muscle-tendon imbalance. Radiographs usually show widening of the proximal humeral physis, and, in more severe cases, metaphyseal demineralization or fragmentation. Surgical fixation is not required for healing. Treatment involves rest until symptoms resolve, followed by initiation of an interval throwing program. Pitching coaches should evaluate throwing mechanics and maintain pitch counts. The dominant shoulders of throwing athletes undergo adaptive changes, resulting in increased external rotation and decreased internal rotation. These changes occur secondary to soft-tissue and bony adaptations, including increased humeral retroversion.
Question 1336
Topic: Knee Sports
Failure of posterolateral corner repair or reconstruction of the knee may be associated with which of the following? Review Topic
Correct Answer & Explanation
. Varus malalignment
Explanation
Failure to reconstruct a torn anterior cruciate ligament or posterior cruciate ligament at the time of posterolateral corner (PLC) repair or reconstruction dramatically increases the likelihood of PLC failure. Uncorrected varus malalignment places extensive tension on a PLC reconstruction and is a well recognized cause of failure. Valgus malalignment and medial collateral ligament reconstruction are not recognized means of failure.
Question 1337
Topic: Shoulder & Hip Sports
Figure 1 is the radiograph of a 21-year-old college lacrosse player who has a 2-year history of progressive left groin pain that is exacerbated by activity. Pain is preventing him from participating with his team. Examination reveals a fit man without tenderness to palpation around the hip. No clicking or popping occurs with hip range of motion. Strength of all muscles about the hip is normal, but there is some mild pain with resisted hip flexion and hip adduction. While lying supine, progressive hip flexion with internal rotation and adduction reproduces his groin pain. The patient participates in physical therapy for 8 weeks with his team's trainer but notes little improvement. What is the most appropriate next diagnostic step to determine the cause of his pain?
Correct Answer & Explanation
. Hip MRI arthrogram
Explanation
This clinical scenario describes a patient with FAI attributable to pincer (acetabular) deformity. This form of FAI, which involves prominence of the anterosuperior acetabular lip, may be more common among women. Decreased range of motion and pain occur secondary to the abutment of the femoral head against the acetabular labrum and rim. Hip flexion, combined with adduction and internal rotation, recreates this contact and causes pain, but CAM or pincer etiology remains unknown. The differential diagnosis of hip pain in a young athlete includes femoral neck stress reaction/fracture, sacroiliac arthritis, intra-articular loose body, trochanteric bursitis, osteitis pubis, and hernia. No information presented in this scenario suggests any of these causes. Diagnosis of FAI is best performed via MR imaging, with an arthrogram increasing the sensitivity and specificity for labral pathology. Ultrasonography may be useful in the diagnosis of dysplasia or for dynamic assessment of a snapping hip, but ultrasonography is not commonlyused to diagnose labral pathology. Although concomitant chondral lesions of the femoral head are uncommon, the forced leverage of the anterosuperior femoral neck upon the anterior acetabulum may result in a “contra-coup” chondral injury on the posteroinferior acetabulum. This is the most common location of chondral lesions in this scenario. Without bony resection to prevent further impingement, this patient will continue to experience symptoms. Because there is no evidence of femoral neck prominence (CAM lesion), there is no indication for osteoplasty of the femoral neck; resection of the pincer lesion is necessary. This will often require take-down of the labrum in this location. If possible, iatrogenic or traumatic labral tears should subsequently be repaired after pincer debridement because the labrum hasimportant functions for hip stability and maintenance of the suction seal of the joint.
Question 1338
Topic: 5. Sports Medicine
What is the effect on knee kinematics following placement of an anterior cruciate ligament (ACL) graft at the 12 o’clock position?
Correct Answer & Explanation
. Decreased rotational stability
Explanation
Endoscopic ACL reconstructive techniques may result in a vertical graft placement. The reconstructed ligament will resist anterior translation of the tibia but the graft will not restore rotatory stability. Decreased flexion and extension are caused by placement of the femoral tunnel too anterior and posterior, respectively. Impingement of the graft on the femoral notch is caused by anterior placement of the tibial tunnel or inadequate notchplasty.
Question 1339
Topic: 5. Sports Medicine
A 13-year-old pitcher is hit in the left intercostal space by a line drive ball. He collapses, is apneic and unresponsive, and his radial pulse is absent. What is the next step in management? Review Topic
Correct Answer & Explanation
. Protect the airway and use smelling salts
Explanation
Sudden death in athletes without structural cardiac damage is referred to as commotio cordis. This is an emergency. The immediate priorities are protection of the airway, starting CPR, and early cardioversion as this patient has an arrhythmia. It is hypothesized to occur from apnea, vasovagal reflex, or ventricular arrhythemia as reported by Maron and associates from the direct impact of the baseball during a vulnerable part of the cardiac rhythm. Janda and associates reported that soft-core baseballs may not differ from standard baseballs with regard to the risk of fatal chest-impact injury while playing baseball. High survival rates are associated with rapid treatment.
Question 1340
Topic: 5. Sports Medicine
During preparation for the NCAA wrestling championships, a participant reports the development of vesicular lesions on his right chest wall that are mildly painful; however, they have not affected his ability to wrestle. How should this athlete be managed? Review Topic
Correct Answer & Explanation
. He may wrestle if his lesions are covered.
Explanation
Herpes simplex virus (HSV) can cause serious outbreaks on athletic teams, especially wrestling. HSV is highly contagious; it is secreted from active blisters, saliva, and mucous membranes. For wrestlers, the NCAA states that the athlete must be free from systemic symptoms and any new blisters for 72 hours before being allowed to participate. Also, all lesions must be dry and crusted and at least 120 hours of antiviral therapy should have been instituted.
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