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5. Sports Medicine MCQs

Practice Set 69 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 1361

Topic: Knee Sports
Reconstruction of the medial patellofemoral ligament (MPFL) requires highly accurate femoral tunnel placement to ensure isometry. According to Schöttle's method, what is the correct radiographic location of the femoral footprint of the MPFL on a true lateral radiograph?
. Anterior to the posterior femoral cortex line and proximal to Blumensaat's line
. Anterior to the posterior femoral cortex line and distal to the posterior femoral condyle margin
. Posterior to the posterior femoral cortex line and proximal to Blumensaat's line
. Anterior to the posterior femoral cortex line, proximal to the posterior condyle margin, and between Blumensaat's line and the posterior cortex
. Posterior to the posterior femoral cortex line and distal to Blumensaat's line

Correct Answer & Explanation

. Anterior to the posterior femoral cortex line, proximal to the posterior condyle margin, and between Blumensaat's line and the posterior cortex

Explanation

Schöttle's point identifies the anatomic femoral origin of the MPFL. It is located just anterior to a line extending the posterior femoral cortex, proximal to the posterior articular margin, and just distal to the intersection of Blumensaat's line with the posterior cortex.

Question 1362

Topic: Knee Sports

A 9-year-old male (Tanner Stage I) sustains a complete midsubstance anterior cruciate ligament (ACL) rupture. He has significant growth remaining. Which surgical technique is most appropriate to minimize the risk of iatrogenic limb length discrepancy and angular deformity?

. Transphyseal hamstring reconstruction
. All-epiphyseal ACL reconstruction
. Bone-patellar tendon-bone autograft
. Anteromedial portal transphyseal drilling
. Standard adult single-bundle reconstruction

Correct Answer & Explanation

. Transphyseal hamstring reconstruction

Explanation

In prepubescent patients with substantial growth remaining (Tanner Stage I or II), physeal-sparing techniques such as an all-epiphyseal or extra-articular reconstruction are indicated. Transphyseal techniques crossing the open physes risk premature arrest and subsequent angular or leg-length deformities.

Question 1363

Topic: Knee Sports

A trauma patient presents with a suspected posterolateral corner (PLC) knee injury. The dial test demonstrates 15 degrees of increased external rotation at 30 degrees of knee flexion compared to the uninjured side, but symmetric rotation at 90 degrees of flexion. This finding is diagnostic of an isolated injury to which structure?

. Anterior cruciate ligament
. Posterior cruciate ligament
. Posterolateral corner structures
. Medial collateral ligament
. Popliteus tendon alone

Correct Answer & Explanation

. Anterior cruciate ligament

Explanation

An increase in external rotation of more than 10 degrees at 30 degrees of flexion, but not at 90 degrees, indicates an isolated injury to the posterolateral corner (PLC). If increased external rotation is present at both 30 and 90 degrees, a combined PLC and PCL injury is diagnosed.

Question 1364

Topic: Knee Sports

During reconstruction of the medial patellofemoral ligament (MPFL), identifying the anatomic femoral footprint (Schottle's point) is critical for graft isometry. Radiographically on a true lateral view, where is this point located?

. 1 mm anterior to the posterior femoral cortical line and just proximal to the extension of Blumensaat's line
. 5 mm posterior to the posterior femoral cortical line and distal to Blumensaat's line
. Directly centered on the medial epicondyle
. 3 mm anterior to the adductor tubercle
. 2 mm distal to the joint line and anterior to the collateral ligament origin

Correct Answer & Explanation

. 1 mm anterior to the posterior femoral cortical line and just proximal to the extension of Blumensaat's line

Explanation

Schottle's point defines the anatomic femoral origin of the MPFL. On a strict lateral radiograph, it is situated 1 mm anterior to the posterior cortex line, just proximal to the posterior extension of Blumensaat's line, and distal to the posterior origin of the medial femoral condyle.

Question 1365

Topic: Shoulder & Hip Sports

In femoroacetabular impingement (FAI), cam morphology leads to specific patterns of intra-articular damage. Which biomechanical mechanism primarily drives the characteristic chondral injury associated with a cam lesion during repetitive hip flexion?

. Pincer-like crushing of the labrum against the femoral neck
. Shear forces causing outside-in chondrolabral delamination at the anterosuperior transition zone
. Global articular cartilage thinning due to upregulation of inflammatory cytokines
. Posterior rim impaction resulting in contrecoup cartilage loss
. Ischemic necrosis of the anterolateral femoral head

Correct Answer & Explanation

. Pincer-like crushing of the labrum against the femoral neck

Explanation

Cam impingement occurs when an aspherical femoral head-neck junction forcefully enters the acetabulum during flexion. This generates significant shear forces at the chondrolabral junction, characteristically causing delamination of the anterosuperior acetabular cartilage from the subchondral bone.

Question 1366

Topic: 5. Sports Medicine
A 21-year-old professional ballet dancer reports a painful popping sensation over her right hip joint. Examination reveals that symptoms are reproduced with hip flexion and external rotation. Which of the following studies will best confirm the diagnosis?
. Radiographs
. Bone scan
. CT
. Ultrasonography
. MRI

Correct Answer & Explanation

. Ultrasonography

Explanation

The patient has snapping hip syndrome of the internal type, which is more common in ballet dancers. It is caused by the iliopsoas tendon gliding over the iliopectineal line or the femoral head. The diagnosis usually can be made by the history and physical examination. Snapping is reproduced by hip flexion and extension or flexion with external rotation and abduction. Conventional and dynamic ultrasonography will confirm the snapping structure. Radiographs occasionally show calcifications near the lesser trochanter. MRI can be used to rule out other diagnoses that can simulate snapping hip.

Question 1367

Topic: Knee Sports

Figure 1 is the MRI scan of a patient with recurrent knee instability, which persists after a period of nonsurgical treatment. Anatomic reconstruction of the torn ligament is recommended. What radiographic finding is the most important independent predictor of recurrent instability following surgery?

. Tibial tubercle to trochlear groove (TT-TG) distance
. Patella alta
. Tibial slope
. Trochlear dysplasia

Correct Answer & Explanation

. Tibial tubercle to trochlear groove (TT-TG) distance

Explanation

The MR image is consistent with an episode of patellar instability with concomitant bruising of the medial patellar facet and lateral femoral condyle. The medial patellofemoral ligament appears torn and attenuated. Kita and associates reported that severe trochlear dysplasia is the most important predictor of residual patellofemoral instability after isolated medial patellofemoral ligament reconstruction. An increased TT-TG affected outcomes of patients with type D trochlear dysplasia (Dejour classification). Wagner and associates also found that high degrees of trochlear dysplasia correlate with poor clinical outcome due to graft overload in dysplastic situations. Other studies by Nelitz and associates and Matsushita and associates have also suggested that TT-TG distance did not reliably correlate with clinical outcome. Tibial slope would not affect recurrent patellar instability.

Question 1368

Topic: 5. Sports Medicine
Which of the following anatomic structures are in contact with internal impingement in the throwing athlete?
. Humerus and posterior-superior glenoid
. Humerus and anterior inferior glenoid
. Humerus and acromion
. Biceps and acromion
. Rotator cuff and acromion

Correct Answer & Explanation

. Humerus and posterior-superior glenoid

Explanation

Internal impingement occurs in the late cocking phase of throwing with humeral head abduction and maximal external rotation. It is a physiologic phenomenon. Internal impingement is defined as impingement of the posterior-superior rotator cuff between the humerus and posterior-superior glenoid rim. Symptomatic internal impingement is felt to be due to the frequency and magnitude of the impingement in throwers.

Question 1369

Topic: 5. Sports Medicine
A 24-year-old runner who underwent an allograft reconstruction of the anterior cruciate ligament (ACL) 3 years ago now reports anterior knee pain. Examination reveals no swelling or effusion, and the patient has full motion. A Lachman test and a pivot-shift test are negative. Palpation reveals tenderness on the patellar tendon and at the inferior pole of the patella. AP and lateral radiographs are shown in Figures 41a and 41b. Management should consist of
. immediate biopsy of the proximal tibia.
. aspiration and culture of the knee.
. observation with activity modification.
. a white blood cell scan.
. revision of the ACL reconstruction.

Correct Answer & Explanation

. observation with activity modification.

Explanation

DISCUSSION: The radiographs show tunnel enlargement, which is seen after ACL reconstruction, particularly with allografts. Occasionally, there will be formation of an associated subcutaneous pretibial cyst. It has been proposed that the tunnel enlargement and cyst are the result of incomplete incorporation of allograft tissues within the bone tunnels. There may be residual graft necrosis, allowing synovial fluid to be transmitted through the tunnel to collect in the pretibial area, manifesting as a synovial cyst. In the absence of cyst formation, the presence of tunnel enlargement does not appear to adversely affect the clinical outcome. Based on studies by Fahey and associates, continued tunnel expansion does not occur. Victoroff and associates report good results with curettage and bone grafting of the tibial tunnel if a pretibial cyst is present. Because this patient does not have a pretibial cyst, observation with activity modification is the preferred treatment. REFERENCES: Fahey M, Indelicato PA: Bone tunnel enlargement after anterior cruciate ligament replacement. Am J Sports Med 1994;22:410-414. Victoroff BN, Paulos L, Beck C, Goodfellow DB: Subcutaneous pretibial cyst formation associated with anterior cruciate ligament allografts: A report of four cases and literature review. Arthroscopy 1995;11:486-494.

Question 1370

Topic: Shoulder & Hip Sports
A 48-year-old ski instructor dislocates his nondominant shoulder in a fall. Management consisting of application of a sling for 1 week results in improvement in his pain. Follow-up examination 6 weeks after the injury reveals that the patient continues to have difficulty with shoulder elevation. Management should now include
. use of the sling for an additional 3 weeks.
. physical therapy.
. a corticosteroid injection.
. an MRI scan of the rotator cuff.
. arthroscopic labral repair.

Correct Answer & Explanation

. an MRI scan of the rotator cuff.

Explanation

DISCUSSION: Patients who are older than age 45 years and have initial dislocations are at greater risk for tearing the rotator cuff. Patients who are unable to lift the upper extremity or who have continued pain should undergo further evaluation for potential rotator cuff tears; early diagnosis is preferred. Physical therapy or continued use of a sling will be of little benefit. A corticosteroid injection might delay the diagnosis and compromise subsequent rotator cuff repair. Repairing the labrum generally is not necessary in a patient of this age who has an initial dislocation. REFERENCES: Hawkins RJ, Bell RH, Hawkins RH, Koppert GJ: Anterior dislocation of the shoulder in the older patient. Clin Orthop 1986;206:192-195. Matsen FA III, Thomas SC, Rockwood CA: Anterior glenohumeral instability, in Rockwood CA, Matsen FA III (eds): The Shoulder. Philadelphia, PA, WB Saunders, 1990, pp 526-622.

Question 1371

Topic: 5. Sports Medicine
When performing an inside-out lateral meniscal repair, capsule exposure is provided by developing the
. iliotibial band and biceps tendon interval, then retracting the lateral head of the gastrocnemius anteriorly.
. iliotibial band and biceps tendon interval, then retracting the lateral head of the gastrocnemius posteriorly.
. iliotibial band and biceps tendon interval, then retracting the lateral collateral ligament posteriorly.
. iliotibial band and biceps tendon interval, then splitting the lateral head of the gastrocnemius.
. lateral head of the gastrocnemius and biceps tendon interval, then retracting the biceps tendon anteriorly.

Correct Answer & Explanation

. iliotibial band and biceps tendon interval, then retracting the lateral head of the gastrocnemius posteriorly.

Explanation

DISCUSSION: Capsular exposure for an inside-out lateral meniscal repair is performed by developing the interval between the iliotibial band and biceps tendon. Posterior retraction of the biceps tendon exposes the lateral head of the gastrocnemius. Posterior retraction of the gastrocnemius provides access to the posterolateral capsule. REFERENCES: Miller DB Jr: Arthroscopic meniscus repair. Am J Sports Med 1988;16:315-320. Nawab A, Hester PW, Caborn DN: Arthroscopic meniscus repair, in Miller MD, Cole BJ (eds): Textbook of Arthroscopy. Philadelphia, PA, WB Saunders, 2004, pp 517-537.

Question 1372

Topic: 5. Sports Medicine
Which of the following diseases has documented transmission by allograft tissue transplantation in the last 20 years?
. Tuberculosis
. Hepatitis B
. HIV
. West Nile virus
. Clostridium

Correct Answer & Explanation

. Clostridium

Explanation

DISCUSSION: The only reported cases of HIV transmission with tissue transplantation occurred more than 20 years ago. The only reported cases of tuberculosis and hepatitis B occurred more than 50 years ago. The donor-associated Clostridium infection occurred in 2001. The facility was not AATB-accredited (American Association of Tissue Banks) and the local AATB facility refused the graft. It is necessary for the surgeon using the allograft tissue to be aware of the current status of tissue regulation, and procurement and processing procedures.

Question 1373

Topic: 5. Sports Medicine

Figures 174a through 174c are the MRI scans of a 16-year-old football player who dislocated his dominant left shoulder 3 weeks ago while landing on his outstretched arm. The dislocation was reduced in the emergency department. He has since had two episodes where he felt like his shoulder slipped partially out of place. Which of the following statements to the athlete and his parents is most accurate regarding treatment options? Review Topic

. Physical therapy should allow him to return to football with recurrent dislocations unlikely.
. Immobilization of his shoulder in an external rotation brace will eliminate the chance of further dislocations.
. Arthroscopic capsulolabral repair is a reasonable option if he wishes to undergo this procedure, despite this being a first-time dislocation.
. Arthroscopic capsular and labral repair will likely fail in this situation.
. Open repair definitely provides a better outcome.

Correct Answer & Explanation

. Physical therapy should allow him to return to football with recurrent dislocations unlikely.

Explanation

Arthroscopic capsulolabral repair is a reasonable option despite this being a first-time dislocation. The patient has had recurrent instability episodes with two subluxations since his dislocation. Outcome studies have shown up to 90% recurrent instability rates in young, active populations. Capsulolabral repair has the best chance to reduce the risk of recurrent instability. Physical therapy is unlikely to significantly reduce the high likelihood of recurrence. While there is controversy regarding immobilization in internal or external rotation, studies have shown that immobilization may not reduce the risk of recurrent instability. While older studies did show that open repairs had lower recurrence rates than arthroscopic repairs, more recent studies have shown similar rates for arthroscopic capsulolabral plication with modern suture anchor techniques and no glenoid bone loss or engaging Hill-Sachs lesion.

Question 1374

Topic: Shoulder & Hip Sports
The MRI scan of the shoulder shown in Figure 2 was performed with the arm in abduction and external rotation. The image reveals what condition?
. Contact between the rotator cuff and the posterior-superior labrum
. Anterior instability
. A ganglion cyst of the spinoglenoid notch
. Osteonecrosis of the humeral head
. Posterior subluxation

Correct Answer & Explanation

. Contact between the rotator cuff and the posterior-superior labrum

Explanation

DISCUSSION: Internal impingement of the shoulder is now a well-recognized cause of shoulder pain in the throwing athlete. First described by Walch and associates, it involves contact of the rotator cuff and labrum in the maximally externally rotated and abducted shoulder, such as in the late cocking phase of the throwing motion. Schickendantz and associates have shown this contact to be physiologic in most patients and becoming pathologic with repetitive overhead activity.

Question 1375

Topic: 5. Sports Medicine

When making a comparison to autograft incorporation, the inflammatory process in allograft tissue anterior cruciate ligament (ACL) reconstruction

. occurs earlier.
. occurs later.
. is prolonged.
. is shortened.

Correct Answer & Explanation

. occurs earlier.

Explanation

Compared to similar autograft, allograft tissue demonstrates a prolonged inflammatory response, slower rate of biological incorporation and remodeling, and a higher proportion of large-diameter collagen fibrils. Native ACL inserts into bone through a transition of 4 distinct zones: tendon, unmineralized fibrocartilage, mineralized fibrocartilage, and bone. This transition is not reproduced with tendon grafts, which instead heal with interposed fibrovascular scar at the graft-tunnel interface. The scar rapidly remodels to form perpendicular fibers resembling Sharpey fibers and, eventually, mature bone growth into the outer portion of the graft. The intra-articular portion of allograft undergoes an initial phase of necrosis followed by repopulation by host synovial cells into the acellular collagen scaffold. Revascularization and maturation complete the ligamentization of graft tissue.

Question 1376

Topic: 5. Sports Medicine

A 12-year-old boy reports knee discomfort after prolonged strenuous activities. He denies knee swelling or catching and has no pain with activities of daily living. A radiograph is shown in Figure 4. Prognosis for the pathology shown is most influenced by

. weight.
. gender.
. the knee compartment involved.
. open or closed growth plates.
. limb alignment.

Correct Answer & Explanation

. weight.

Explanation

DISCUSSION: While many factors play a role in the outcome of osteochondritis dissecans, ample evidence has shown that the prognosis is most influenced by the growth status of the plates.  If the growth plates are open, the chance of a successful outcome is significantly greater than if they are closed.REFERENCES: Federico DJ, Lynch JK, Jokl P: Osteochondritis dissecans of the knee: A historical review of etiology and treatment.  Arthroscopy 1990;6:190-197.Linden B: Osteochondritis dissecans of the femoral condyles: A long-term follow-up study.  J Bone Joint Surg Am 1977;59:769-776.

Question 1377

Topic: Knee Sports

A 28-year-old man has left knee pain after a snow skiing accident. The MRI scan shown in Figure 47 reveals which of the following? Review Topic

. Osteosarcoma
. Bucket-handle medial meniscal tear
. Lateral collateral ligament tear
. Bone bruise
. Tibial spine avulsion

Correct Answer & Explanation

. Osteosarcoma

Explanation

Bone bruises are often noted on MRI after anterior cruciate and medial collateral ligament injuries. The significance of these injuries awaits long-term follow-up studies. The areas of increased signal on T2-weighted images represent areas of acute hemorrhage and are secondary to microfractures of the adjacent medullary trabeculae.

Question 1378

Topic: Shoulder & Hip Sports

Figures 25a and 25b show the clinical photographs of a 19-year-old baseball outfielder who has shoulder pain after sliding headfirst into second base. He reports pain while batting, sliding, and catching. Examination reveals a posterior prominence during midranges of forward elevation, which then disappears with a palpable clunk during terminal elevation and abduction. What is the most likely diagnosis?

. Superior labrum anterior and posterior (SLAP) lesion
. Bankart lesion
. Rotator cuff interval tear
. Rotator cuff tendinitis
. Posterior glenohumeral subluxation

Correct Answer & Explanation

. Superior labrum anterior and posterior (SLAP) lesion

Explanation

DISCUSSION: A headfirst slide with the arm extended can injure the posterior shoulder.  Winging of the scapula is dynamic and is considered a compensatory effort to prevent subluxation; it is not related to nerve injury.  Posterior glenohumeral subluxation can be present during the initiation of a bat swing.  Rotator cuff function, interval tears, and superior labrum tears can be painful but do not produce winging.REFERENCES: Kuhn JE, Plancher KD, Hawkins RJ: Scapular winging.  J Am Acad Orthop Surg 1995;3:319-325.Fiddian NJ, Kling RJ: The winged scapula.  Clin Orthop 1984;185:228-236.

Question 1379

Topic: 5. Sports Medicine

A 19-year-old man who plays college volleyball undergoes a routine preparticipation physical examination. Figure 35 shows a posterior view of his dominant shoulder. An electromyogram shows that this is a chronic injury, and an MRI scan shows no abnormalities. The best course of action should be

. a program of shoulder strengthening exercises.
. decompression of the nerve at the spinoglenoid notch.
. decompression of the nerve at the transverse suprascapular ligament.
. release of the fascial elements of the muscle tethering the nerve.
. arthroscopy, repair of the posterior labrum lesion, and an anterior capsular shift.

Correct Answer & Explanation

. a program of shoulder strengthening exercises.

Explanation

DISCUSSION: 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.REFERENCES: Ferretti A, Cerullo G, Russo G: Suprascapular neuropathy in volleyball players.  J Bone Joint Surg Am 1987;69:260-263.Martin SD, Warren RF, Martin TL, Kennedy K, O’Brien SJ, Wickiewicz TL: Suprascapular neuropathy: Results of non-operative treatment.  J Bone Joint Surg Am 1997;79:1159-1165.

Question 1380

Topic: Shoulder & Hip Sports

Internal impingement is characterized by which of the following anatomic lesions? Review Topic

. Subscapularis tear
. Bursal-sided rotator cuff tear
. Articular-sided rotator cuff tear
. Tight anterior capsule
. Laxity of the posterior capsule

Correct Answer & Explanation

. Subscapularis tear

Explanation

Internal impingement is characterized by articular-sided partial-thickness rotator cuff tears and superior glenoid labral tears. The capsule is characterized by laxity anteriorly and tightness posteriorly.

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