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5. Sports Medicine MCQs

Practice Set 72 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 1421

Topic: Shoulder & Hip Sports

An otherwise healthy 30-year-old man undergoes right shoulder arthroscopic Bankart repair under regional anesthesia using an interscalene brachial plexus block. In the recovery room, he reports mild difficulty breathing and his chest radiograph shows a high riding diaphragm on the right side. His peripheral oxygenation is 97% on 2 liters of oxygen by nasal cannula. What is the most appropriate management?

. Continued observation and monitoring
. Obtain arterial blood gas measurements
. Obtain emergent spiral CT scan to assess for pulmonary embolism
. Insertion of a chest tube
. Airway control and, if necessary, endotracheal intubation

Correct Answer & Explanation

. Continued observation and monitoring

Explanation

Because the phrenic nerve lies in close proximity to the site of anesthetic injection, temporary hemidiaphragmatic paresis is a very common side effect of interscalene brachial plexus block. Pulmonary function and chest wall mechanics may be slightly compromised, but can easily be compensated in a healthy patient. Therefore, with sufficient oxygenation, aggressive assessments or treatments such as arterial blood gas measurements, emergent spiral CT scans, chest tube insertions, or endotracheal intubation are not warranted. For this stable patient, continued monitoring with gradual withdrawal of oxygen is the most appropriate treatment.

Question 1422

Topic: Knee Sports

Figure 1 is the MR image of a 36-year-old athlete who is tackled from behind and falls forward onto his left knee. He has pain, swelling, and stiffness. Examination includes a moderate effusion, positive quadriceps active test, and normal Lachman test finding. The injured structure is composed of an

. anterolateral bundle that is tight in flexion and a posteromedial bundle that is tight in extension.
. anterolateral bundle that is tight in extension and a posteromedial bundle that is tight in flexion.
. anteromedial bundle that is tight in flexion and a posterolateral bundle that is tight in extension.
. anteromedial bundle that is tight in extension and a posterolateral bundle that is tight in flexion.

Correct Answer & Explanation

. anterolateral bundle that is tight in flexion and a posteromedial bundle that is tight in extension.

Explanation

The clinical description and MR image point to an injury to the posterior cruciate ligament (PCL). This ligament is thought to be primarily composed of anterolateral and posteromedial bundles, with the former tightening in flexion and the latter in extension. Because of alterations in knee kinematics and increased varus alignment in PCL insufficiency, contact stresses and cartilage loads increase in the patellofemoral and medial compartments. Although good outcomes may be obtained with transtibial, open inlay, and arthroscopic inlay techniques, one major difference is the creation of the “killer-turn” during the transtibial approach. This sharp turn in the graft as it emerges from the tibia appears to lead to more pronounced attenuation and thinning of the graft during cyclic loading. The scenario describes a patient with chronic PCL and posterolateral corner (PLC) injury, as evidenced by the varus thrust and abnormal Dial test finding. A valgus-producing osteotomy may be effective, and, in fact, may be the only treatment necessary to address chronic PLC injury. Accordingly, an opening lateral osteotomy would not be appropriate. Of the remaining responses, an osteotomy that increases tibial slope would also address the PCL deficiency by reducing posterior tibial sag. Vascular injury is an uncommon, but potentially devastating, complication associated with PCL surgery and may occur regardless of the technique used.Numerous strategies have been described to reduce the risk, including use of a posteromedial accessory incision to allow finger retraction of the popliteal neurovascular bundle, oscillating drills to prevent excessive soft-tissue entanglement, and tapered (rather than square) drill bits that may minimize cut-out of sharp edges as drilling reaches the posterior tibial cortex. Knee extension lessens, rather than increases, the distance between the posterior tibia and the neurovascular bundle and increases, not lessens, risk forvascular injury.

Question 1423

Topic: 5. Sports Medicine

Compared to eumenorrheic athletes, amenorrheic athletes have more frequent occurrences of

. stress fractures.
. scoliosis.
. pes planus.
. meniscal tears.
. ankle sprains.

Correct Answer & Explanation

. stress fractures.

Explanation

DISCUSSION: In secondary amenorrhea, women do not receive the estrogen needed to maintain adequate bone mineralization.  This hypoestrogenic state affects bone density, and there is evidence that stress fractures are more frequent in amenorrheic than eumenorrheic athletes.  The other conditions are not seen with increased frequency in amenorrheic athletes.REFERENCES: Warren MP: Health issues for women athletes: Exercise-induced amenorrhea.J Clin Endocrinol Metab 1999;84:1892-1896.Rencken ML, Chesnut CH III, Drinkwater BL: Bone density at multiple skeletal sites in amenorrheic athletes.  JAMA 1996;276:238-240.

Question 1424

Topic: Knee Sports
  • A 32-year-old man has swelling of the knee as a result of falling with the knee flexed and his foot in plantar flexion. A Lachman’s test reveals an apparent increase in anterior translation. Passive external tibial rotation at 30 degrees and 90 degrees is equal to the contralateral side, and the quadriceps active test is positive on the affected side. The neurovascular examination is normal. Treatment should consist of
. An anterior cruciate functional knee brace.
. A physical therapy program.
. Reconstruction of the posterior cruciate ligament and the posterolateral corner.
. Reconstruction of the posterior cruciate ligament.
. Reconstruction of the anterior cruciate ligament.

Correct Answer & Explanation

. An anterior cruciate functional knee brace.

Explanation

The question describes a patient with an isolated PCL injury. The mechanism of most athletic PCL injuries is a fall on the flexed knee with the foot in plantar flexion. The results of the physical examination—Lachman’s test with increased anterior translation and a positive quadriceps active test—suggests a PCL injury. The passive external tibial rotation at 30 degrees and 90 degrees being equal to the contralateral side suggest an intact posterolateral corner. In light of these findings, the patient appears to have an isolated PCL injury. In acute isolated posterior cruciate ligament tears with less than 10mm of posterior laxity at 90 degrees of flexion, current knowledge suggests nonoperative treatment that stresses aggressive quadriceps rehabilitation.

Question 1425

Topic: Shoulder & Hip Sports

A 25-year-old tennis player has shoulder pain and weakness to external rotation. MRI scans are shown in Figures 16a and 16b. What is the most likely cause of his weakness?

. Supraspinatus tear
. Infraspinatus tear
. Suprascapular nerve compression
. C5 radiculopathy
. Subacromial impingement

Correct Answer & Explanation

. Suprascapular nerve compression

Explanation

DISCUSSION: The MRI scans show a paralabral cyst, which is most commonly associated with labral tears.  Compression of the suprascapular nerve results in weakness of the supraspinatus and/or infraspinatus depending on the level of compression.REFERENCES: Piatt BE, Hawkins RJ, Fritz RC, et al: Clinical evaluation and treatment of spinoglenoid notch ganglion cysts.  J Shoulder Elbow Surg 2002;11:600-604.Inokuchi W, Ogawa K, Horiuchi Y: Magnetic resonance imaging of suprascapular nerve palsy.J Shoulder Elbow Surg 1998;7;223-227.

Question 1426

Topic: Shoulder & Hip Sports

Figure 177 is an intra-articular photograph taken while viewing from the anterior superior portal during arthroscopy of a right shoulder. Which of the following findings identified at the time of surgery would be the most predictive for recurrence following arthroscopic repair of the demonstrated pathology? Review Topic

. Nonengaging Hill-Sachs deformity
. Intra-articular loose body
. Anterior glenoid bone deficiency of 35%
. Subacromial bursitis
. 10% partial-thickness, articular side tear of the supraspinatous

Correct Answer & Explanation

. Anterior glenoid bone deficiency of 35%

Explanation

Anterior glenoid bone deficiency of 35% is most predictive of recurrence. Figure 177 shows an acute tear of the anterior inferior glenoid labrum consistent with a Bankart lesion. It has been clearly shown that there is a direct relationship between failure (ie, recurrent dislocation) of arthroscopic Bankart repair and anterior glenoid bone loss. Anterior glenoid bone loss of greater than 25% in the setting of anterior glenohumeral instability is a relative contraindication to performing arthroscopic stabilization and instead is an indication to perform a bony glenoid augmentation procedure to address the articular arc deficit. Therefore, an anterior bony defect of 35% is the most predictive finding at the time of surgery for recurrent dislocation. An engaging Hill-Sachs deformity has a significant effect on the rate of redislocation, but a nonengaging one should not. An intra-articular loose body, subacromial bursitis, and a partial-thickness articular-sided supraspinatous tear should not lead to an increased risk of recurrent dislocation following Bankart repair.

Question 1427

Topic: 5. Sports Medicine

A 23-year-old soccer player sustains a grade III complete posterior cruciate ligament (PCL) tear after colliding with another player. In reconstructing the PCL, it is optimal to reconstruct the

. anterolateral bundle and tension the graft at 10° of flexion.
. anterolateral bundle and tension the graft at 90° of flexion.
. posteromedial bundle and tension the graft at 10° of flexion.
. posteromedial bundle and tension the graft at 45° of flexion.
. posteromedial bundle and tension the graft at 90° of flexion.

Correct Answer & Explanation

. anterolateral bundle and tension the graft at 90° of flexion.

Explanation

DISCUSSION: The PCL is a nonisometric structure with nonuniform tension during knee motion, with maximum tension at 90° of flexion.  While the posteromedial PCL fibers have been found to be the most isometric, the anterolateral fibers represent the bulk of the ligament.  Studies have suggested that anterior placement of the femoral tunnel is superior to placement in an isometric position.  The anterolateral bundle tightens as the knee flexes; therefore, it is optimal to tension the graft at 90° of flexion.REFERENCES: Harner CD, Xerogeanes JW, Livesay GA, et al: The human posterior cruciate ligament complex: An interdisciplinary study.  Ligament morphology and biomechanical evaluation.  Am J Sports Med 1995;23:736-745.Burns WC II, Draganich LF, Pyevich M, Reider B: The effect of femoral tunnel position and graft tensioning technique on posterior laxity of the posterior cruciate ligament-reconstructed knee.  Am J Sports Med 1995;23:424-430.

Question 1428

Topic: Shoulder & Hip Sports

A 22-year-old female collegiate javelin thrower has shoulder pain. She notes that her pain is primarily located in the posterior aspect of her shoulder, is exacerbated with throwing, and she experiences maximal tenderness in the extreme cocking phase of the throwing cycle. On examination, she reports deep posterior shoulder pain when the arm is abducted 90 degrees and maximally externally rotated to 110 degrees. This reproduces her symptoms precisely. Shoulder radiographs are normal. What is the most likely diagnosis? Review Topic

. Anterior shoulder instability
. Early adhesive capsulitis
. Internal impingement
. Subacromial impingement
. Full-thickness rotator cuff tear

Correct Answer & Explanation

. Internal impingement

Explanation

The patient has internal impingement. Internal impingement is commonly seen in overhead throwing athletes. When positioned in the extreme cocking phase of the throwing cycle, the posterior glenoid impacts the articular surface of the infraspinatus and posterior fibers of the supraspinatus tendon. This impact can cause partial-thickness rotator cuff tearing and posterosuperior labral lesions. She has no evidence of anterior shoulder instability, and her range of motion is excellent which rules out adhesive capsulitis. Subacromial impingement is identified with anterolateral shoulder pain with internal rotation in the abducted position. A full-thickness rotator cuff tear in a 22-year-old individual would require significant trauma and would likely result in pain at rest and with lifting.

Question 1429

Topic: 5. Sports Medicine

A 22-year-old college football player reports shortness of breath and dyspnea after a tackle. Examination reveals tachypnea, tachycardia, the trachea is shifted to the right, and there are decreased breath sounds on the left lung fields. The first line of treatment on the field should be

. placement of a chest tube.
. insertion of a large gauge needle into the second intercostal space.
. cardiopulmonary resuscitation.
. administration of adrenaline.
. immediate transfer to the emergency department.

Correct Answer & Explanation

. insertion of a large gauge needle into the second intercostal space.

Explanation

DISCUSSION: The patient has a tension pneumothorax.  This is a life-threatening emergency where air is trapped between the pleura and the lung, which prevents expansion of the lung.  This causes hypoxia and cardiopulmonary compromise.  The first line of treatment is to place a needle into the second intercostal space in the midclavicular line.  The athlete should then be transported to the emergency department for chest tube placement.  The athlete cannot return to play, and resuscitation is not necessary because he has not gone into cardiopulmonary arrest.REFERENCES: Amaral JF: Thoracoabdominal injuries in the athlete.  Clin Sports Med 1997;16:739-753.Perron AD: Chest pain in athletes. Clin Sports Med 2003;22:37-50.

Question 1430

Topic: 5. Sports Medicine

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?

. Medial meniscus tear
. Popliteus tendon rupture
. Lateral meniscus tear
. Proximal tibia-fibula disruption
. Pes anserine bursitis

Correct Answer & Explanation

. Lateral meniscus tear

Explanation

DISCUSSION: 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.REFERENCES: Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, p 201.Greis PE, Bardana DD, Holmstrom MC, et al: Meniscal injury: I. Basic science and evaluation. J Am Acad Orthop Surg 2002;10:168-176.Duncan JB, Hunter R, Purnell M, et al: Meniscal injuries associated with acute anterior cruciate ligament tears in alpine skiers. Am J Sports Med 1995;23:170-172.

Question 1431

Topic: Shoulder & Hip Sports

What pathology is most likely to result in failure of an arthroscopic Bankart repair?

. A 25% or greater anterior-inferior glenoid rim defect
. Nonengaging moderate Hill-Sachs defect
. Associated type IV superior labrum anterior and posterior (SLAP) lesion
. Absence of an intact cartilaginous labrum
. Atttenuated anterior-inferior capsule and glenohumeral ligament complex

Correct Answer & Explanation

. A 25% or greater anterior-inferior glenoid rim defect

Explanation

DISCUSSION: Recent studies have documented that an arthroscopic Bankart repair performed with good technique can produce success rates similar to an open repair.  However, the results of an arthroscopic repair deteriorate significantly if there is a 25% or greater anterior-inferior glenoid rim defect (inverted pear configuration) or an engaging Hill-Sachs lesion in which the humeral head defect keys onto the glenoid rim in abduction and external rotation.  If either of these entities exist or there is multidirectional instability with pathologic hyperextensible tissue laxity, an open repair is recommended.  An associated SLAP lesion would not significantly affect the result of the Bankart procedure.  Not infrequently, the anterior glenoid labrum is partially or completely disrupted and, in itself, is not a contraindication to arthroscopic Bankart repair.  In almost all patients with predominantly unidirectional instability, some degree of capsular/anterior-inferior glenohumeral ligament attenuation is present and can be addressed during the arthroscopic repair.REFERENCES: Burkhart SS, De Beer JF: Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: Significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion.  Arthroscopy 2000;16:677-694.Cole BJ, Romeo AA: Arthroscopic shoulder stabilization with suture anchors: Technique, technology, and pitfalls.  Clin Orthop 2001;390:17-30.

Question 1432

Topic: Shoulder & Hip Sports

A 50-year-old pipefitter falls from a ladder at work and dislocates his non-dominant shoulder. His MRI scan shows supraspinatus and infraspinatus tears with retraction to the glenoid. He cannot actively raise his arm away from his side. He denies prior shoulder symptoms before his fall. Three weeks of physical therapy have failed to improve his function. Which factor has been demonstrated to result in a poor clinical outcome following surgical intervention?

. The patient's age
. he patient's gender
. Work-related injury
. Acute nature of the tear

Correct Answer & Explanation

. The patient's age

Explanation

Several studies have demonstrated that patients with work-related injuries do not do as well as those whose injuries are not work-related after repair of the rotator cuff. This patient’s age and gender are not negative prognostic indicators. The acute nature of the tear does not lead to an inferior outcome.

Question 1433

Topic: 5. Sports Medicine

What is the most common cause of rotator cuff injury in high school athletes?

. A curved or type III acromion
. A tight coracoacromial ligament
. Overuse
. Limited internal rotation
. Scapulothoracic dyskinesia

Correct Answer & Explanation

. A curved or type III acromion

Explanation

DISCUSSION: A large number of etiologies of rotator cuff injury have been proposed.  Both intrinsic and extrinsic mechanisms have been suggested.  In the young athlete the common underlying mechanism is overuse.  Contributing factors include increased laxity, anatomic variation in the coracoacromial arch, and altered kinematics.REFERENCES: Wilkins KE: Shoulder injuries: Epidemiology, in Stanitski CL, DeLee JC, Drez D Jr (eds): Pediatric and Adolescent Sports Medicine.  Philadelphia, PA, WB Saunders, 1994, pp 175-182.Sher JS: Anatomy, biomechanics, and pathophysiology of rotator cuff disease, in Iannnotti JP, Williams GR (eds): Disorders of the Shoulder: Diagnosis and Management. Philadelphia, PA, Lippincott Williams and Wilkins, 1999, pp 3-30.

Question 1434

Topic: 5. Sports Medicine

A coach of three football teams—the B team, junior varsity team, and varsity team—wants to study the average times in the 40-yard dash for his players. Which test would help him determine if the mean 40-yard dash times for the athletes on one team are different from those on the other teams?

. Independent 2-samplettest
. Analysis of variance (ANOVA)
. Chi-square test
. Fisher's exact test

Correct Answer & Explanation

. Analysis of variance (ANOVA)

Explanation

Data collected in research studies fall into one of two categories—continuous or discrete. Continuous data can be displayed on a curve. Examples include height, weight, and time recorded in a 40-yard dash. Discrete data represent data that fall into specific categories such as gender or the presence or absence of a risk factor. ANOVA is used to determine statistical significance in mean values of continuous data when there are more than two independent samples. The 2-samplettest compares mean values of continuous data between two independent groups. The Chi-square test and Fisher's exact tests are tests used to analyze discrete data.

Question 1435

Topic: 5. Sports Medicine

What is the most likely contributory factor to this patient's problem?

. Throwing curveballs
. Year-round throwing
. Poor calcium intake
. Shoulder laxity

Correct Answer & Explanation

. Year-round throwing

Explanation

DISCUSSIONProximal humeral epiphysiolysis (little leaguer’s shoulder) is an overuse condition of the proximal humeral physis. Patients report diffuse pain that is worse with throwing. Little leaguer’s shoulder is caused by rotational stress placed on the proximal humeral epiphysis during overhead throwing. The growth plate is weakest to torsion stress and is most susceptible to injury during periods of rapid growth commonly seen during puberty. Most chronic shoulder injuries occur in throwing athletes between 13 and 16 years of age. Factors that contribute to the condition include excessive throwing, improper throwing mechanics, and muscle-tendon imbalance. Radiographic findings typically are normal but may indicate subtle widening of the proximal humeral physis, and, in more severe cases, metaphyseal demineralization or fragmentation. Surgical fixation is not required for healing. An initial 3-month period of rest and activity modification will typically result in resolution of symptoms. Nonsteroidal anti-inflammatory drugs may be used as needed. After the rest period, a gradual return to throwing is implemented until the patient’s condition returns to baseline. This protocol has a long-term success rate exceeding 90%. Pitching coaches should evaluate throwing mechanics and maintain pitch counts. The most common cause of this condition is overuse, as is seen in pitchers who throw all year. Internal rotation deficit and internal impingement is typically a finding in older athletes without open physes. This patient had no evidence of rotation deficit upon examination, making this diagnosis unlikely.

Question 1436

Topic: Shoulder & Hip Sports

-The patient experienced little improvement with activity modification and physical therapy. An intraarticular corticosteroid injection provides excellent but short-lived pain control. She requests surgical treatment for her hip and she is counseled regarding arthroscopy and consent is obtained. Intraoperatively,a capsulolabral separation is observed with an underlying pincer lesion. No articular cartilage injury is seen. What treatment is most appropriate considering these findings?

. Suture anchor repair of the labral tear and no bony resection
. Suture anchor repair of the labral tear and bony resection of the pincer lesion
. Debridement of the labral tear and bony resection of the pincer lesion
. Debridement of the labral tear with no bony resection of the pincer lesion

Correct Answer & Explanation

. Suture anchor repair of the labral tear and bony resection of the pincer lesion

Explanation

DISCUSSION FOR QUESTIONS 26 THROUGH 29The clinical scenario, examination, and MRI scans are consistent with a pincer-type FAI. The decreased range of motion is secondary to the pain produced by the continued abutment of the femoral head against the anterosuperior acetabulum. Flexing the hip while internally rotating and adducting the leg recreates this contact and is typically painful. No clinical signs suggest sacroiliac joint arthritis, an intra-articular loose body, or trochanteric bursitis, although these are all diagnoses that should be considered in a patient with a painful hip. The most sensitive and specific study to detect an acetabular labral tear is an MRI arthrogram of the hip. This study should be obtained in this patient to evaluate the labrum as well as the status of the articular cartilage. An MRI scan without intra-articular contrast is not as sensitive as an arthrogram. An ultrasound can provide a dynamic assessment of the hip and help in the setting of a snapping hip; however, this study is not reliable to determine the presence of a labral tear. In the setting of pincer FAI, the forced leverage of the anterosuperior femoral head upon the anterior acetabulum results in abnormal forces against the posteroinferior acetabulum. This continued force can lead to a chondral lesion in this location know as a “counter-coup” injury. Chondral lesions of the femoral head are rare in the setting of pincer FAI. The posterosuperior quadrant does not experience increased force and rarely sustains chondral injuries. The patient is a young, active individual with no pre-existing degenerative changes, so repair of the tear with bony resection of the pincer lesion is the most appropriate treatment.A capsulolabral detachment should be repaired because these tears can heal and the labrum functions as a seal, preventing egress of synovial fluid from the joint space. If the pincer lesion is not resected, the patient will continue to experience abnormal contact and the repair will likely fail. There is no evidence that the patient has a cam impingement, and recontouring of the femoral head/neck junction is not appropriate. Simple debridement should be reserved for intrasubstance tears of the labrum, which would not be expected to heal with repair.CLINICAL SITUATION FOR QUESTIONS 30 THROUGH 32Figures 30a and 30b are the radiographs of a 20-year-old college multisport athlete who has had longstanding pain in his left hip. He denies any specific event that initiated his pain, but he notes that he had hip problems when he was an infant. He denies pain with activities of daily living, but hebelieves his pain is increasingly limiting his ability to exercise. He localizes the pain to his groin. He denies low-back or buttock pain or pain that radiates down his leg.

Question 1437

Topic: 5. Sports Medicine

A 26-year-old female twists her knee while playing soccer and sustains the injury shown in Figure A. She undergoes a reconstructive surgery and is started on an accelerated rehabilitation program. Which of the following is true regarding this type of rehabilitation protocol? Review Topic

. Increased knee laxity compared with nonaccelerated rehabilitation programs
. No weightbearing allowed for 2-weeks post-operatively
. Accelerated rehabiliation program duration is 32-weeks
. Equal outcomes compared with nonaccelerated rehabilitation programs
. Improved range of motion compared with nonaccelerated rehabilitation programs

Correct Answer & Explanation

. Equal outcomes compared with nonaccelerated rehabilitation programs

Explanation

The literature indicates that there is no difference in outcomes of accelerated rehabilitation programs compared with nonaccelerated rehabilitation programs after anterior cruciate ligament (ACL) reconstruction.Rehabilitation after ACL reconstruction is necessary for a successful surgical outcome and remains an important topic of research interest. Accelerated programs allow for earlier weightbearing and certain strengthening exercises, rather than waiting several weeks before performing certain activities which put strain on the graft. Despite initial concerns that accelerated rehabilitation programs may lead to worse outcomes, many studies have demonstrated comparable outcomes between accelerated and nonaccelerated rehabilitation programs. No significant long-term differences have been reported regarding ACL laxity, range of motion, strength, or return to sports. Use of an accelerated program does not imply earlier return to sports. The optimal time to return to sports has not yet been elucidated.Beynnon et al. performed a randomized controlled trial of patients who underwent ACL reconstruction with bone-patellar tendon-bone autograft comparing rehabilitiaton with either accelerated (19 week) or nonaccelerated (32 week) programs. At final evaluation, patients in both programs had the same increase in the envelope of knee laxity, clinical assessment, functional performance, proprioception,andthighmusclestrength.Kruse et al. presented a systematic review evaluating studies on rehabilitation following ACL reconstruction. The authors found that accelerated rehabilitation does not appear to be harmful. It is likely safe for patients to begin immediate postoperative weight bearing, range of motion from 0-90 degrees of flexion, and perform closed-chain exercises. Bracing following ACL reconstruction is neither necessary nor beneficial and often adds to the cost of the procedure.Figure A is a sagittal MRI demonstrating a complete ACL tear.Incorrect

Question 1438

Topic: Knee Sports

belowdepicttheAPandlateralradiographsobtainedfromayear-oldmanwithlong-standing
rightkneeosteoarthritisandpainthatisunresponsivetononsurgicaltreatment.Thepatientundergoes navigatedcruciate-retainingrighttotalkneearthroplasty.Aftersurgery,thispatientcontinuesto experiencepainandswellingofthekneewithrecurrenteffusions.Hereturnstotheofficereporting continuedpain2yearsaftersurgery.Hedescribesinstability,particularlywhendescendingstairs.On examination,rangeofmotionof0°to120°isobserved,withnoextensorlag.Slopeofthetibialcomponent is7°.Thekneeisstabletovarusandvalgusstressinextension,butflexioninstabilityispresentinboth theanterior-posteriordirectionandthevarus-valgusdirection.Bracingleadstoaslightdecreasein symptomsbutisnotwelltolerated.Isokinetictestingdemonstratesdecreasedkneeextensionvelocityat
midpush.Radiographsdemonstratewell-alignedandfixedkneeimplants.Aninfectionwork-upis negative.Whatisthemostappropriatesurgicalinterventionatthistime?

. Tibial polyethylene exchange
. Revision of the femoral and tibial components and conversion to a posterior stabilized insert
. Revision of the femoral and tibial components to a constrained rotating hinge prosthesis
. Isolated femoral component revision and upsizing of the femoral implant with a new posterior cruciate ligament (PCL)-retaining polyethylene insert

Correct Answer & Explanation

. Revision of the femoral and tibial components and conversion to a posterior stabilized insert

Explanation

DISCUSSION:The  patient’s  symptoms  at  follow-up—pain,  swelling,  and  difficulty  descending  stairs—suggest  knee flexion instability. Considering his history, an incompetent PCL must be considered. Revision of the knee to a posterior stabilized or nonlinked constrained condylar implant (depending on the condition of the ligaments) likely is needed to address his symptoms. The difference in extension stability and flexion stability makes polyethylene exchange a poor option. A constrained rotating hinge design is not necessary. Repeat use of a PCL-retaining insert is not recommended. Tibial and femoral revision both are required. Correction of excessive slope will be attained with tibial revision, femoral component revision is required to convert to a PCL-substituting design. There is also an opportunity to increase posterior condylar offset if needed.

Question 1439

Topic: 5. Sports Medicine

Which of the following is the only nonreversible effect of anabolic steroids?

. Muscle hypertrophy
. Alterations in high density lipoprotein (HDL) and low density lipoprotein (LDL) ratios
. Alopecia
. Personality effects
. Acne

Correct Answer & Explanation

. Alopecia

Explanation

DISCUSSION: The loss of hair or alopecia, is the only nonreversible effect of anabolic steroid use.Once anabolic steroids are stopped, muscle hypertrophy and training gains are quickly lost and the HDL/ LDL ratios return to their preexisting levels. Fortunately, the personality effects and the acute acne are reversible.REFERENCES: Hartgens F, Kuipers H: Effects of androgenic-anabolic steroids in athletes. Sports Med 2004;34:513-554.Evans NA: Current concepts in anabolic-androgenic steroids. Am J Sports Med 2004;32:534-542.

Question 1440

Topic: 5. Sports Medicine

Which of the following cohorts of patients is at highest risk of a future anterior cruciate ligament (ACL) tear? Review Topic

. Men with a hip abduction moment during landing
. Men with a neutral hip abduction-adduction moment during landing
. Men with varus knee abduction moment during landing
. Women with a hip adduction moment during landing
. Women with a knee valgus moment during landing

Correct Answer & Explanation

. Women with a knee valgus moment during landing

Explanation

Hewett and associates reported in a study of 205 female athletes that female athletes, with increased dynamic valgus and high abduction loads, were at increased risk of ACL injury. The same investigators in an earlier study of 81 high school basketball players reported that female athletes landed with greater total valgus knee motion and a greater maximum valgus knee angle than male athletes. Female athletes were also found to have significant differences between their dominant and nondominant side in maximum valgus knee angle. Lephart and associates reported that in single-leg landing and forward hop tasks that female athletes had significantly less knee flexion and lower leg internal rotation maximum angular displacement, and less knee flexion time to maximum angular displacement than males. Females with an adduction moment during landing should have a lower incidence of ACL tears. Males in general have a lower incidence of ACL tears.

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