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5. Sports Medicine MCQs

Practice Set 75 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 1481

Topic: Shoulder & Hip Sports

A 36-year-old woman reports vague right shoulder pain. She denies any previous shoulder problems or any recent trauma. MRI scans are shown in Figures 81a and 81b. Weakness of which of the following is the most likely finding in her physical examination? Review Topic

. Shoulder abduction and internal rotation
. Shoulder external rotation and scapula protraction
. Shoulder external rotation with the arm at the side
. Shoulder internal rotation with the arm at the side
. Scapula protraction

Correct Answer & Explanation

. Shoulder abduction and internal rotation

Explanation

The MRI scans show a cyst formation within the suprascapular notch that can compress the suprascapular nerve. The suprascapular nerve innervates both the supraspinatus and the infraspinatus muscles. Therefore, patients with compression of this nerve may demonstrate weakness of shoulder abduction and external rotation with the arm at the side. If the nerve is compressed after its innervation of the supraspinatus muscle, however, patients will demonstrate weakness of shoulder external rotation only. Suprascapular nerve does not innervate muscles that control scapula motion or shoulder internal rotation.

Question 1482

Topic: 5. Sports Medicine

The patient has no postsurgical complications and begins physical therapy rehabilitation. The boy and his parents stress they “want to get the therapy over with as fast as possible” to expedite his return to sports, and the surgeon and rehabilitation team consider their request. Compared to nonaccelerated rehabilitation, patients who follow an early accelerated rehabilitation protocol experience

. increased laxity.
. increased risk for graft failure.
. no differences in long-term results.
. lower Knee Injury and Osteoarthritis Outcome Scores (KOOS).

Correct Answer & Explanation

. increased laxity.

Explanation

DISCUSSIONThe MR image shows bone bruises (“kissing contusions”) consistent with an ACL tear. During the ACL subluxation event, the posterolateral tibia plateau subluxes anteriorly, making contact with the mid portion of the lateral femoral condyle and resulting in this characteristic bone bruise pattern on MRI. Randomized clinical trials comparing early accelerated vs nonaccelerated rehabilitation programs have demonstrated no significant differences in longterm results with regard to function, reinjury, and successful return to play. These studies did not address timing of return to play with an early accelerated rehabilitation program. At 2 and 3 years postsurgically, there are no differences in laxity, number of graft failures, or KOOS scores.

Question 1483

Topic: Shoulder & Hip Sports

Figure 28 shows an arthroscopic view of a right shoulder in the lateral position through a posterior portal. What is the area between structure B (biceps) and SS (subscapularis tendon)? Review Topic

. Inferior glenohumeral ligament
. Superior glenohumeral ligament
. Rotator cuff interval
. Subscapularis recess
. Interior recess

Correct Answer & Explanation

. Inferior glenohumeral ligament

Explanation

The rotator cuff interval is located between the supraspinatus and subscapularis and the biceps tendon is deep to the interval. It is a triangular area where the base is the coracoid process and the apex is the transverse humeral ligament at the biceps sulcus. Closure or tightening of this area is often helpful in patients with shoulder instability. Conversely, this area is often contracted in patients with adhesive capsulitis and may need to be released.

Question 1484

Topic: 5. Sports Medicine

A 32-year-old man underwent a total medial meniscectomy 2 years ago. He now reports pain and recurrent swelling for the past 3 months. Work-up includes full standing hip-knee-ankle radiographs, standing AP radiographs of both knees in full extension, an axial view of the patellofemoral joint, and a 45-degree flexion AP radiograph. Contraindication to meniscus allograft transplantation includes which of the following? Review Topic

. 4 mm of tibiofemoral joint space on a 45-degree weight-bearing AP radiograph
. Intact anterior cruciate ligament on MRI and physical examination
. Recurrent effusions
. Flattening of the femoral condyles
. Healed high tibial osteotomy

Correct Answer & Explanation

. 4 mm of tibiofemoral joint space on a 45-degree weight-bearing AP radiograph

Explanation

Flattening of the femoral condyles indicates the onset of significant arthritis of the joint and is a contraindication to meniscus allograft transplantation. Criteria to proceed with allograft transplantation includes prior total meniscectomy, age of 50 years or younger, BMI of less than 30, clinical symptoms of pain in the involved tibiofemoral compartment, 2 mm or more of tibiofemoral joint space on a 45-degree weight-bearing AP radiograph, ligamentous stability, normal alignment, and no radiographic evidence of advanced arthrosis. Recurrent effusions are associated with chronic meniscus deficiency, and is one criteria for meniscal transplantation. High tibial osteotomy is often considered in conjunction with meniscal transplantation to correct tibiofemoral malalignment.

Question 1485

Topic: 5. Sports Medicine

A 16-year-old right-hand dominant pitcher has had pain with throwing for the past 6 months but denies any history of trauma. Figures 9a and 9b show noncontrast MRI scans of the involved shoulder. What is the most likely diagnosis? Review Topic

. Rotator cuff tear
. Epiphyseal stress fracture
. Bicipital tendinitis
. Internal impingement
. Loose body

Correct Answer & Explanation

. Rotator cuff tear

Explanation

Internal impingement differs from standard, or outlet, impingement because instability of the glenohumeral joint is commonly the primary etiology. Sports with repetitive stress of the glenohumeral joint, such as swimming, volleyball, and baseball, are most often associated with this problem. Pathology identified with diagnostic imaging and arthroscopy include: posterolateral humeral head edema, undersurface partial tearing of the rotator cuff, and increased anterior capsular volume. In throwing athletes, prevention and treatment centers on directed posterior capsular stretching and dynamic strengthening of the rotator cuff musculature.

Question 1486

Topic: Shoulder & Hip Sports

A baseball player reports a dull pain in the posterior aspect of his throwing arm. Examination reveals decreased internal rotation and prominence of the inferomedial corner of the scapula. An MRI scan suggests a partial-thickness tear of the posterior supraspinatus tendon. Successful treatment would most likely include which of the following? Review Topic

. Anti-inflammatory medication, posterior capsular stretching, and rotator cuff strengthening
. SLAP repair
. Debridement of the partial-thickness rotator cuff tear
. Rotator cuff repair
. Imbrication of the labrum and anterior capsule

Correct Answer & Explanation

. Anti-inflammatory medication, posterior capsular stretching, and rotator cuff strengthening

Explanation

Internal impingement is related to an internal rotation contracture (GIRD-glenohumeral internal rotation deficit) and an increase in external rotation caused by repetitive overhead throwing. Most patients can be successfully treated with rehabilitation that focuses on internal rotation stretches along with anti-inflammatory medication and strengthening as symptoms improve. SLAP repair and rotator cuff debridement may be considered in refractory cases. Rotator cuff repair is not typicallyrequired, and capsulolabral imbrication is more consistent with the surgical treatment for multidirectional instability.

Question 1487

Topic: 5. Sports Medicine

A 45-year-old distance runner has a hyaluronic acid injection to his knee because of degenerative arthritis. He immediately develops a severe rash and a systemic hypersensitivity reaction. This patient most likely is also allergic to which of the following?

. Penicillin
. Sulfur
. Shellfish
. Chicken or eggs
. Lidocaine

Correct Answer & Explanation

. Penicillin

Explanation

DISCUSSION: Preparations of hyaluronic acid can be divided into low and high molecular weight compounds. Contraindications to intra-articular hyaluronic acid include joint or skin infection, overlying skin disease, and allergies to chicken or egg products if using a preparation derived from rooster comb.REFERENCES: Gloyscen DN, Gillespie MJ, Schenek RC: The effects of medication in sports injuries, in DeLee JC, Drez D Jr, Miller MD (eds): Orthopedic Sports Medicine: Principles and Practice, ed 2.Philadelphia, PA, WB Saunders, 2003, vol 1, pp 121-124.Schenck RC Jr: New approaches to the treatment of osteoarthritis: Oral glucosamine and chondroitin sulfate. Instr Course Lect 2000;49:491-494.

Question 1488

Topic: Shoulder & Hip Sports

A 62-year-old man with a long history of right shoulder pain and weakness is scheduled to undergo hemiarthroplasty. Based on the radiographs shown in Figures 6a through 6c, what preoperative factor will most affect postoperative functional outcome?

. Humeral head erosion
. Glenoid erosion
. Rotator cuff integrity
. Status of the coracoacromial ligament
. Acromioclavicular arthritis

Correct Answer & Explanation

. Humeral head erosion

Explanation

DISCUSSION: The radiographs reveal osteoarthritis and proximal humeral head migration.  Integrity of the rotator cuff must be questioned based on these radiographic changes.  The status of the rotator cuff is the most influential factor affecting postoperative function in shoulder hemiarthroplasty.  The coracoacromial ligament provides a barrier to humeral head proximal migration in the face of a rotator cuff tear.  The radiographs do not indicate significant humeral head or glenoid erosion.  Acromioclavicular arthritis is often asymptomatic.REFERENCES: Iannotti JP, Norris TR: Influence of preoperative factors on outcome of shoulder arthroplasty for glenohumeral osteoarthritis. J Bone Joint Surg Am 2003;85:251-258.Hettrich CM, Weldon E III, Boorman RS, et al: Preoperative factors associated with improvements in shoulder function after humeral hemiarthroplasty.  J Bone Joint Surg Am 2004;86:1446-1451.

Question 1489

Topic: Shoulder & Hip Sports

Figures 57a and 57b are the MRI scans of a 61-year-old man who is unable to elevate his dominant arm following a golf injury 24 hours ago. He has moderate pain during attempted arm elevation. Examination reveals significant spinati atrophy and he is only able to elevate his arm fully overhead while supine. The neurologic examination is normal. What is the next most appropriate step in management? Review Topic

. Lidocaine injection test
. Supraspinatus strengthening
. Reverse shoulder arthroplasty
. Conventional total shoulder arthroplasty
. Arthroscopic rotator cuff repair/subacromial decompression

Correct Answer & Explanation

. Lidocaine injection test

Explanation

The patient unknowingly has a chronic massive rotator cuff tear. Because of excellent compensation, he remained functional and was without symptoms. This is evidenced by the significant muscle atrophy. Following even trivial injury, the compensation process of arm elevation fails and the patient suddenly loses the ability to elevate the arm. At this time in management, it is critical to recognize that the rotator cuff had already been torn and that pain now prevents the patient from actively using the arm. To better ascertain a prognosis of return of function, injecting a local anesthetic (lidocaine) into the joint is important. If, with an anesthetized joint, the patient can now elevate the arm, a supine strengthening program will likely return the patient to his pre-injury state. If there is no improvement in the ability to elevate the arm after the injection, surgical considerations may become relevant. There is no role for arthroscopic repair in this chronic, massive rotator cuff tear and decompression would likely lead to superior escape. A reverse shoulder arthroplasty would be contraindicated in a very active 61-year-old patient who 2 days ago was functioning normally. Based on the MRI scan, there is no supraspinatus muscle remaining to strengthen. Total shoulder arthroplasty is contraindicated in patients with a deficient rotator cuff mechanism.

Question 1490

Topic: 5. Sports Medicine

Which of the following can be seen in the heart of a well-conditioned athlete? Review Topic

. Decreased stroke volume
. Decreased cardiac output
. Decreased resting heart rate
. Decreased ventricular wall thickness
. Decreased vagal tone

Correct Answer & Explanation

. Decreased stroke volume

Explanation

The well-conditioned heart of an athlete leads to increased ventricular wall thickness which in turn increases the amount of blood ejected from the heart per given stroke (stroke volume). The increased parasympathetic (vagal) tone also leads to a lower (decreased) resting heart rate. Cardiac output is equal to stroke volume X heart rate and is increased during exercise in a well-conditioned athlete.

Question 1491

Topic: Shoulder & Hip Sports

Figures 1 and 2 are the MR arthrogram images of a 16-year-old, right-hand-dominant baseball player who injured his left shoulder 4 weeks ago during a game. He now has pain, weakness, and the inability to swing a bat and can no longer do push-ups. He denies prior injury to his left shoulder. Radiographs are unremarkable. The patient fails an extensive course of physical therapy and is unable to return to baseball. He and his orthopaedic surgeon elect to proceed with surgery. During a repeat evaluation, he has negative sulcus and Beighton sign findings, and radiographs show 5° of glenoid retroversion. What is the most appropriate surgical plan?

. Arthroscopic infraspinatus tenodesis
. Arthroscopic posterior labral repair
. Arthroscopic capsular shift and rotator interval closure
. Posterior glenoid opening-wedge osteotomy

Correct Answer & Explanation

. Arthroscopic infraspinatus tenodesis

Explanation

Posterior shoulder instability is a rare form of instability that often presents with pain rather than feelings of instability. It often occurs in young athletes during activities that put the shoulder in an “at-risk position” (flexion, adduction, internal rotation). Repetitive microtrauma can lead to posterior shoulder instability such as seen in football linemen. Swinging a bat or golf club places the lead arm in a flexed, adducted, and internally rotated position, which can lead to posterior translation of the humeral head that is forcibly reduced in follow-through, as seen in this patient. The glenohumeral joint relies on static and dynamic stabilizers. Static stabilizers help prevent instability at the end ranges of motion when the ligaments are taut. Dynamic stabilizers work to prevent subluxation at midranges of motion, at which the ligaments are lax. The rotator cuff is integral as a dynamic stabilizer of the shoulder. It works through a process called concavity compression. The four muscles of the rotator cuff compress the humeral head into the concavity of the glenoid-labrum. This prevents the humeral head from subluxing during the midranges of motion. Of the four rotator cuff muscles, the subscapularis is most important at preventing posterior subluxation. This patient has posterior instability, and various surgical techniques may be indicated depending on findings. Arthroscopic labral repair is indicated for anterior instability. Arthroscopic posterior labral repair is indicated for this patient because he has a posterior labral tear and posterior instability. If a patient has ligamentous laxity (not seen in this scenario because sulcus and Beighton sign findings would be negative), a posterior capsular shift with rotator interval closure is indicated. If a patient has excessive glenoid retroversion (not seen in this scenario with 5 degrees of retroversion), a posterior opening-wedge osteotomy is appropriate. The most common complication seen after arthroscopic posterior labral repair is stiffness, followed by recurrent instabilityand         degenerative         joint         disease.

Question 1492

Topic: 5. Sports Medicine

A 19-year-old college football player reports persistent weakness, tingling, and numbness of both upper extremities at half time. He states that these symptoms initially occurred after tackling an opposing player with his head early in the game. History reveals that he has had “burners” in the past that typically resolved within 15 to 30 minutes. Examination reveals pain-free cervical motion, weakness to shoulder abduction testing bilaterally, normal upper extremity reflexes, and decreased sensation over both shoulders and the upper arms. Appropriate initial management should consist of

. no treatment, the athlete may return to play.
. modification of the shoulder pads and a return to play.
. shoulder rehabilitation exercises and a return to play when strength is normal.
. MRI of the cervical spine.
. CT of the brain.

Correct Answer & Explanation

. no treatment, the athlete may return to play.

Explanation

DISCUSSION: The player’s symptoms represent more than the mere “burner syndrome,” which leads to unilateral symptoms that typically last less than 1 minute.  Return to play following a burner is allowed following nonsurgical management and once the symptoms have subsided and the player exhibits normal strength and motion of the neck and upper extremities.  This player has the history, symptoms, and examination findings that are consistent with cervical neurapraxia.  Return to play in contact sports is contraindicated with bilateral symptoms prior to MRI evaluation of the cervical spine.  CT of the brain is indicated with a history of loss of consciousness or other symptoms suggestive of a concussion.REFERENCES: Torg JS, Sennett B, Pavlov H, et al: Spear tackler’s spine: An entity precluding participation in tackle football and collision activities that expose the cervical spine to axial energy inputs.  Am J Sports Med 1993;21:640-649.Torg JS: Cervical spinal stenosis with cord neurapraxia and transient quadriplegia.  Sports Med 1995;20:429-434.Torg JS, Guille JT, Jaffe S: Injuries to the cervical spine in American football players.  J Bone Joint Surg Am 2002;84:112-122.

Question 1493

Topic: Knee Sports

Risk for vascular injury during transtibial drilling for reconstruction of this injury is increased by

. accessory incisions.
. use of tapered drill bits.
. use of oscillating drills.
. greater knee extension.

Correct Answer & Explanation

. accessory incisions.

Explanation

DISCUSSIONThe 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, 1 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.In Question 12, 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 for vascular injury.

Question 1494

Topic: 5. Sports Medicine

A 20-year-old college soccer player comes for an evaluation 6 months after an injury during which he landed awkwardly from a jump. Although physical therapy, ice, and activity modification have helped him return to baseline motion, strength, and swelling, he continues to have lateral knee pain. He also notes a popping sensation on the lateral side of his knee with activity. A Lachman test, anterior and posterior drawer tests, a pivot shift test, and McMurray test findings are all negative. MR images reveal a 12-mm x 15-mm osteochondral defect in the lateral femoral condyle with full-thickness cartilage loss and approximately 4 mm of subchondral bone loss.

. Physical therapy and a home exercise program
. Corticosteroid injection
. Arthroscopic debridement
. Microfracture
. Osteochondral autograft transplantation (OAT)

Correct Answer & Explanation

. Physical therapy and a home exercise program

Explanation

DISCUSSIONPatellofemoral pain in a young athlete without patellar instability or a chondral or osteochondral defect often can be managed with nonsurgical treatment such as physical therapy and a home exercise program. Microfracture surgery is associated with good short-term results for younger athletes. Patients with no history of prior surgery, primary chondral rather than osteochondral lesions, and lesions smaller than 2 cm have experienced the best results. Microfracture surgery performed for chondral lesions of the central aspect of the medial femoral condyle is associated with worse results. Decreased activity levels over time of patients who undergo microfracture surgery are a concern. OAT provides good outcomes and return-to-sports rates for athletic people who are younger and have lesions smaller than 2 cm. Patients with lesions on the lateral femoral condyle have better success rates. Both microfracture surgery and OAT provide better results for chondral defects than osteochondral defects. OAT is associated with better results than microfracture for medium-sized lesions between 2 cm and 4 cm, while autologous chondrocyte implantation yields better improvement for patients with defects larger than 4 cm. All of the surgical techniques listed for articular cartilage repair are associated with better outcomes for patients younger than age 30.

Question 1495

Topic: 5. Sports Medicine
A 16-year-old ice hockey player is struck on the chest by the puck. He skates a few strides and then collapses. What is the most likely diagnosis?
. Acute aortic dissection
. Pulmonary contusion
. Commotio cordis
. Acute cardiac tamponade
. Splenic rupture

Correct Answer & Explanation

. Commotio cordis

Explanation

DISCUSSION: Sudden cardiac arrest following a blow to the chest in young athletes has been termed “commotio cordis.” It is most common in Little League and other youth projectile sports (e.g., ice hockey, lacrosse). The cause, although not completely determined, is most likely an arrhythmia related to the impact in a vulnerable time in the cardiac cycle. Resuscitation has proven to be exceedingly difficult, resulting in a high mortality rate.

Question 1496

Topic: 5. Sports Medicine
Osteochondritis dissecans of the capitellum is a source of elbow pain and most commonly occurs in what patient population?
. Swimmers and divers
. Football lineman
. Rugby players
. Gymnasts and throwing athletes
. Cyclists

Correct Answer & Explanation

. Gymnasts and throwing athletes

Explanation

DISCUSSION: The etiology of osteochondritis dissecans of the capitellum is somewhat unclear. However, trauma has been implicated in this disease process. Gymnasts who load their upper extremities during tumbling and throwing athletes with repetitive trauma during the throwing motion are common patient subgroups in which osteochondritis dissecans of the elbow is seen. This often occurs in the adolescent age population. REFERENCES: Baumgarten TE, Andrews JR, Satterwhite YE: The arthroscopic classification and treatment of osteochondritis dissecans of the capitellum. Am J Sports Med 1998;26:520-523. Takahara M, Ogino T, Fukushima S, et al: Nonoperative treatment of osteochondritis dissecans of the humeral capitellum. Am J Sports Med 1999;27:728-732.

Question 1497

Topic: Shoulder & Hip Sports
A 24-year-old man has bilateral hip pain. An examination and imaging studies (plain radiographs and MR imaging) confirm evidence of femoroacetabular impingement (FAI) with a CAM deformity in both hips. The patient mentions that he has a 19-year-old brother who has occasional hip pain. With respect to his brother’s pain, how should you counsel the patient?
. His younger brother’s hip pain is almost certainly attributable to some other cause
. His younger brother’s hip pain likely represents established osteoarthritis of the hip
. His younger brother’s hip pain may be related to FAI
. There is no known genetic influence in the etiology of FAI

Correct Answer & Explanation

. His younger brother’s hip pain may be related to FAI

Explanation

DISCUSSION: Evidence suggests that FAI is more common in siblings of patients with FAI, particularly those with a CAM deformity. It is unlikely this patient has well-established osteoarthritis, even in the presence of FAI.

Question 1498

Topic: 5. Sports Medicine
Figure 23 shows the postoperative radiograph of a patient who underwent an anterior cruciate ligament (ACL) reconstruction (with bone-patella tendon-bone autograft) that failed. He initially had loss of flexion postoperatively. What is the most likely cause of this failure?
. Fixation in the tibial tunnel
. Fixation in the femoral tunnel
. Posterior placement of the tibial tunnel
. Anterior placement of the femoral tunnel
. Size of the patellar autograft

Correct Answer & Explanation

. Anterior placement of the femoral tunnel

Explanation

The key to this question is the fact that the patient initially lost flexion postoperatively and this relates to anterior placement of the femoral tunnel, thus capturing the knee. The bone plug seen on the radiograph is actually from the tibial tunnel, but this occurred as the patient forced flexion until failure of the ACL graft and pullout of the plug from the tunnel. Although it could be argued that better tibial fixation would have prevented this failure, poor placement of the femoral tunnel led to the failure of this ACL reconstruction.

Question 1499

Topic: Shoulder & Hip Sports
A 25-year-old man injures his shoulder while skiing. Examination reveals increased passive external rotation, pain in the cocked position, and a positive lift-off test. What is the most likely diagnosis?
. Ruptured biceps tendon
. Subscapularis tear
. Anterior subluxation
. Internal impingement syndrome
. Locked posterior dislocation

Correct Answer & Explanation

. Subscapularis tear

Explanation

A positive lift-off test and increased passive external rotation are diagnostic of a subscapularis tear or detachment. Although a similar injury could produce anterior instability, this will test the integrity of the subscapularis. A locked dislocation has limited passive movement. A ruptured biceps tendon will most likely produce ecchymosis and findings similar to supraspinatus trauma. Internal impingement is not associated with subscapularis weakness.

Question 1500

Topic: 5. Sports Medicine
Which of the following nerves is most commonly injured during ankle arthroscopy?
. Sural
. Deep peroneal
. Saphenous
. Superficial peroneal
. Posterior tibial

Correct Answer & Explanation

. Superficial peroneal

Explanation

DISCUSSION: The superficial peroneal nerve, which is adjacent to the location of the lateral arthroscopic portal, is most commonly injured. REFERENCES: Ferkel RD, Heath DD, Guhl JF: Neurological complications of ankle arthroscopy. Arthroscopy 1996;12:200-208. Barber CL, Click J, Britt BT: Complications of ankle arthroscopy. Foot Ankle 1990;10:263-266.

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