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5. Sports Medicine MCQs

Practice Set 78 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 1541

Topic: Shoulder & Hip Sports
A 55-year-old man who works as a carpenter reports chronic right anterior shoulder pain and weakness. Examination reveals 90 degrees of external rotation (with the arm at the side) compared to 45 degrees on the left side. His lift-off examination is positive, along with a positive belly press finding. An MRI scan reveals a chronic, retracted atrophied subscapularis tendon. What is the most appropriate management of his shoulder pain and weakness?
. Shoulder fusion
. Arthroscopic subscapularis repair
. Intra-articular corticosteroid injection
. Open subscapularis repair
. Pectoralis major transfer

Correct Answer & Explanation

. Pectoralis major transfer

Explanation

DISCUSSION: Chronic subscapularis tendon ruptures preclude primary repair. In such instances, subcoracoid pectoralis major tendon transfers may improve function and diminish pain. The subcoracoid position of the transfer allows redirection of the pectoralis major in a direction recreating the vector of the subscapularis tendon. Shoulder fusion is a salvage procedure, and corticosteroid injection may reduce pain but will not improve function.

Question 1542

Topic: Shoulder & Hip Sports

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? Review Topic

. Radiographs
. Bone scan
. CT
. Ultrasonography
. MRI

Correct Answer & Explanation

. Radiographs

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 1543

Topic: 5. Sports Medicine

Which of the following types of intra-articular pathology is associated with lateral meniscal cysts? Review Topic

. Discoid meniscus
. Posterolateral corner injury
. Vertical meniscal tears
. Middle third lateral meniscal tears
. Popliteus tendon tears

Correct Answer & Explanation

. Discoid meniscus

Explanation

Lateral meniscal cysts often arise from myxoid degeneration that progresses from the meniscal center and then outside the meniscus. Horizontal cleavage tears are commonly associated with the condition. Cysts of the lateral meniscus are most commonly the consequence of a tear located in the medial third. If the tear communicates with the joint, arthroscopic partial meniscectomy and cyst decompression are indicated. If the tear does not open into the joint, arthroscopy should be followed by an open cystectomy.

Question 1544

Topic: Shoulder & Hip Sports

A 69-year-old woman has just undergone an uncomplicated total shoulder arthroplasty for glenohumeral osteoarthritis. A press-fit humeral stem and a cemented all-polyethylene glenoid component were placed. At this point, what is the postoperative rehabilitation plan? Review Topic

. Maintain sling immobilization for 6 weeks, and then begin a global range-of-motion program.
. Maintain sling immobilization for 3 weeks, and then begin a global range-of-motion program.
. Immediately begin an active assisted range-of-motion program emphasizing forward elevation and external rotation to the side.
. Immediately begin a passive range-of-motion program for forward elevation only; no external rotation is allowed for 6 weeks.
. Immediately begin active range of motion in forward elevation and external rotation to the side with a progression to full rotator cuff strengthening in 3 weeks.

Correct Answer & Explanation

. Maintain sling immobilization for 6 weeks, and then begin a global range-of-motion program.

Explanation

The patient needs to immediately begin an active assisted range-of-motion program emphasizing forward elevation and external rotation to the side. Sling immobilization without stretching for either 3 or 6 weeks will result in severe stiffness that will compromise her ultimate range of motion. Since she has a good quality subscapularis tendon, there is no need to avoid beginning external rotation to the side. However, starting a strengthening program at 3 weeks risks tearing the subscapularis tendon repair. Active strengthening should not begin for 6 weeks postoperatively to allow the subscapularis tendon repair time to heal.

Question 1545

Topic: 5. Sports Medicine

A 16-year-old boy has had knee pain for the past 6 months, and activity restrictions have not provided relief. An MRI scan reveals a stable 1.5 cm by 1 cm osteochondritis dissecans on the weight-bearing surface of the lateral femoral condyle. What is the best course of treatment? Review Topic

. Continued activity restrictions for 6 more months or until asymptomatic
. An aggressive physical therapy program that includes closed chain quadriceps strengthening
. Arthroscopic drilling of the subchondral bone
. Open debridement and screw fixation
. Osteochondral autograft transplant procedure

Correct Answer & Explanation

. Continued activity restrictions for 6 more months or until asymptomatic

Explanation

As a child approaches skeletal maturity, osteochondritis dissecans lesions are unlikely to heal with continued nonsurgical management. Drilling of the lesion has a high success rate. The lesion is stable and an open repair or osteochondral transplant is not needed.

Question 1546

Topic: 5. Sports Medicine
Longitudinal radioulnar dissociation, including Essex-Lopresti fractures, requires disruption of the interosseous membrane (IOM). The interosseous membrane (IOM) consists of all of the following ligaments EXCEPT?
. Central band ligament
. Accessory band ligament
. Annular ligament
. Dorsal oblique accessory cord ligament
. Distal oblique bundle ligament

Correct Answer & Explanation

. Annular ligament

Explanation

DISCUSSION: The IOM includes 5 types of ligaments: central band, accessory band, distal oblique bundle, proximal oblique cord, and dorsal oblique accessory cord. The annular ligament is not a part of the IOM. The IOM bridges the radius and ulna and acts as a hinge for rotation of radius about ulna. The central portion is thickened, and forms the central band which is the most important ligament for IOM load distribution characteristics.

Question 1547

Topic: Shoulder & Hip Sports
A 68-year-old woman has been progressing slowly after undergoing humeral head replacement for a four-part fracture 3 months ago. She has not regained active elevation, she feels an audible clunk on attempting elevation, and she reports pain and weakness. She used a sling for 2 weeks in the immediate postoperative period. Radiographs are shown in Figure 37a through 37c. Management should consist of
. tuberosity and rotator cuff repair with bone graft.
. revision arthroplasty leaving the prosthesis proud to increase humeral length and muscle tension.
. revision total shoulder arthroplasty to neutralize eccentric glenoid wear.
. revision of the humeral head replacement alone with increased retroversion.
. additional therapy to include internal and external rotation strengthening of the rotator cuff.

Correct Answer & Explanation

. tuberosity and rotator cuff repair with bone graft.

Explanation

DISCUSSION: Immediate repair of the tuberosity and rotator cuff is recommended on identifying the avulsion or nonunion. Revising the humeral component to increase tension and length will overtighten the cuff and increase the chance of tuberosity pull-off. The glenoid is uninvolved and should not be replaced. Attempts to strengthen the rotator cuff will be unsuccessful because the insertions are no longer attached to the humerus when the tuberosities avulse.

Question 1548

Topic: 5. Sports Medicine
An 18-year-old lacrosse player sustained a hamstring pull during a game. Examination the next day reveals ecchymosis through the posterior thigh and a palpable defect in the hamstring musculature in the middle third of the thigh. What is the most likely site of anatomic injury?
. Rupture of the biceps femoris at the myotendinous junction
. Rupture of the biceps femoris muscle belly
. Avulsion of the common hamstring origin from the ischium
. Complete rupture of the semimembranosus muscle belly
. Complete tear of all hamstring muscles

Correct Answer & Explanation

. Rupture of the biceps femoris at the myotendinous junction

Explanation

Hamstring strains are common in athletes. Basic science research and clinical data indicate that the majority of these injuries occur at the myotendinous junction, not within the muscle belly. Avulsion of hamstring origin from the ischial tuberosity does occur but is less common. Complete tearing of all hamstring muscles is unlikely to occur.

Question 1549

Topic: 5. Sports Medicine
Following an acute dislocation of the patella, the risk of a recurrent dislocation is greater if the patient has which of the following findings?
. Bipartite patella
. Age greater than 15 years at the time of the initial dislocation
. Persistent atrophy of the vastus lateralis
. Low-lying position of the patella (patella baja)
. Passive lateral hypermobility of the unaffected knee

Correct Answer & Explanation

. Passive lateral hypermobility of the unaffected knee

Explanation

The incidence of recurrence was greater in patients who demonstrated a predisposition to dislocation as determined by evaluation of the unaffected knee. Predisposing signs included passive lateral hypermobility of the patella, a dysplastic distal third of the vastus medialis obliquus muscle, and a high and/or lateral position of the patella.

Question 1550

Topic: Shoulder & Hip Sports

Figures 1 and 2 are the MR arthrogram images of a 20-year-old right-hand dominant collegiate basketball player who sustained an initial shoulder dislocation 1 year ago. In the month prior to presentation, he dislocated his shoulder two more times. Each time it occurred when going up for a rebound and an opponent grabbed the ball from behind him, hyperextending his shoulder. Physical examination demonstrates full range of motion, absence of atrophy, a positive apprehension sign and relocation test, and a positive Kim test. What is the best next step?

. Anterior labral repair
. Anterior labral repair and remplissage
. Posterior labral repair and rotator interval closure
. Anterior and posterior labral repair

Correct Answer & Explanation

. Anterior labral repair

Explanation

The mechanism of injury/dislocation is most consistent with anterior glenohumeral joint instability. The axial cuts of the MR arthrogram reveals an anteroinferior labral tear, as well as a posterior labral tear. A Hill-Sachs lesion is also consistent with anterior glenohumeral joint instability. At the time of examination under anesthesia, this patient exhibited 2+ anterior and 2+ posterior glenohumeral joint instability. Patients with pan-labral tears and 270ยฐ tears can be challenging to diagnose, because patients can report anterior or posterior shoulder instability alone. Thephysical examination and advanced imaging in these patients are crucial in directing appropriate treatment.

Question 1551

Topic: Knee Sports

You are evaluating a patient with recurrent patellar instability who has failed conservative management. MRI demonstrates articular cartilage loss in the patella. In addition to a cartilage restoration procedure, you recommend the procedure depicted in Figures A and B. Which of the following imaging findings best supports your decision? Review Topic

. Open tibial apophysis
. Medial patellar cartilage defect
. Femoral trochlear sulcus angle = 165ยฐ
. Tibial tubercle-trochlear groove distance = 25mm
. Patella tilt = 25ยฐ

Correct Answer & Explanation

. Open tibial apophysis

Explanation

A tibial tubercle-trochlear groove (TT-TG) distance > 20mm is highly associated with patellar instability secondary to rotational malalignment and is an indication for anteromedialization of the tibial tubercle (AMZ), pictured in Figures A and B, to enhance patellofemoral stability and decrease patellofemoral contact pressures in the setting of cartilage restoration procedures.Recurrent patellar instability is often associated with chondral lesions of the patellofemoral joint. In addition to managing the cartilage injury, the underlying etiology of the instability must also be addressed to ensure a successful outcome. Patellar instability may arise from coronal or rotational malalignment, patella alta, trochlear dysplasia or damage to soft tissue restraints including the medial patellofemoral ligament (MPFL). Rotational malalignment, defined by a TT-TG distance > 20mm, can be addressed by AMZ. Medialization of the tubercle restores a normal TT-TG distance while anteriorization of the tubercle unloads patellofemoral contact forces.Beck et al performed a cadaveric study measuring patellofemoral contact pressures on the trochlear surface following AMZ. They found that anteromedialization decreased the mean contact pressures and shifted contact pressures to the medial trochlea. The authors concluded that while this procedure successfully unloads the lateral trochlea, it likely has minimal benefit for central chondral defects and may be detrimental for medial chondral defects where contact pressures are increased.Strauss et al authored a review article detailing the surgical treatment options for patellofemoral cartilage lesions, including concomitant realignment/unloading procedures. AMZ is designed to correct rotational malalignment while unloading the patellofemoral compartment in the setting of cartilage restoration surgery. While AMZ has demonstrated good outcomes for lesions located in the lateral facet or distalpole of the patella, poor outcomes have been seen with medial facet or central trochlear lesions.Figures A and B are the AP and lateral radiographs, respectively, of a knee s/p AMZ, also know as a Fulkerson procedure. Illustration A is an algorithm detailing the approach to recurrent patellar instability in both skeletally immature and mature patients. Illustration B demonstrates how to measure the TT-TG distance, the distance between two lines drawn perpendicular to the posterior condylar axis to the tibial tubercle and deepest portion of the trochlear groove (normal 8-10mm). Illustration C depicts the measurement of the femoral trochlear angle or sulcus angle (normal 137ยฐ+/- 8ยฐ). Illustration D shows how to measure lateral patellar tilt (normal < 5ยฐ). Illustration E is a postoperative radiograph after AMZ. A long (> 5cm) and thick (> 0.75cm) osteotomy cut is required to allow adequate fixation with two screws.Incorrect Responses:

Question 1552

Topic: 5. Sports Medicine
Figure 22 shows the MRI scan of a 20-year-old female basketball player who has pain over the anterior knee that interferes with her performance. Examination reveals phase III Blazina patellar tendinosis. Management should consist of
. local modalities including iontophoresis.
. quadriceps and iliotibial band stretching exercises.
. progressive eccentric strengthening exercises.
. a patellar tendon strap.
. excision of the abnormal area.

Correct Answer & Explanation

. excision of the abnormal area.

Explanation

Excision of the affected mucoid degenerative area is considered appropriate management in the Blazina classification system. A finding of phase III indicates persistent pain with or without activities, as well as deterioration of performance. With the appearance of the mucoid degeneration and the vigorous activity level of the intercollegiate basketball player, it is unlikely that nonsurgical management will provide adequate relief. When excising the affected degenerative area, care must be taken to retain normal tendon fibers.

Question 1553

Topic: Shoulder & Hip Sports

Which of the following plain radiographic views of the shoulder best reveals a Hill-Sachs lesion of the humeral head?

. Lateral Y
. Scapular AP
. Neutral rotation AP
. Internal rotation AP
. External rotation AP

Correct Answer & Explanation

. Lateral Y

Explanation

Hill-Sachs lesion is an impression fracture of the posterosuperior aspect of the humeral head, produced by contact with the anteroinferior glenoid when dislocated. Hill-Sachs lesion is demonstrated on plain AP radiograph in internal rotation.

Question 1554

Topic: Shoulder & Hip Sports
A 22-year-old professional baseball catcher has posterior shoulder pain and severe external rotation weakness with the arm in adduction. Radiographs are normal. MRI scans are shown in Figures 15a through 15c. Management should consist of
. aspiration and steroid injection.
. rest.
. acromioplasty.
. arthroscopic repair and decompression.
. rehabilitation.

Correct Answer & Explanation

. arthroscopic repair and decompression.

Explanation

The MRI scans reveal a large posterior paralabral cyst associated with a posterior-superior labral tear. The cyst appears as a well-defined, smoothly marginated mass with low signal intensity on T1-weighted MRI scans and with high signal intensity on T2-weighted MRI scans. MRI also reveals changes in the supraspinatus and infraspinatus muscles secondary to denervation, including decreased muscle bulk and fatty infiltration. In this case of a professional baseball player with a space-occupying lesion causing nerve compression with an associated labral tear, the treatment of choice is arthroscopic decompression of the cyst and repair of the tear.

Question 1555

Topic: 5. Sports Medicine

Figure 1 is the MR image of a 14-year-old football player who injured his right knee during a game. He describes feeling a "pop" and then needing help walking off the field. His knee is visibly swollen. The patient undergoes surgery to repair/reconstruct the damaged structure and has no postsurgical complications and begins physical therapy rehabilitation. The boy and his parents stress they want to โ€œget the therapy over with as fast as possible" to expedite his return to sports, and the surgeon and rehabilitation team consider their request. Compared with 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 Score (KOOS).

Correct Answer & Explanation

. increased laxity.

Explanation

The MR image shows bone bruises (โ€œkissing contusionsโ€) consistent with an ACL tear. During the ACL subluxation event, the posterolateral tibial 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 versus nonaccelerated rehabilitation programs have demonstrated no significant differences in long-term 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 graftfailures, or KOOS scores.

Question 1556

Topic: 5. Sports Medicine
What is the function of the rotator cuff during throwing?
. Limits humeral head translation in the transverse plane but not in the sagittal plane
. Limits superior migration but not anterior and posterior translation
. Limits superior migration and anterior and posterior translation
. Provides little control of superior anterior and posterior translation
. Creates inferior migration with maximal contraction during acceleration

Correct Answer & Explanation

. Limits superior migration and anterior and posterior translation

Explanation

The coupled action of the rotator cuff prevents superior migration and controls anterior and posterior translation by depressing the humeral head.

Question 1557

Topic: Shoulder & Hip Sports

A 72-year-old man who underwent total shoulder arthroplasty 2 years ago slipped on ice and fell on his shoulder 3 weeks ago. Immediately after falling he was unable to elevate his arm. Motor examination reveals deltoid 5-/5, subscapularis 5-/5, external rotation 4-/5, and supraspinatus 2/5. Radiographs are shown in Figures 8a and 8b. What is the most likely diagnosis? Review Topic

. Anterior shoulder dislocation
. Humeral component loosening
. Glenoid component loosening
. Glenoid component catastrophic fracture
. Rotator cuff tear

Correct Answer & Explanation

. Anterior shoulder dislocation

Explanation

The patient has a traumatic rotator cuff tear. The history of the fall, the weakness on examination, and normal radiographic findings make a traumatic rotator cuff tear the most likely diagnosis. An MRI scan can be obtained to further evaluate the integrity of the rotator cuff. The axillary radiograph shows a reduced, nondislocated total shoulder arthroplasty. His radiographs show a well-seated humeral stem and no signs of loosening. The glenoid is a cemented all-polyethylene component with no evidence of radiolucent lines surrounding the cemented pegs. The polyethylene glenoid component is radiolucent; however, the space between the metallic humeral head and the glenoid bone is the thickness of the polyethylene glenoid component. If the humeral head were directly against the glenoid bone, then catastrophic fracture of the glenoid would be the working diagnosis.

Question 1558

Topic: 5. Sports Medicine

Figures below show the radiographs, MRI, and MR arthrogram obtained from a 25-year-old collegiate soccer player who has new-onset left groin pain. He played competitive soccer from a young age and has competed or practiced 5 to 6 times per week since the age of 10. He denies any specific hip injury that necessitated treatment, but his trainer contends that he had a groin pull. He reports groin pain with passive flexion and internal rotation of the left hip, and his hip has less internal rotation than his asymptomatic right hip. He is otherwise healthy.When counseling patients who have a cam deformity, the orthopaedic surgeon should note that

. osteoarthritis of the hip is likely to occur later in life.
. correction prevents later development of osteoarthritis.
. most acetabular tears are symptomatic, and surgical treatment will be necessary.
. this is an inherited deformity.

Correct Answer & Explanation

. osteoarthritis of the hip is likely to occur later in life.

Explanation

Multiple studies have confirmed that cam or pincer anatomy is commonly present in asymptomatic hips. According to a large systematic review, cam deformities are present in approximately one-third of asymptomatic hips in young adults, and the proportion is higher than 50% in the subgroup of athletes. Ganz and associates proposed that femoral acetabular impingement is the root cause of osteoarthritis in most nontraumatic, nondysplastic hips, and functional improvement with surgical correction of the deformity has been demonstrated. Despite the link between cam deformity and hip osteoarthritis, a corresponding link between the correction of the deformity and prevention of osteoarthritis has never been proven. The results of cam deformity correction, typically including repair of the degenerative labral tear, are much poorer when substantial joint space loss is present. A typical joint space cutoff of 2 mm or less is used to recommend against hip preservation surgery.

Question 1559

Topic: 5. Sports Medicine
An AP radiograph of the pelvis is shown in Figure 4. What muscle attaches to the avulsed fragment of bone identified by the arrow?
. Short head of the biceps femoris
. Adductor longus
. Pectineus
. Piriformis
. Semitendinosus

Correct Answer & Explanation

. Semitendinosus

Explanation

DISCUSSION: The radiograph reveals an avulsion of the ischial apophysis, most likely the result of violent contraction of the attached hamstring tendons (semimembranosus, semitendinosus, and long head of the biceps femoris). The short head of the biceps femoris arises from the linea aspera on the posterior femur. The pectineus and adductor longus attach to the pubic portion of the pelvis. The piriformis runs from the sacrum to the femur. REFERENCES: Woodburne RT (ed): Essentials of Human Anatomy. New York, NY, Oxford University Press, 1978, pp 542-545. Metzmaker JN, Pappas AM: Avulsion fractures of the pelvis. Am J Sports Med 1985;13:349-358.

Question 1560

Topic: Knee Sports

What type of medial collateral ligament tear heals the most reliably? Review Topic

. Proximal
. Midsubstance
. Distal
. Associated with an anterior cruciate ligament tear
. Associated with a posterior cruciate ligament tear

Correct Answer & Explanation

. Proximal

Explanation

Proximal medial collateral ligament (MCL) injuries adjacent to the medial epicondyle heal robustly. These proximal injuries are more prone to calcification, characterized clinically with temporarily increased pain and stiffness. The distal MCL, despite its long attachment site on the proximal tibia, heals less well. MCL injuries associated with other ligament injuries heal less reliably.

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