5. Sports Medicine MCQs

Prevention is the key to controlling infections among athletes. Proper hygiene is critical and should mandate showering, hand washing, wearing breathable clothing, and shower sandals. The sharing of towels or athletic equipment should be forbidden. Daily skin surveillance by athletes, trainers, and physicians can allow early recognition and treatment initiation during the early stages of infection, limiting risk for further transmission. Additionally, disinfecting shared equipment, covering lesions with occlusive dressing during sporting activity, and restricting the contact activities of infected athletes can limit risk for an infectious outbreak among teammates.

Using the traditional concussion grading scale, the patient sustained a grade I concussion because he did not lose consciousness and his abnormal cognitive level lasted less than 1 hour. If this was the player’s first concussion, theoretically he could return to play later in the game provided that he had no confusion, headache, or associated symptoms. However, because it was the third concussion for the year, participation in contact sports should be terminated for the season.

HAGL lesions may initially be treated without surgery. Recurrent instability in the setting of a HAGL lesion may be treated with a soft-tissue repair. A non-engaging or non-tracking Hill-Sachs lesion may be treated with an anterior soft-tissue (Bankart) repair. A tracking or engaging lesion may be treated with a bony glenoid procedure or a soft-tissue procedure plus remplissage. An ALPSA lesion may be treated with a soft-tissue procedure unless it is associated with a glenoid bony defect >25%. A glenoid bony defect >25% is associated with substantially higher recurrence than defects <20%, and consideration for bony glenoid reconstruction is advised. Consideration of bone augmentation procedures with less severe glenoid bone loss may be consideredin collision athletes.

The MRI scan shows a cyst at the spinoglenoid notch. These cysts are often associated with a labral injury, such as a superior labrum anterior and posterior (SLAP) lesion. The suprascapular nerve passes through the suprascapular notch and sends motor branches to the supraspinatus and sensory branches to the capsule. At the spinoglenoid notch, the infraspinatus branch of the suprascapular nerve is compressed by the cyst, leading to isolated infraspinatus atrophy. The teres minor and the deltoid are innervated by the axillary nerve.

Repetitive overhead slams and serves may produce a traction injury to the distal branch of the suprascapular nerve. Bankart, biceps, and superior labrum anterior and posterior injuries can occur but usually do not produce visible atrophy. Muscle avulsion is uncommon.

DISCUSSION: The MR images show injuries to the ACL, PCL, and PLC consistent with a knee dislocation. The optimal timing of surgery after multiligament knee injury remains unclear. Orthopaedic surgeons performing arthroscopy during the early postinjury period must be mindful of the extensive soft-tissue damage present in these patients, including potential capsular defects. Use of high-pressure irrigation can lead to substantial fluid extravasation into the thigh or lower leg compartments, placing patients at increased risk for compartment syndrome.

DISCUSSION: A rotator cuff tear is the most common cause of recurrent instability following a first-time dislocation in patients older than age 40 years. Dislocations occur through a posterior mechanism rather than by an isolated labral avulsion or a Bankart lesion as seen in younger patients. REFERENCES: Nevaiser RJ, Nevaiser TJ: Recurrent instability of the shoulder after age 40. J Shoulder Elbow Surg 1995;4:416-418. Pevny T, Hunter RE, Freeman JR: Primary traumatic anterior shoulder dislocation in patients 40 years of age and older. Arthroscopy 1998;14:289-294.

This patient underwent an ACL reconstruction that has now failed. Based on his examination, he also has a posterolateral corner injury. Because this concomitant injury was not treated, the patient had undue strain on his graft, resulting in ultimate failure. Hamstring grafts are as effective as other graft types for ACL reconstruction. The medial meniscus provides secondary stabilization to the knee; however, this patient has a missed lateral ligamentous injury, and meniscus tears do not result in the development of a varus thrust. An unrecognized PCL tear likely results in mild-to-moderate medial and patellofemoral osteoarthritis without significant lateral laxity and thrust.(SBQ12SP.35) A 16-year-old male football player is tackled into the ground during a game. He comes to the sideline with unilateral upper extremity pain, burning dysesthesias, and muscle weakness. Several minutes later, his symptoms resolve. In this scenario, what muscles are most likely to be affected?Review TopicDeltoid and bicepsTricepsWrist flexorsFinger flexorsInterosseiThis patient presents with a 'burner' or 'stinger,' a transient unilateral neurapraxia that most commonly involves the biceps, deltoid and rotator cuff muscles.Hypotheses for the mechanism of neurapraxia in stingers include nerve root compression in the neural foramen as a result of extension and compression, traction on the brachial plexus or a direct blow to the plexus. C5-C6 is the most commonly involved level, indicating root injury or upper trunk brachial plexus injury. Unilateral and transient symptoms are required for diagnosis. Bilateral 'stinger' symptoms of numbness, tingling, and weakness are consistent with cervical spinal cord neurapraxia. Return to play in contact sports is contraindicated with bilateral symptoms prior to MRI evaluation of the cervical spine.Shannon et al. review burner syndrome in athletes. They emphasize that criteria for return to play are based on a complete and thorough neurologic and physical exam. Normal strength and sensation in both upper extremities as well as a normal cervical spine exam (including range of motion, compression, Spurling's, Adson's, and resistive head pressures) are required for return to play. Any positive findings mandate withdrawal of the player from competition.Illustration A shows hypothesized areas of involvement by mechanism according toShannon et al. A, Extension-ipsilateral compression. B, Flexion-contralateral flexion (traction) or direct trauma.Incorrect Answer Answer Answer2:3:4:Wrist FingerTricepsflexors flexorsC7 C7 C8

This patient has cam-type femoroacetabular impingement. Decreased internal rotation and a positive impingement test (forced flexion, adduction, and internal rotation) are classic findings. The lack of pain with resisted hip flexion makes hip flexor strain unlikely, and the lack of tenderness at the greatertrochanter renders trochanteric bursitis unlikely. Although athletic pubalgia can be a source of longstanding groin pain, he lacks the pain with a resisted sit-up and tenderness along the pubic ramus that is frequently noted in patients with pubalgia. His radiographs reveal a focal femoral neck prominence consistent with cam impingement, although pistol grip deformities and flattening of the lateral femoral head are often present as well. His MRI scan shows a labral tear, which is common in cam impingement. Surgical treatment for cam impingement can be effective for symptomatic patients. Even among high-level athletes, open surgical dislocation of the hip has been shown to have good results. Most patients with cam impingement can be treated with arthroscopic osteoplasty and achieve results comparable with those realized with open surgical dislocation. The literature describes success in terms of athletes returning to sports (even professional athletes) to be approximately 90% after arthroscopic treatment. Byrd and Jones described five patients who developed transient neurapraxias that resolved uneventfully. The patients in his series who had concomitant microfracture had a 92% return to sports within the follow-up period. Cam impingement has long been thought to be associated with a history of a slipped capital femoral epiphysis. The capitis in these patients is displaced posteriorly, resulting in a prominent anterior femoral neck and decreased hip internal rotation. Pincer impingement is associated with a deep acetabulum, such as protrusion acetabula and acetabular retroversion. A patient who underwent aperiacetabular osteotomy can develop a more retroverted acetabulum as well.

Discussion: The milking test, as seen in the photograph, elicits pain when a tear is present in the medial collateral ligament. Complete rupture is possible but unlikely when there is no history of trauma and the patient is able to throw pain-free for several innings. Subluxation of the ulnar nerve and triceps tendon subluxation present as a painful snapping over the medial aspect of the elbow.

Discussion: The arthroscopic images show a microfracture procedure. Perforation of the subchondral bone results in so-called “marrow stimulation” that results in the formation of fibrocartilage. This reparative tissue is composed predominantly of type I collagen with a disorganized matrix lacking a true tidemark, as opposed to hyaline cartilage which is composed primarily of type II collagen. This operation is indicated for full-thickness chondral defects without associated degenerative arthrosis.

DISCUSSION: Passing the 70-degree arthroscope through the intercondylar notch provides excellent visualization of the posteromedial corner of the knee. This view should be part of every knee arthroscopy because these structures are often not well visualized from the anterior portals. If this view is omitted, tears of the peripheral posterior horn of the medial meniscus can be overlooked. The arrow points to the peripheral aspect of the posterior horn of the medial meniscus. With an intact medial meniscus, the medial tibial plateau should not be seen from this view. The semimembranosus and gastrocnemius tendons are extra-articular and not visualized. REFERENCES: Miller MD: Basic arthroscopic principles, in DeLee JC, Drez D Jr, Miller MD (eds): Orthopaedic Sports Medicine, ed 2. Philadelphia, PA, Saunders, 2003, pp 224-237. Gold DI, Schaner PJ, Sapega AA: The posteromedial portal in knee arthroscopy: An analysis of diagnostic and surgical utility. Arthroscopy 1995;11:139-145.

A sulcus sign represents inferior subluxation of the shoulder. The elimination of this sign and correction of the inferior subluxation is best achieved through either an open or arthroscopic rotator interval closure. A SLAP repair stabilizes the biceps anchor but does not affect the sulcus sign. A Bankart repair, which corrects anterior-inferior laxity, is not sufficient to eliminate a sulcus sign. Subacromial decompression and supraspinatus repairs have no effect on inferior subluxation.

DISCUSSION: Femoral acetabular impingement usually presents in active young adults with the slow onset of groin pain that often starts after a minor trauma. Physical examination reveals limitation of motion with a positive impingement test which consists of forceful internal rotation with flexion and adduction. Femoral acetabular impingement is a mechanism for the development of early osteoarthritis in nondysplastic hips.

DISCUSSION: The MRI scan shows bone bruises in the medial aspect of the patella and the lateral aspect of the lateral femoral condyle. Both of these signs are typical for a lateral dislocation of the patella with spontaneous reduction. In addition, there may be associated tearing of the medial retinaculum or distal aspect of the vastus medialis. REFERENCES: Elias DA, White LM, Fithian DC: Acute lateral patellar dislocation at MR imaging: Injury patterns of medial patellar soft-tissue restraints and osteochondral injuries of the inferomedial patella. Radiology 2002;225:736-743. Sanders TG, Miller MD: A systematic approach to magnetic resonance imaging interpretation of sports medicine injuries of the knee. Am J Sports Med 2005;33:131-148. Miller TT: Magnetic resonance imaging of the knee, in Insall JN, Scott WN (eds): Surgery of the Knee, ed 4. Philadelphia, PA, Churchill Livingstone, 2006, vol 1, pp 201-224.

DISCUSSION: The MRI scan reveals a partial patellar tendon rupture in conjunction with chronic patellar tendinitis. Mild and moderate patellar tendinitis may be treated nonsurgically with rest, stretching, strengthening, and anti-inflammatory drugs. Severe tendinopathy or extensor mechanism disruption is best treated surgically with tendon debridement and repair. REFERENCES: Al-Duri ZA, Aichroth PM: Surgical aspects of patella tendonitis: Techniques and results. Am J Knee Surg 2001;14:43-50. Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 218-219.

DISCUSSION: An isolated tear of the subscapularis tendon has been noted as early as 1835 by Smith. In Gerber and associates’ 1991 report of 16 men with an average age of 51 years, isolated subscapularis tendon rupture was often caused by a violent hyperextension injury. All patients reported pain anteriorly along with night pain. They also noted pain and weakness of the arm. The lift-off test is performed by having the patient lift the palm of the hand away from the small of the back. The patient must have sufficient internal rotation to allow this test to be performed. A subscapularis rupture is likely if the patient cannot perform the lift-off test. REFERENCES: Hertel R, Ballmer FT, Lombert SM, Gerber C: Lag signs in the diagnosis of rotator cuff rupture. J Shoulder Elbow Surg 1996;5:307-313. Gerber C, Krushell RJ: Isolated rupture of the tendon of the subscapularis muscle: Clinical features in 16 cases. J Bone Joint Surg Br 1991;73:389-394. Greis PE, Kuhn JE, Schultheis J, Hintermeister R, Hawkins R: Validation of the lift-off test and analysis of subscapularis activity during maximal internal rotation. Am J Sports Med 1996;24:589-593. Gerber C, Hersche O, Farron A: Isolated rupture of the subscapularis tendon. J Bone Joint Surg Am 1996;78:1015-1023.

The patient has sustained a complex tear involving the posterior horn of the medial meniscus. Localizing joint line tenderness is the most sensitive physical examination finding for this injury.Many provocative tests have been described to aid in the diagnosis of meniscus tears.The Apley test is performed with the patient prone, by axially loading the tibiofemoral joint at 90° of knee flexion. Pain with compression and external rotation (medial meniscus) or internal rotation (lateral meniscus) is considered positive.The Ege's test is performed by having the patient squat with their knees maximally externally rotated or internally rotated. The test is positive when pain and/or a click is felt by the patient.The McMurray test is performed by passively moving the knee from flexion to extension while externally or internally rotating the leg. A palpable click at the joint line with external rotation (medial meniscus) or internal rotation (lateral meniscus) is considered positive.The Thessaly test is performed by supporting the patient as they internally or externally rotate their knee and body while keeping the foot planted, with the knee in 5° of flexion and then 20° of flexion. The test is positive when joint line pain and/or sense of locking/catching is experienced by the patient.Ryzewicz et al. performed a systematic review of prospective cohort studies comparing magnetic resonance imaging (MRI) and clinical examination to arthroscopy in the diagnosis of meniscus tears. The Apley test, Ege's test, McMurray test and Thessaly test at 5° were shown have high specificity but low sensitivity. Joint line tenderness has a higher sensitivity, but lower specificity. The Thessaly test at 20° demonstrated the highest sensitivity and specificity, although there was only one available study evaluating this test.Abdon et al. performed a prospective study looking at 68 clinical parameters todetermine which combinations of symptoms and signs indicated the presence of a meniscus tear. They found that joint-line tenderness and mechanical locking were predictive of a meniscus tear, while the McMurray sign did not prove valuable. Pain at rest, sick leave and medial patellar tenderness all negated the presence of a meniscus tear. The clinical accuracy in diagnosing meniscal tears was 61% in this study.Figures A and B are T1 sagittal MR images demonstrating an intact anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL), respectively. Figures C and D are T2 coronal and sagittal MR images showing a complex tear of the posterior horn of the medial meniscus. Illustration A demonstrates the Ege's test. Illustration B shows the Thessaly test at 5° of flexion.Incorrect

The reference article is a landmark in female ACL injury literature. Hewett et al, “Plyometric Training in Female Athletes.” Am. J. Sports Med 1996, 24(6) pg 765-773. The conclusion: “This training may have significant effect on knee stabilization and prevention of serious knee injury among female athletes.” Prophylactic surgery and oral contraceptive prescription are not supported by evidence for injury prevention. Derotation braces are typically used for ACL-deficient knees, not for primary prevention.

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 for vascular injury.