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5. Sports Medicine MCQs

Practice Set 81 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 1601

Topic: 5. Sports Medicine
A 23-year-old right-hand dominant professional baseball pitcher has right shoulder pain when releasing the ball. He has noticed his velocity has decreased over the past 2 months. Examination reveals supine abducted external rotation of 110 degrees compared to 100 degrees on the left side. His internal rotation is 30 degrees on the right compared to 70 degrees on the left side. Rotator cuff strength is normal. All other clinical tests are normal. MRI with contrast reveals no intra-articular lesions. What is the best course of treatment?
. Arthroscopic capsular plication
. Arthroscopic thermal shift
. Arthroscopic subacromial decompression
. Posterior capsular stretching
. Selective external rotation stretching

Correct Answer & Explanation

. Posterior capsular stretching

Explanation

The examination reveals that the patient has posterior capsular tightness. Surgery should not be considered until the patient has failed to respond to nonsurgical management. The internal rotation contracture (GIRD - glenohumeral internal rotation deficit) should be addressed with appropriate posterior capsular stretching.

Question 1602

Topic: Shoulder & Hip Sports
For which of the following conditions will a rehabilitation program for shoulder instability most likely result in a satisfactory response?
. recurrent traumatic anterior dislocation
. recurrent traumatic posterior dislocation
. traumatic subluxation with no previous dislocation
. traumatic anterior subluxation
. atraumatic involuntary subluxation

Correct Answer & Explanation

. atraumatic involuntary subluxation

Explanation

In a study by Burkhead and Rockwood, shoulder instability was classified with criteria applying to whether a patient had traumatic or atraumatic subluxation of the glenohumeral joint. In this classification Type I is a traumatic subluxation without previous dislocation, Type II is a traumatic subluxation after previous dislocation, Type IIIA is an atraumatic, voluntary subluxation in patients with psychological problems, Type IIIB is an atraumatic, voluntary subluxation in a patient without psychological problems and Type IV is an involuntary subluxation. In their study they found that shoulders that have traumatic instability (type I or type II) had a 15 percent chance of a good or excellent outcome with a rehab program as compared with atraumatic subluxations (type III or type IV) which had an 83 percent good to excellent result. Since answer 5 is the only atraumatic type of subluxation it would statistically stand the best chance for improvement with a rehab program.

Question 1603

Topic: 5. Sports Medicine
Figure 19 shows an arthroscopic view from the anterior lateral portal of the knee looking into the suprapatellar pouch. The use of an electrothermal device during this procedure most commonly causes significant postoperative complications by damaging which of the following structures?
. Lateral facet articular cartilage of the patella
. Peroneal nerve
. Superior lateral geniculate artery
. Inferior lateral geniculate artery
. Lateral collateral ligament femoral insertion

Correct Answer & Explanation

. Superior lateral geniculate artery

Explanation

While it is possible to damage any of these structures, unrecognized intraoperative laceration without adequate coagulation of the superior lateral geniculate artery is common. This can result in significant postoperative hemarthrosis and a return to surgery when bleeding cannot be controlled.

Question 1604

Topic: Knee Sports

Figure 1 is the MRI scan of a 15-year-old boy who has had knee pain with running for 5 months. Radiographs show an osteochondritis dissecans (OCD) lesion of the medial femoral condyle. What is the most appropriate treatment?

. Arthroscopic or open reduction and internal fixation
. Arthroscopic loose body removal
. Activity restriction for up to 9 months
. Subchondral drilling

Correct Answer & Explanation

. Arthroscopic or open reduction and internal fixation

Explanation

OCD is an acquired lesion of the subchondral bone. Patients with OCD initially report nonspecific pain and variable amounts of swelling. Initial radiographs help identify the lesion and establish the status of the physes. An MRI scan is useful for assessing the potential for the lesion to heal with nonsurgical treatment. Nonsurgical treatment is appropriate for small, stable lesions in patients with open physes and focuses on activity restriction for 3 to 9 months. Surgical treatment is necessary for unstable or detached lesions. Stable lesions with intact articular cartilage can be treated with subchondral drilling to stimulate vascular ingrowth, with radiographic healing at an average of 4.4 months. Fixation is indicated for unstable or hinged lesions, and stabilization of the fragment can be achieved using a variety of implants through an arthroscopic or open approach. The fragment should be salvaged and the normal articularsurface restored whenever possible.

Question 1605

Topic: 5. Sports Medicine

A 32-year-old recreational basketball player underwent a successful anterior cruciate ligament (ACL) reconstruction using hamstring autograft approximately 15 months ago. His chart notes that he has good functional knee outcome scores as tested by his physical therapist. However, he has not returned to play despite being cleared by his physician 3 months ago. After successful ACL reconstruction, which of the following factors has shown to contribute the greatest influence on a player's decision to return to sport? Review Topic

. Surgeon's advice not to return
. Persistent knee pain
. Duration of sport participation
. Lifestyle and psychological factors
. Autograft harvasting surgical technique

Correct Answer & Explanation

. Surgeon's advice not to return

Explanation

Athletes who do not return to their preinjury level of sport after primary ACL reconstruction despite having good knee function are largely influenced by lifestyle and psychological factors.The return to their preinjury level of sport is frequently expected within 1 year after anterior cruciate ligament (ACL) reconstruction, yet many athletes do not achieve this milestone. Having a previous ACL reconstruction to either knee, poorer hop-test symmetry and subjective knee function, and more negative psychological responses were associated with not returning to the preinjury level sport. Fear of reinjury is considered one of the most common reasons cited for a postoperative reduction in orcessation of sports participation.Tjong et al. conducted a qualitative study of 31 patients, aged 18 to 40 years, to understand the factors influencing a patient's decision to return to his or her preinjury level of sport after ACL reconstruction. They found 3 overarching factors what largely influenced their decision to return to the preinjury sport: fear, lifestyle changes, and innate personality traits. This highlighted the importance of recognizing and addressing the psychological factors and lifestyle changes that significantly contribute to a patient's postoperative decision to return to sport.Ardern et al. investigated the return-to-sport rates at 2 years after ACL reconstruction in athletes. At 2 years after surgery, 66% were playing sport, with 41% playing their preinjury level of sport and 25% playing a lower level of sport. Demographics, physical function, and psychological factors were supported as the most important influencing factors for the return to their preinjury level of sport.Incorrect Answers:

Question 1606

Topic: 5. Sports Medicine
Baseball pitchers who have internal impingement will most likely demonstrate what changes in range of motion?
. Increase in internal rotation, decrease in external rotation
. Increase in internal rotation, increase in external rotation
. Decrease in internal rotation, decrease in external rotation
. Decrease in internal rotation, increase in external rotation
. Decrease in forward flexion, increase in external rotation

Correct Answer & Explanation

. Decrease in internal rotation, increase in external rotation

Explanation

DISCUSSION: Pitchers tend to have a decrease in internal rotation and an increase in external rotation. The increase in external rotation is felt to be multifactorial. An increase in humeral retroversion occurs from repeated throwing. This results in increased soft-tissue stretching and results in a posterior capsular contracture. REFERENCES: Meister K, Buckley B, Batts J: The posterior impingement sign: Diagnosis of rotator cuff and posterior labral tears secondary to internal impingement in overhand athletes. Am J Orthop 2004;33:412-415. Crockett HC, Gross LB, Wilk KE, et al: Osseous adaptation and range of motion at the glenohumeral joint in professional baseball pitchers. Am J Sports Med 2002;30:20-26.

Question 1607

Topic: 5. Sports Medicine
A 35-year-old carpenter sustained an injury to his dominant shoulder in a fall. He reports that he felt a sharp tearing sensation as he held on to a scaffold to keep from falling. Examination reveals swelling and ecchymosis down the upper arm, weakness to internal rotation, and deformity of the anterior axilla. He has good strength in external rotation and no apprehension with instability testing. Radiographs are normal. Management should consist of:
. physical therapy for range of motion and strengthening following a decrease in pain and swelling.
. shoulder arthroscopy for diagnosis and treatment of a possible labral tear.
. open exploration and repair of a pectoralis major tendon avulsion.
. MRI of the rotator cuff.
. immobilization in a sling and swathe for 3 to 6 weeks, followed by mobilization and strengthening.

Correct Answer & Explanation

. open exploration and repair of a pectoralis major tendon avulsion.

Explanation

DISCUSSION: The findings are classic for a pectoralis major tendon avulsion. Deformity of the anterior axillary fold is a classic finding, and ecchymosis down the arm suggests that the injury is at the humeral attachment rather than at the musculotendinous junction. Good external rotation strength indicates that function in the supraspinatus and infraspinatus has been preserved. The treatment of choice for a tendon avulsion in a young individual is early surgical repair. Conversely, if the injury is within the muscle or at the musculotendinous junction, initial nonsurgical management is recommended. If the location of the injury cannot be determined by physical examination, then MRI of the pectoralis major can be helpful. REFERENCES: Hanna CM, Glenny AB, Stanley SN, et al: Pectoralis major tears: Comparison of surgical and conservative treatment. Br J Sports Med 2001;35:202-206. Connell DA, Potter HG, Sherman MF, et al: Injuries of the pectoralis major muscle: Evaluation with MR imaging. Radiology 1999;210:785-791.

Question 1608

Topic: Knee Sports
Figures 21a through 21c show the MRI scans of a 21-year-old football player who sustained a valgus knee injury while changing direction. Examination reveals swelling and tenderness along the medial aspect of the knee. There is a positive Lachman test, 3+ valgus laxity at 30 degrees, and 1+ valgus laxity at 0 degrees extension. The anterior drawer test is increased with the tibia in external rotation. The increase in the anterior drawer test with the tibia in external rotation is most likely the result of:
. An occult fracture of the tibial plateau.
. A tear of the medial collateral ligament and the posteromedial capsule.
. A tear of the posterior cruciate ligament.
. A tear of the anterior and posterior cruciate ligaments.
. A tear of the anterior cruciate and medial collateral ligaments and the posteromedial capsule.

Correct Answer & Explanation

. A tear of the anterior cruciate and medial collateral ligaments and the posteromedial capsule.

Explanation

The injury mechanism involves a valgus load applied to the knee with the foot in external rotation. The primary stabilizer to valgus laxity is the medial collateral ligament. The secondary restraints to valgus rotation are the cruciate ligaments. Examination indicates disruption of the medial collateral and anterior cruciate ligaments. Valgus opening in extension should also arouse suspicion for an injury to the posterior cruciate ligament; however, in this patient, the valgus opening in extension is mild. The slight opening in extension and the increased anterior drawer, especially with external rotation, indicate disruption of the posteromedial capsule and posterior oblique ligament. Figure 21a shows complete disruption of the superficial and deep medial collateral ligaments involving the meniscofemoral ligament. Figure 21b shows a more posterior coronal section with a torn posterior oblique ligament. Figure 21c shows disruption of the anterior cruciate ligament, while the posterior cruciate ligament at the tibial insertion appears with a homogenous normal signal.

Question 1609

Topic: 5. Sports Medicine
A 30-year-old patient reports chronic medial knee pain and swelling. Figure 9a shows an articular cartilage lesion observed during arthroscopy. The surgeon decides to treat the lesion with the microfracture technique seen in Figure 9b. A biopsy of the repaired tissue 1 year after treatment is likely to show which of the following findings?
. Fibrocartilage
. Fibrous tissue
. Bone
. Articular cartilage
. Type II collagen

Correct Answer & Explanation

. Fibrocartilage

Explanation

DISCUSSION: Microfracture is a marrow stimulation technique where stem cells from the underlying subchondral bone marrow can form at the base of the lesion. The rationale for this technique is based on these cells differentiating into cells that will produce an articular cartilage repair. Biopsy findings in animals and humans have demonstrated primarily a fibrocartilaginous repair tissue and not articular cartilage. The collagen type found in hyaline or articular cartilage is of the type II variety. Fibrocartilage possesses mostly type I and III collagen. REFERENCES: Buckwalter JA, Mankin HJ: Articular cartilage: Degeneration and osteoarthritis, repair, regeneration, and transplantation. Instr Course Lect 1998;47:487-504. Buckwalter JA, Einhorn TA, Simon SR (eds): Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal System, ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 471-488.

Question 1610

Topic: 5. Sports Medicine
When comparing the failure load of an evenly tensioned four-stranded hamstring tendon anterior cruciate ligament autograft to a 10-mm bone-patellar tendon-bone autograft, the hamstring graft will fail at a tension
. equal to the bone-patellar tendon-bone graft.
. one half the failure load of the bone-patellar tendon-bone graft.
. one quarter the failure load of the bone-patellar tendon-bone graft.
. approximately two times the failure load of the bone-patellar tendon-bone graft.
. four times the failure load of the bone-patellar tendon-bone graft.

Correct Answer & Explanation

. approximately two times the failure load of the bone-patellar tendon-bone graft.

Explanation

DISCUSSION: The failure load of an evenly tensioned four-stranded hamstring tendon autograft has been reported to be 4,500 Newtons. The failure load of a 10-mm patellar tendon autograft has been estimated at 2,600 Newtons. The intact anterior cruciate ligament failure load has been calculated at 1,725 Newtons. REFERENCES: Corry IS, Webb JM, Clingeleffer AJ, Pinczewski LA: Arthroscopic reconstruction of the anterior cruciate ligament: A comparison of patellar tendon autograft and four-strand hamstring tendon autograft. Am J Sports Med 1999;27:448-454. Hamner DL, Brown CH Jr, Steiner ME, et al: Hamstring tendon grafts for reconstruction of the anterior cruciate ligament: Biomechanical evaluation of the use of multiple strands and tensioning techniques. J Bone Joint Surg Am 1999;81:549-557. Noyes FR, Butler DL, Grood ES, et al: Biomechanical analysis of human ligament grafts used in knee-ligament repairs and reconstructions. J Bone Joint Surg Am 1984;66:344-352.

Question 1611

Topic: Shoulder & Hip Sports
Figure 56 shows an arthroscopic view of the long head of the biceps; it has an incompetent biceps sling and is unstable, and an axial glenohumeral MRI scan reveals that it is dislocated medially out of the intertubercular groove. What structure is also most likely injured?
. Middle glenohumeral ligament
. Supraspinatus
. Infraspinatus
. Subscapularis
. Bankart tear

Correct Answer & Explanation

. Subscapularis

Explanation

It is important to recognize that rotator cuff tears are a common finding in the setting of a dislocated long head of the biceps tendon (LHB) from the intertubercular groove of the shoulder. If a LHB tendon dislocation is found on examination or radiographic work-up, it is imperative to rule out associated rotator cuff pathology, specifically of the subscapularis tendon. The subscapularis tendon is the primary stabilizer of the biceps in the groove.

Question 1612

Topic: Knee Sports
Figures 28a and 28b show AP and lateral radiographs of the knee. Based on these findings, which of the following structures has most likely been injured?
. Popliteal artery
. Quadriceps tendon
. Patellar tendon
. Anterior cruciate ligament
. Peroneal nerve

Correct Answer & Explanation

. Anterior cruciate ligament

Explanation

DISCUSSION: The radiographs show a posterior knee dislocation. Knee dislocations almost always involve rupture of both the anterior and posterior cruciate ligaments. Collateral ligament injuries also are common. Arterial, nerve, and tendon injuries each occur in less than half of knee dislocations.

Question 1613

Topic: 5. Sports Medicine
A 64-year-old woman with rheumatoid arthritis cannot fully extend her fingers actively at the metacarpophalangeal (MCP) level. Full passive extension is possible, but she cannot actively maintain that extension when her fingers are released. The MCP joints do extend when her wrist is passively flexed. What is the most likely cause of this problem?
. Extensor tendon ruptures at the wrist
. Subluxation of the extensor mechanisms at the MCP joint
. Caput ulnae syndrome
. Posterior interosseous nerve palsy

Correct Answer & Explanation

. Subluxation of the extensor mechanisms at the MCP joint

Explanation

EXPLANATION: Loss of MCP extension is common in the setting of rheumatoid arthritis. Subluxation of the extensor tendons at the MCP joints, as seen in attenuation of the sagittal bands, will usually preclude the initiation of active extension, but patients will be able to maintain extension of the MCP joints once they are placed in extension by the examiner. Extensor tendon ruptures allow for passive MCP extension, but not active extension or the ability to maintain extension actively, and would not involve finger extension with passive flexion tenodesis of the wrist.

Question 1614

Topic: 5. Sports Medicine

-What is the most appropriate initial treatment for her condition?

. Complete rest and a slow return to sports
. Physical therapy
. Corticosteroid injection
. Arthroscopic surgery PREFERRED RESPONSE: 2Question 75-After 1 year of following recommended treatment, this patient continues to experience her symptoms and has had to cease all sports activity. An MRI scan reveals no evidence of definitive labral or rotator cuff pathology. At this stage, what is the most appropriate treatment option?
. Arthroscopic rotator cuff repair
. Arthroscopic biceps tenodesis
. Arthroscopic capsular plication
. Arthroscopic superior labral anterior-posterior repair

Correct Answer & Explanation

. Arthroscopic capsular plication

Explanation

DISCUSSION FOR QUESTIONS 73 THROUGH 75This patient has a history most consistent with multidirectional instability. A lax capsule causes subluxation of the shoulder and strain on the rotator cuff and may result in pain and instability. The capsule is most closely associated with the cause of her problem. Initial treatment for multidirectional instability is physical therapy focusing on restoring balance to the shoulder with rotator cuff and scapular stabilization exercises. Nonsurgical therapy should be protracted and is the mainstay of treatment in this scenario. This patient has exhausted all nonsurgical measures and is now a candidate for surgical reconstruction. Capsular plication will best address the lax capsule and provide the best option for reducing her symptoms. The rotator cuff and biceps tendon may be secondarily strained but are not the primary sources of the problem. The brachial plexus does not address the etiology, but rather the symptoms that may occur as a result of instability of the shoulder joint.Complete rest will not alleviate the patient's underlying condition because the shoulder girdle may still be weak and symptoms likely will return. A corticosteroid injection and arthroscopic surgery are too invasive as initial treatment for this condition. Arthroscopic rotator cuff repair, a biceps tenodesis, and superior labral anterior-posterior repair are unlikely to result in symptomatic improvement for this patient and are not associated with pathologic findings in the setting of multidirectional instability.

Question 1615

Topic: Shoulder & Hip Sports

One week ago a 25-year-old man slipped on the ice and fell, catching himself on a railing. He sustained an anterior shoulder dislocation that was subsequently reduced without difficulty in the emergency department, and he was discharged in a sling. He is now back for follow-up and reports no pain. Examination reveals no weakness on external rotation strength testing. What is the most appropriate management for this patient? Review Topic

. Arthroscopic Bankart repair
. MRI for possible rotator cuff tear
. Physical therapy
. Sling immobilization for an additional 2 weeks
. Cortisone injection

Correct Answer & Explanation

. Sling immobilization for an additional 2 weeks

Explanation

On the basis of the patient's age, lack of weakness, and the fact that this is a first-time traumatic shoulder dislocation, he is unlikely to have sustained a rotator cuff tear. Immobilization should be continued for 2 more weeks. Scheduling a surgical stabilization procedure at this time is not indicated. Immediate therapy is contraindicated because of the acuity of the injury. A cortisone injection is not indicated in an acute traumatic shoulder dislocation.

Question 1616

Topic: Shoulder & Hip Sports

Which of the following best describes the pathologic anatomy of cam impingement of the hip? Review Topic

. Retroversion of the acetabulum
. Posteroinferior labral tears
. Morphologic abnormality of the femoral head
. Femoral anteversion
. Femoral head osteonecrosis

Correct Answer & Explanation

. Morphologic abnormality of the femoral head

Explanation

Cam impingement creates shearing forces that result in an outside-in directed detachment of the labrum in the anterosuperior quadrant. Retroversion of the acetabulum is associated with pincer impingement. The impingement is exhibited with hip flexion. Cam impingement involves a morphologic abnormality of the femoral head. Pincer lesions result from stresses of a normal femoral neck against an abnormal acetabular rim. Cam impingement is not associated with osteonecrosis.

Question 1617

Topic: 5. Sports Medicine

A 23-year-old otherwise healthy 6-ft, 4-in basketball player complains of pain in his knees. An examination reveals localized tenderness to palpation over the inferior pole of the patella. The patient notes a significant exacerbation of his pain when the examiner takes the knee from flexion to extension. Review Topic

. Semimembranosis tendonitis
. Patellar tendonitis
. Iliotibial band friction syndrome
. Quadriceps tendonitis

Correct Answer & Explanation

. Patellar tendonitis

Explanation

Patellar tendonitis is common in jumping sports such as basketball and volleyball. The pain is localized to the inferior border of the patella and is exacerbated by extension of the knee. Treatment for the vast majority of patients is nonsurgical and includes nonsteroidal anti-inflammatory drugs, physical therapy, and orthoses (patella tendon strap). Iliotibial band friction most commonly occurs in cyclists and runners (especially those who run up hills) and is a result of abrasion between the iliotibial band and the lateral femoral condyle. Localized tenderness with the knee flexed at 30 degrees is common. The Ober test may be helpful in making the diagnosis. Semimembranosis tendonitis most commonly occurs in male athletes during their fourth decade of life. The diagnosis is usually made with an MRI scan or nuclear imaging. Quadriceps tendonitis is similar to patellar tendonitis but is much less common. The pain may be associated with clicking and is localized to the superior border of the patella.

Question 1618

Topic: 5. Sports Medicine
A 19-year-old woman presents with a 3-year history of progressive hip pain in the left groin with activity, which is unresponsive to activity modification and physical therapy. Examination reveals normal range of motion, with pain on anterior impingement testing. What treatment is associated with the best long-term results?
. Hip arthroscopy with labral repair
. Reverse periacetabular osteotomy
. Varus rotational osteotomy
. Open surgical dislocation with rim trimming

Correct Answer & Explanation

. Reverse periacetabular osteotomy

Explanation

DISCUSSION: This patient has symptomatic femoroacetabular impingement as well as clinical and radiographic signs of acetabular retroversion, including a cross-over sign, ischial spine sign, and posterior wall sign bilaterally. Good midterm to long-term outcomes have been reported with reverse (anteverting) Bernese periacetabular osteotomy (PAO). In patients with less retroversion, open or arthroscopic rim trimming with labral refixation have shown good short-term results, but longer-term results have yet to be fully delineated. Isolated hip arthroscopy and labral repair would not be indicated without addressing the retroversion deformity. Femoral varus rotational osteotomy plays no role in the treatment of this pathology. Open surgical dislocation with rim trimming could be considered in patients with less deformity, but some studies have shown inferior long-term results compared with reverse PAO.

Question 1619

Topic: 5. Sports Medicine
Closed-chain exercise differs from open-chain exercise in which of the following ways?
. Distal portion of the extremity is free during exercise
. More commonly used in upper extremity exercise
. Predictable movement is produced by co-contraction of muscles
. Joint compression is decreased
. Usually involves a single joint

Correct Answer & Explanation

. Predictable movement is produced by co-contraction of muscles

Explanation

DISCUSSION: Closed-chain exercise requires the distal portion of the extremity to be fixed. It is more commonly used in lower extremity exercise, and movement is produced by co-contraction of muscles. Joint compression is increased, and multiple joints are involved with closed-chain exercise. In open-chain exercise, the distal portion of the extremity is free. REFERENCES: Braddom RL (ed): Physical Medicine and Rehabilitation, ed 2. Philadelphia, PA, Saunders, 2000, pp 975-976. Childs DC, Irrang JJ: The language of exercise and rehabilitation, in Delee JC, Drez D (eds): Orthopaedic Sports Medicine, ed 2. Philadelphia, PA, WB Saunders, 2003, vol 1, p 329.

Question 1620

Topic: Shoulder & Hip Sports
  • A branch of what nerve is at risk for injury when vigorous superior/medial retraction is applied to the interval between the teres minor and the infraspinatus during a posterior approach to the shoulder?
. radial
. axillary
. suprascapular
. thoracodorsal
. long thoracic

Correct Answer & Explanation

. suprascapular

Explanation

In the posterior approach to the shoulder the suprascapular nerve is located in the superior aspect of operative field coursing through the spinoglenoid notch and on the undersurface of the infra-spinatus muscle. When the interval between the teres minor muscle and the infraspinatus muscle is retracted tension is placed on the infraspinatus muscle as well as the suprascapular nerve, which could damage it. The axillary nerve runs through the operative field, but well below and is not retracted supramedially, so although there is a risk for injury to the axillary nerve it is not from the retraction superior medially. The radial, thoracodorsal and long thoracic nerves all lie anterior to the scapula.

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