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5. Sports Medicine MCQs

Practice Set 82 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 1621

Topic: Shoulder & Hip Sports
Figures 39a and 39b show the MRI scans of a 25-year-old man with right shoulder pain. Figure 39c shows the arthroscopic view from a posterior portal in the beach chair position. What is the most likely diagnosis?
. Bankart lesion
. Superior labral tear
. Partial articular surface supraspinatus tear
. Partial bursal surface supraspinatus tear
. Full-thickness supraspinatus tear

Correct Answer & Explanation

. Partial articular surface supraspinatus tear

Explanation

DISCUSSION: The MRI scans show coronal oblique and sagittal oblique views of a partial articular surface supraspinatus tear or tendon avulsion (PASTA lesion). The arthroscopic view is a posterior portal of the glenohumeral joint viewing the articular surface of the supraspinatus. These tears are a common source of shoulder pain and are often amenable to transtendon arthroscopic repair without detachment of the intact bursal surface. REFERENCES: Sanders TG, Miller MD: A systematic approach to magnetic resonance imaging interpretation of sports medicine injuries of the shoulder. Am J Sports Med 2005;33:1088-1105. McConville OR, Iannotti JP: Partial-thickness tears of the rotator cuff: Evaluation and management. J Am Acad Orthop Surg 1999;7:32-43. Burkhart SS: Arthroscopic management of rotator cuff tears, in McGinty JB (ed): Operative Arthroscopy, ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 2003, pp 508-546.

Question 1622

Topic: Shoulder & Hip Sports
In patients older than age 40 years who sustain a first-time anterior dislocation of the shoulder, prolonged morbidity is most commonly associated with:
. recurrent dislocation.
. posttraumatic arthritis.
. a rotator cuff tear.
. stiffness secondary to immobilization.
. nerve injury.

Correct Answer & Explanation

. a rotator cuff tear.

Explanation

DISCUSSION: In the study done by Pevny and associates, 35% of patients older than age 40 years sustained rotator cuff tears and 8% had axillary nerve palsies. All of the patients with axillary nerve palsy also had rotator cuff tears. Imaging of the rotator cuff is indicated in this age group. The incidence of recurrent instability in patients older than age 40 years is 10% to 15%. REFERENCES: Pevny T, Hunter RE, Freeman JR: Primary traumatic anterior shoulder dislocation in patients 40 years of age and older. Arthroscopy 1998;14:289-294. Sonnabend DH: Treatment of primary anterior shoulder dislocation in patients older than 40 years of age: Conservative versus operative. Clin Orthop 1994;304:74-77. Hawkins RJ, Mohtadi NG: Controversy in anterior shoulder instability. Clin Orthop 1991;272:152-161.

Question 1623

Topic: 5. Sports Medicine
A 16-year-old boy sustains a twisting injury to the left knee while wrestling. MRI scans are shown in Figures 22a through 22c. What is the most likely diagnosis?
. Anterior cruciate ligament rupture
. Posterior cruciate ligament rupture
. Bucket-handle medial meniscus tear
. Lateral meniscus tear
. Osteochondral lesion

Correct Answer & Explanation

. Bucket-handle medial meniscus tear

Explanation

DISCUSSION: The MRI scans show a displaced bucket-handle medial meniscus tear that can be visualized on coronal, sagittal, and axial views. The sagittal view shows the typical “double posterior cruciate ligament sign,” in which the low-signal bucket-handle fragment parallels the normal low-signal posterior cruciate ligament. The coronal and axial images both show the displaced medial meniscus in the notch. REFERENCES: 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.

Question 1624

Topic: 5. Sports Medicine
A 22-year-old college baseball pitcher reports the recent onset of anterior and posterosuperior shoulder pain in his throwing shoulder. Examination shows a 15-degree loss of internal rotation, tenderness over the coracoid, and a positive relocation test. Radiographs are normal, and an MRI scan without contrast shows no definitive lesions. A rehabilitation program is prescribed. Which of the following regimens should be initially employed?
. Stretching the posterior capsule and pectoralis minor tendon
. Stretching the posterior capsule and strengthening the subscapularis
. Stretching the posterior capsule and using shoulder plyometrics
. Stretching the anterior capsule and strengthening all components of the rotator cuff
. Stretching the anterior capsule and improving pitching mechanics

Correct Answer & Explanation

. Stretching the posterior capsule and pectoralis minor tendon

Explanation

DISCUSSION: Throwing athletes, particularly pitchers, have a high incidence of shoulder pain. Recent evidence suggests that posteroinferior capsular tightness and scapular dyskinesis may play a substantial role in the pathologic cascade, culminating in the development of articular surface rotator cuff tears and tearing of the posterosuperior labrum. These patients have posterosuperior shoulder pain primarily. Furthermore, these athletes are susceptible to a muscular fatigue syndrome, the SICK (Scapular malposition, Inferior medial border prominence, Coracoid pain and malposition, and dysKinesis of scapular movement) scapula syndrome. This patient has an internal rotation deficit and tenderness over the coracoid. The internal rotation deficit is addressed by stretching the posterior capsule. The tenderness over the coracoid has been attributed to a contracture of the pectoralis minor tendon secondary to scapular malposition. The initial phase of the rehabilitation regimen is directed at stretching the posterior capsule and pectoralis minor tendon. REFERENCES: Burkhart SS, Morgan CD, Kibler WB: The disabled throwing shoulder: Spectrum of pathology. Part III. Arthroscopy 2003;19:641-661. Kibler WB, McMullen J: Scapular dyskinesis and its relationship to shoulder pain. J Am Acad Orthop Surg 2003;11:142-151.

Question 1625

Topic: 5. Sports Medicine
What is the recommended treatment for this injury?
. Bankart repair
. Hanging arm cast
. Rest and no pitching for 3 months
. Resume a throwing program but avoid curveballs and sliders

Correct Answer & Explanation

. Rest and no pitching for 3 months

Explanation

DISCUSSION: The hypertrophic zone of the growth plate has been implicated as the weak link in the physis in acute injuries. Epiphysiolysis of the proximal humerus in throwing athletes occurs as the result of tension and shear on the physis. More than 90% of affected patients who are treated with rest for an average of 3 months become asymptomatic. Prevention is the best option. Set limitations of the number of pitches and types of pitches depending on the age of the player. Also recommend use of proper pitching mechanics.

Question 1626

Topic: 5. Sports Medicine
What is the most common associated pathology in patients who have suprascapular nerve entrapment secondary to ganglion cysts?
. Glenohumeral arthritis
. Fracture of the clavicle
. Tear of the rotator cuff
. Rupture of the long head of the biceps tendon
. Superior labrum anterior and posterior (SLAP) lesion

Correct Answer & Explanation

. Superior labrum anterior and posterior (SLAP) lesion

Explanation

DISCUSSION: It is well known that suprascapular nerve entrapment can be secondary to many entities, and its association with ganglion cysts and SLAP lesions has been well documented. Because of a superior labral tear, synovial fluid will leak out of the joint underneath the labrum, causing the cyst and secondary compression of the nerve.

Question 1627

Topic: 5. Sports Medicine
What ligament is the primary restraint to applied valgus loading of the knee?
. Posteromedial capsule
. Posterior cruciate ligament (PCL)
. Superficial medial collateral ligament (MCL)
. Deep MCL
. Medial meniscus

Correct Answer & Explanation

. Superficial medial collateral ligament (MCL)

Explanation

DISCUSSION: The superficial portion of the MCL contributes 57% and 78% of medial stability at 5 degrees and 25 degrees of knee flexion, respectively. The deep MCL and posteromedial capsule act as secondary restraints at full knee extension. The anterior cruciate ligament and PCL also provide secondary resistance to valgus loads.

Question 1628

Topic: Shoulder & Hip Sports
A woman with a neck and chest tumor has weakness in the biceps and paresthesias in the thumb. Brachioradialis and infraspinatus function are normal. The lesion is affecting which of the following structures?
. C6
. Upper trunk
. Middle trunk
. Posterior cord
. Lateral cord

Correct Answer & Explanation

. Lateral cord

Explanation

The lateral cord terminates as the musculocutaneous nerve and also contributes sensory fibers to the median nerve. Involvement of the C6 root or upper trunk could potentially cause weakness of the infraspinatus and the brachioradialis. The middle trunk and the posterior cord do not contribute motor fibers to the thumb or sensory fibers to the thumb.

Question 1629

Topic: 5. Sports Medicine
A 22-year-old professional baseball pitcher has had pain in the axillary region of his dominant shoulder for the past several weeks. While throwing a pitch during a game, he notes a sharp pulling sensation with a “pop” in his shoulder. Examination the following day reveals tenderness along the posterior axillary fold and pain and weakness with resisted extension of the shoulder. What is the most likely cause of his symptoms?
. Type 2 tear of the superior labrum anterior and posterior
. Tear of the anterior labrum
. Tear of the subscapularis tendon
. Tear of the latissimus dorsi tendon
. Tear of the supraspinatus tendon

Correct Answer & Explanation

. Tear of the latissimus dorsi tendon

Explanation

Injury to the latissimus dorsi tendon recently has been reported as a cause of pain in the thrower’s shoulder. The etiology of this injury is felt to be eccentric overload during the follow-through of the throwing motion. Recommended management for this unusual injury consists of a short period of rest, followed by physical therapy to restore shoulder motion and strength.

Question 1630

Topic: 5. Sports Medicine
Which factor increases the success rate associated with all-inside lateral meniscal repair?
. Concomitant anterior cruciate ligament (ACL) reconstruction
. Concomitant medial meniscus repair
. Older patient age
. Varus knee alignment

Correct Answer & Explanation

. Concomitant anterior cruciate ligament (ACL) reconstruction

Explanation

Decreased patient age, neutral alignment, and a concomitant ACL tear are associated with improved success rates of meniscal repair. Meniscus tears on the contralateral side of the knee and articular cartilage defects are not associated with improved healing rates.

Question 1631

Topic: 5. Sports Medicine

Figure 50 shows the cross table lateral radiograph of a 31-year-old paratrooper who has recalcitrant groin pain. The pain is worse after activities such as standing or sitting (driving). Examination reveals that pain can be reproduced by internal rotation of the leg with the hip and knee in 90 degrees of flexion. Extensive nonsurgical management has failed to provide relief. What is the treatment of choice? Review Topic

. Periacetabular osteotomy
. Femoral neck osteotomy
. Femoroacetabular osteoplasty
. Hip arthroscopy and labral debridement
. Hip arthrodesis

Correct Answer & Explanation

. Periacetabular osteotomy

Explanation

The radiograph reveals the classic “bump” that is seen in patients with femoroacetabular impingement (FAI). Ganz and associates described two types of FAI. This patient has cam impingement, which describes a nonspherical femoral head being forced into the acetabulum during hip motion and resulting in labral and chondral injury. Hip arthroscopy and labral debridement is unlikely to control the symptoms because the underlying anatomic abnormality is often difficult to address with arthroscopy. The treatment involves surgical dislocation of the hip with preservation of the blood supply to the femoral head, removal of the asphericity on the femoral side (femoral osteoplasty), and removal of the acetabular rim (acetabular osteoplasty) if the latter is found to contribute to impingement.

Question 1632

Topic: Knee Sports
  • Posterior cruciate insufficiency diagnosed using the quadriceps active test is confirmed with tibial translation
. Anteriorly at 20 to 30 degrees of flexion
. Anteriorly at 70 to 90 degrees of flexion
. Posteriorly at 20 to 30 degrees of flexion
. Posteriorly at 70 to 90 degrees of flexion
. Anteriorly with the knee in full flexion

Correct Answer & Explanation

. Anteriorly at 20 to 30 degrees of flexion

Explanation

In the quadriceps active drawer test, with the subject supine, the leg is relaxed and supported with the knee flexed 70 to 90 degrees. The examiner must adequately support the patient’s thigh so that the subject’s muscles are completely relaxed. The patient is then asked to perform a gentle quadriceps contraction without extending the knee. In the normal knee in 90 degrees of flexion, the patellar ligament is already slightly posterior, and contraction of the quadriceps does not result in an anterior shift of the tibia. However if the PCL is ruptured, the tibia sags into a posteriorly subluxed position, and the patellar ligament is then directed anteriorly. In this situation, contraction of the quadriceps muscle in the posterior cruciate deficient knee results in an anterior shift of the tibia 2mm or more. The examiner can visualize this anterior shift of the tibia with the knee is 90 degrees of flexion.

Question 1633

Topic: Shoulder & Hip Sports

Which of the following postoperative rehabilitation techniques causes minimal rotator cuff muscle activation? Review Topic

. Active forward flexion
. Passive forward flexion
. Active-assisted forward flexion
. Overhead pulley-assisted passive forward flexion
. Isometric strengthening

Correct Answer & Explanation

. Active forward flexion

Explanation

Electromyography (EMG) studies have shown that the rotator cuff is least active with passive range of motion and hence this is allowed early in most postoperative rotator cuff rehabilitation protocols. Active forward flexion, active-assisted motion, and isometric strengthening all cause activation of the rotator cuff muscles (as measured by EMG) and therefore should be introduced later in rehabilitation when the repair can withstand these forces. Whereas some authors have felt that pulley-assisted range of motion exercises are safe, EMG analysis has demonstrated that these exercises do cause activation of the rotator cuff musculature and probably should be avoided early in the rehabilitation protocol.

Question 1634

Topic: Shoulder & Hip Sports

A 39-year-old man has had persistent right shoulder pain for the past 6 months. A formal physical therapy program has failed to provide relief, and an injection several months ago provided only short-term relief. Examination reveals a positive Neer and Hawkins test. There is no instability and the neurovascular

. Arthroscopic debridement alone of the partial rotator cuff tear
. Repair of the partial rotator cuff tear and subacromial decompression
. Arthroscopic debridement combined with subacromial decompression
. Arthroscopic subacromial decompression
. Biceps tenotomy

Correct Answer & Explanation

. Arthroscopic debridement alone of the partial rotator cuff tear

Explanation

Although arthroscopic debridement with or without subacromial decompression is a reasonable response, the patient has positive impingement signs. Several recent studies regarding the surgical treatment of partial rotator cuff tears have demonstrated good to excellent results after repair of tears involving more than 50% of the tendon thickness. This was shown specifically for bursal-sided tears and joint-side tears. Biceps tenotomy is not indicated in a young patient.

Question 1635

Topic: Knee Sports

Figure 82 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? Review Topic

. 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 articular surface restored whenever possible.

Question 1636

Topic: Shoulder & Hip Sports
A 64-year-old man who underwent total shoulder arthroplasty 4 weeks ago is making satisfactory progress in physical therapy, but his therapist notes limitations in external rotation to neutral. A stretching program is started, and the patient suddenly gains 90 degrees of external rotation but now reports increased pain and weakness. What is the best course of action?
. Early surgical exploration and repair of the torn subscapularis tendon
. Observation and reassurance that the pain will resolve
. A slow progressive resistance program to restore strength
. CT to assess for component malrotation
. Electromyography to evaluate for possible nerve injury

Correct Answer & Explanation

. Early surgical exploration and repair of the torn subscapularis tendon

Explanation

DISCUSSION: Nearly all approaches to shoulder arthroplasty require detachment of the subscapularis tendon from the humerus and subsequent repair. Healing of this tenotomy is one of the limiting factors in postoperative recovery. Failure of the tenotomy repair must be recognized and treated early with repeat repair or pectoralis muscle transfer for optimal results. Failure of the subscapularis is diagnosed clinically as excessive external rotation and weakness, especially in the lift-off or belly press position.

Question 1637

Topic: Shoulder & Hip Sports

The patient experiences little improvement with activity modification and more physical therapy. An intra-articular corticosteroid injection provides excellent relief, but relief only lasts for 1 month. The player requests further treatment for his hip and is counseled regarding surgical intervention. Hip arthroscopy is performed. Intrasurgically, a capsulolabral separation is observed with an underlying pincer lesion. No articular cartilage injury is seen. Which treatment is most appropriate considering these findings?

. Debridement of the labral tear plus bony resection of the pincer lesion
. Debridement of the labral tear and no bony resection of the pincer lesion
. Femoral neck osteoplasty plus labral repair using suture anchor
. Resection of the bony pincer lesion plus labral repair using suture anchor

Correct Answer & Explanation

. Debridement of the labral tear plus bony resection of the pincer lesion

Explanation

DISCUSSIONVideo 67 for referenceThis clinical scenario describes a patient with FAI attributable to pincer (acetabular) deformity. This form of FAI, which involves prominence of the anterosuperior acetabular lip, may be more common among women. Decreased range of motion and pain occur secondary to the abutment of the femoral head against the acetabular labrum and rim. Hip flexion, combined with adduction and internal rotation, recreates this contact and causes pain, but CAM or pincer etiology remains unknown.The differential diagnosis of hip pain in a young athlete includes femoral neck stress reaction/fracture, sacroiliac arthritis, intra-articular loose body, trochanteric bursitis, osteitis pubis, and hernia. No information presented in this scenario suggests any of these causes. Diagnosis of FAI is best performed via MR imaging, with an arthrogram increasing the sensitivity and specificity for labral pathology. An ultrasound may be useful in the diagnosis of dysplasia or for dynamic assessment of a snapping hip, but ultrasound is not commonly used to diagnose labral pathology.Although concomitant chondral lesions of the femoral head are uncommon, the forced leverage of the anterosuperior femoral neck upon the anterior acetabulum may result a “contra-coup” chondral injury on the posteroinferior acetabulum. This is the most common location of chondral lesions in this scenario. Without bony resection to prevent further impingement, this patient will continue to experience symptoms. Because there is no evidence of femoral neck prominence (CAM lesion), there is no indication for osteoplasty of the femoral neck; resection of the pincer lesion is necessary. This will often require take-down of the labrum in this location. If possible, iatrogenic or traumatic labral tears should subsequently be repaired after pincer debridement because the labrum has important functions for hip stability and maintenance of the suction seal of the joint.

Question 1638

Topic: 5. Sports Medicine
A 12-year-old boy reports the acute onset of pain and a pop over the right side of his pelvis while swinging a baseball bat during a Little League game. Radiographs reveal an avulsion of the anterior superior iliac spine with 2 cm of displacement. Management should consist of
. open reduction and internal fixation of the fragment along with the rectus femoris.
. open reduction and internal fixation of the fragment along with the sartorius.
. open reduction and internal fixation of the fragment along with the iliopsoas.
. rest and protected weight bearing with crutches.
. excision of the fragment.

Correct Answer & Explanation

. rest and protected weight bearing with crutches.

Explanation

DISCUSSION: Anterior superior iliac spine avulsion fractures are caused by sudden, forceful contractions of the sartorius and tensor fascia lata. In most patients, nonsurgical management consisting of rest and protected weight bearing yields satisfactory outcomes. Surgery is usually reserved for fractures with displacement of more than 3 cm and painful nonunions.

Question 1639

Topic: 5. Sports Medicine

A 26-year-old right hand-dominant man has had right shoulder pain for the past 6 months. History reveals that he was the starting pitcher for his high school team. Activity modification, physical therapy, cortisone injection, and anti-inflammatory drugs have failed to improve his symptoms. He has a positive O’Brien’s active compression test. What is the next most appropriate step in the diagnosis of this patient? Review Topic

. Diagnostic arthroscopy
. MRI-arthrography
. Stress radiographs
. CT
. Weighted radiographs of the arm

Correct Answer & Explanation

. Diagnostic arthroscopy

Explanation

MRI-arthrography has been shown to be an accurate technique for assessing the glenoid labrum in patients with suspected labral tears. Often standard MRI technique will not identify labral lesions. The use of MRI-arthrography with an intra-articular injection of gadolinium provides improved visualization of labral lesions. Bencardino and associates demonstrated a sensitivity of 89%, a specificity of 91%, and an accuracy of 90% in detecting labral lesions. SLAP lesions can be visualized on coronal oblique sequences as a deep cleft between the superior labrum and the glenoid that extends well around and below the biceps anchor. Often, contrast will diffuse into the labral fragment, causing it to appear ragged or indistinct.

Question 1640

Topic: Shoulder & Hip Sports
During shoulder motion with the elbow controlled in a brace, electromyographic studies of the supraspinatus show significant activity with all range-of-motion testing. Concurrent electromyographic studies of the long head of the biceps will most likely show
. minimal activity.
. moderate activity compared to the supraspinatus.
. significant activity with a supraspinatus tear.
. significant activity with an intact supraspinatus.
. significant activity with both intact and torn rotator cuffs.

Correct Answer & Explanation

. minimal activity.

Explanation

During electromyographic studies, the long head of the biceps has been shown to have little activity throughout a wide range of shoulder motion as long as the elbow is immobilized. The supraspinatus is active throughout the range of shoulder motion. Rotator cuff tears do not influence biceps activity as long as the elbow is controlled.

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