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5. Sports Medicine MCQs

Practice Set 86 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 1701

Topic: 5. Sports Medicine

A 40-year-old man who is a manual laborer has had 3 years of worsening medial-sided left knee pain that has inhibited his ability to work. He reports undergoing a left subtotal medial meniscectomy 10 years ago. He has been treated with nonsteroidal anti-inflammatory drugs and two different corticosteroids, with the most recent injection given 1 month ago. Each injection provided him with a few weeks of pain control. His medical history is unremarkable, and he has smoked 20 cigarettes per day for the last 15 years. His BMI is 22. On examination, he has varus alignment of the involved leg and medial joint line tenderness and no lateral or patellofemoral pain. His knee range of motion is 3° shy of full extension to 130° of flexion. He has negative Lachman and posterior drawer test results. He demonstrates no lateral thrust with ambulation. What is the most appropriate next step in treatment?

. Repeat corticosteroid injection
. Trial of a medial unloader brace
. MRI scan of the knee to evaluate for recurrent medial meniscus tear
. Referral to pain management

Correct Answer & Explanation

. Trial of a medial unloader brace

Explanation

This patient has a classic presentation of postmeniscectomy medial compartment arthritis. The appropriate diagnostic study is weight-bearing radiographs to confirm the diagnosis. An MRI scan will reveal medial compartment arthritis but will not provide information about alignment. A CT scan would be appropriate to detect an occult fracture; however, this condition is not suspected in this clinical scenario. Ultrasonography can provide information about fluid collection around the knee or a deep vein thrombosis; however, these conditions also are not suspected in this clinical scenario. Because the patient has a correctable deformity (gaps 3 mm with valgus stress), and his symptoms are localized to the involved compartment, a trial of a medial unloader brace is appropriate both diagnostically and therapeutically. If unloading the medial compartment resolves the patient’s symptoms, he would be an excellent candidate for an osteotomy. An MRI scan may be obtained to evaluate ligamentous integrity or to evaluate degenerative involvement of the lateral and patellofemoral compartment for presurgical planning of an osteotomy; however, the integrity of the medial meniscus has no clinical importance in a patient with severe medial compartment arthritis. A repeat corticosteroid injection is not indicated within 1 month of his last injection, and referral to pain management is not appropriate with other options available to help this patient. A VPHTO is the appropriate intervention considering the patient’s young age, high-functional occupation, examination, radiographic findings, and response to medial unloader bracing. A revision knee arthroscopy would be appropriate for a recurrent medial meniscus tear, but not appropriate in a patient with severe medial compartment arthritis. The patient’s young age and high functional requirements are contraindications to TKA. The presence of severe arthritis is a contraindication to medial meniscus transplant. The patient is a candidate for a VPHTO. The technical options include a medial opening-wedge or a lateral closing-wedge osteotomy. Both techniques have advantages and disadvantages; however, a medial opening-wedge osteotomy is contraindicated in a smoker because of concern for nonunion. As a result, current smoking history is the only factor listed that would influence the technique used. The history of prior arthroscopy has no relevance in the decision about which type of osteotomy is appropriate. Normal BMI is between 18.5 and 24.9, so this patient’s BMI is considered normal and would not affect the surgical technique (if this patient were obese, a lateral closing-wedge osteotomy would be considered, but this is controversial). His age of 40 years is an indication for HTObut does not influence technique.

Question 1702

Topic: 5. Sports Medicine
Management of a grade IV osteochondritis dissecans lesion of the capitellum should consist of
. Use of a sling for 3 weeks followed by a gradual return to activities
. Physical therapy
. Arthroscopy with removal of the loose fragment
. Arthroscopy with in situ drilling of the fragment
. Internal fixation of the fragment

Correct Answer & Explanation

. Arthroscopy with removal of the loose fragment

Explanation

Osteochondritis dissecans of the capitellum is seen most commonly in adolescent athletes. It should be distinguished from osteochondrosis of the capitellum (Panner’s disease), a self-limiting condition seen in younger patients. Lesions are graded I through V based on radiographic and arthroscopic appearance. Grade IV lesions show a loose but nondisplaced osteoarticular flap. Simple excision of the loose osteoarticular flap is the treatment of choice for grade IV and V lesions. More complex procedures such as drilling of the in situ lesion, bone grafting, or internal fixation are associated with significantly worse results.

Question 1703

Topic: 5. Sports Medicine
A 20-year-old soccer player who collapsed after a goal kick reports weakness and nausea. He appears slightly confused. Examination reveals that he is not sweating. His skin is warm and dry. The outdoor temperature is 80°F (26.6°C) with a relative humidity of 80%. Management should consist of
. a drink of water.
. a sports drink with electrolytes.
. placement in the reverse Trendelenburg position in a shaded area.
. immersion in a warm water bath.
. transportation to the emergency department.

Correct Answer & Explanation

. transportation to the emergency department.

Explanation

DISCUSSION: There is a spectrum of heat-related conditions. Heat cramps are the mildest form of heat illness. In heat exhaustion, cramps are associated with headache and weakness, and the skin is pale and moist. Treatment of heat cramps or heat exhaustion consists of removing and loosening excess clothing, applying ice to the axilla and groin, ingestion of cool water, and cool water sprays. This patient demonstrates symptoms of heat stroke, which is a medical emergency. The core body temperature may be as high as 106 to 110°F (41.1 to 43.3°C). In heat stroke, the patient may no longer be sweating, and the skin may be hot and red. The athlete is usually confused, weak, nauseated, and may have seizure activity. Central nervous system depression has been called the most important marker of heat stroke and progresses from confusion and bizarre behavior to collapse, delirium, and coma. Bizarre behavior is often the first sign of heat stroke. The patient needs to be treated and moved to a medical facility rapidly. During transfer, IV fluids and cooling of the athlete should be initiated. The best treatment of heat-related illness appears to be prevention with adequate hydration and monitoring of conditions (temperature and humidity), with cancellation of competition when conditions do not comply with guidelines.

Question 1704

Topic: 5. Sports Medicine

Figure 23 shows the postoperative radiograph of a patient who underwent an anterior cruciate ligament (ACL) reconstruction (with bone-patella tendon-bone autograft) that failed. He initially had loss of flexion postoperatively. What is the most likely cause of this failure? Review Topic

. Fixation in the tibial tunnel
. Fixation in the femoral tunnel
. Posterior placement of the tibial tunnel
. Anterior placement of the femoral tunnel
. Size of the patellar autograft

Correct Answer & Explanation

. Anterior placement of the femoral tunnel

Explanation

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

Question 1705

Topic: Knee Sports
A 16-year-old football player sustains a direct blow to the anterior aspect of his flexed right knee. Examination reveals a contusion over the anterior tibial tubercle and a small effusion. MRI scans are shown in Figures 33a through 33c. What is the most likely diagnosis?
. Partial tear of the patellar tendon
. Osteochondral fracture of the femur
. Anterior cruciate ligament (ACL) tear
. Posterior cruciate ligament (PCL) tear
. Patella fracture

Correct Answer & Explanation

. Posterior cruciate ligament (PCL) tear

Explanation

DISCUSSION: The MRI scans show disruption of the fibers of the PCL. Patients sustaining an isolated acute PCL injury can present with only minimal discomfort and have full range of motion. When examination reveals a contusion over the tibial tubercle and discomfort with the posterior drawer examination, with or without instability, a possible injury to the PCL should be considered. In acute injuries, the reported accuracy of MRI imaging for diagnosing PCL tears ranges from 96% to 100%. REFERENCES: Resnick D, Kang HS: Internal Derangement of Joints: Emphasis on MRI Imaging. Philadelphia, PA, WB Saunders, 1997, pp 699-700. Harner CD, Hoher J: Evaluation and treatment of posterior cruciate ligament injuries. Am J Sports Med 1998;26:471-482. Fischer SP, Fox JM, Del Pizzo W, Friedman MJ, Snyder SJ, Ferkel RD: Accuracy of diagnoses from magnetic imaging of the knee: A multi-center analysis of one thousand and fourteen patients. J Bone Joint Surg Am 1991;73:2-10.

Question 1706

Topic: 5. Sports Medicine

A 29-year-old recreational basketball player has developed pain to the distal aspect of her patella that occurs during warm-ups and returns toward the end of the game. She reports no history of trauma, effusions, instability, and no mechanical symptoms. On examination, she is point tender at the inferior pole of the patella, lacks patella apprehension, and has a Q-angle of 15°. She has no ligamentous laxity. Radiographs are unremarkable. What is the best next step?

. Therapy with an emphasis on eccentric exercises
. Steroid injection
. Platelet-rich plasma
. Extracorporeal shock therapy

Correct Answer & Explanation

. Therapy with an emphasis on eccentric exercises

Explanation

Patellar tendinopathy is a relatively common condition in athletes for which repetitive jumping is the norm, especially volleyball and basketball athletes. The prevalence has been reported to be up to 32% in professional basketball players. Initial management is nonoperative in nature with eccentric exercises providing the most reliable clinical results. The other selections have not demonstrated consistent longterm results.

Question 1707

Topic: Shoulder & Hip Sports

Figures 42a and 42b show the radiographs of a 52-year-old man who sustained a fall from a motorcycle 6 months ago and now reports pain and stiffness in his left shoulder. What is the most reliable treatment to improve function and comfort of the shoulder? Review Topic

. Vigorous physical therapy
. Manipulation under anesthesia
. Arthroscopic capsular release
. Hemiarthroplasty
. Arthroscopic capsular plication

Correct Answer & Explanation

. Hemiarthroplasty

Explanation

Appropriate treatment is based on multiple considerations, which include the chronicity of the dislocation, the amount of humeral head involvement, the medical condition, and functional limitations of the patient. It has been shown that shoulder arthroplasty for locked posterior dislocation provides pain relief and improved motion. Transfer of the lesser tuberosity with its attached subscapularis tendon into the defect is recommended for anteromedial humeral defects that are smaller than approximately 40% of the joint surface. Subscapularis transfer as described by McLaughlin and the modification thereof later described by Hawkins and associates in which the lesser tuberosity is transferred into the defect, have yielded good results if the defect is less than 40% of the humeral head. Prosthetic replacement is preferred for larger defects. If the dislocation is less than 3 weeks old and has less than 25% of humeral head involvement, closed reduction with the patient under general anesthesia should be attempted and the stability assessed by internally rotating the arm. If the arm can be safely internally rotated to the abdomen, then 6 weeks of immobilization in an orthosis that maintains the shoulder in slight extension and external rotation can yield a good result. If the dislocation has been present for more than 3 weeks, closed reduction becomes exceedingly difficult.

Question 1708

Topic: 5. Sports Medicine
A patient with refractory long head biceps pain in the shoulder undergoes biceps tenotomy. The patient is concerned about possible postoperative deformity and loss of supination strength. Which of the following techniques provides the strongest initial fixation to prevent distal migration?
. Tenotomy with medial transfer
. Tenotomy with soft-tissue tenodesis
. Tenotomy with tenodesis using suture anchors
. Tenotomy with tenodesis using bone tunnels
. Tenotomy with tenodesis using an interference screw

Correct Answer & Explanation

. Tenotomy with tenodesis using an interference screw

Explanation

DISCUSSION: Recent articles have looked at the cyclic load failure and ultimate load failure of biceps tenodesis techniques. The interference screw has proved superior to bone tunnel, suture anchor, and soft-tissue tenodesis techniques in laboratory cadaveric testing. Whether this is clinically relevant or not is still unknown. REFERENCES: Ozalay M, Akpinar S, Karaeminogullari O, et al: Mechanical strength of four different biceps tenodesis techniques. Arthroscopy 2005;21:992-998. Richards DP, Burkhart SS: A biomechanical analysis of two biceps tenodesis fixation techniques. Arthroscopy 2005;21:861-866.

Question 1709

Topic: 5. Sports Medicine

A 14-year-old gymnast misses her dismount off of the uneven bars, hits the mat face first, and loses consciousness for about 15 seconds. She is dazed and confused for several minutes. She does not complain of pain; numbness; or weakness, and she is moving all extremities without deficit. The athlete and coach want to go back to competition that day. How should they be advised?

. Concussion precludes same-day return to play.
. Order an urgent MRI scan; if findings are normal, she can return to competition.
. Order neurocognitive testing; if findings are normal, she can return to competition.
. If she is symptom-free after a 15-minute exertional test, she may return to competition.

Correct Answer & Explanation

. Concussion precludes same-day return to play.

Explanation

The National Collegiate Athletic Association's (NCAA) 2011 revised health and safety guidelines regarding concussion management recommend no return to play on the same day of an injury. In particular, athletes sustaining a concussion should not return to play the same day as their injury. Before resuming exercise, athletes must be asymptomatic or returned to baseline symptoms at rest and have nosymptoms with cognitive effort. They must be off of medications that could mask or alter concussion symptoms. Neurocognitive testing can be a helpful tool in determining brain function even after all symptoms of concussion have resolved. With a comparison baseline test, this evaluation, in conjunction with a physician's examination, may reduce risk for second impact syndrome. The athlete's clinical neurologic examination findings (cognitive, cranial nerve, balance testing) must return to baseline before resuming exercise. Research has shown that among youth athletes, it may take longer for tested functions to return to baseline (compared with the recovery rate in adult athletes). Brain MRI scan has no role in evaluating athletes for return to play in this situation.

Question 1710

Topic: 5. Sports Medicine
A 17-year-old pitcher reports pain over the medial aspect of the elbow that occurs during the acceleration phase of throwing, and it prevents him from throwing at the velocity needed to be competitive. What structure is most likely injured in this patient?
. Radial collateral ligament
. Posterior bundle of the ulnar collateral ligament
. Anterior bundle of the ulnar collateral ligament
. Flexor carpi ulnaris
. Pronator teres

Correct Answer & Explanation

. Anterior bundle of the ulnar collateral ligament

Explanation

DISCUSSION: The anterior bundle of the ulnar collateral ligament of the elbow is the primary constraint to valgus force of the elbow. In pitchers and in overhead athletes, injury to this portion of the ligament results in valgus instability. Reconstruction of the anterior band of the ulnar collateral ligament is necessary in many elite athletic throwers to allow them to return to this competitive activity. REFERENCES: Azar FM, Andrews JR, Wilk KE, et al: Operative treatment of ulnar collateral ligament injuries of the elbow in athletes. Am J Sports Med 2000;28:16-23. Cain EL, Dugas JR, Wolf RS, et al: Elbow injuries in throwing athletes: A current concepts review. Am J Sports Med 2003;31:621-635. Rettig AC, Sherrill C, Snead DS, et al: Nonoperative treatment of ulnar collateral ligament injuries in throwing athletes. Am J Sports Med 2001;29:15-17.

Question 1711

Topic: Shoulder & Hip Sports
Figures 78a and 78b are the radiographs of a 47-year-old right-hand-dominant woman who has a 3-month history of gradually progressive right shoulder pain. She reports no previous trauma, but does report pain at night and with activity such as weight training. Examination demonstrates active and passive range of motion to be 110 degrees forward elevation, external rotation to 20 degrees, and internal rotation to the sacrum. The next treatment step should include:
. an MRI of the shoulder.
. a physical therapy referral for rotator cuff strengthening and proprioceptive exercise.
. a home stretching program and corticosteroid injection.
. arthroscopic glenohumeral capsular release.

Correct Answer & Explanation

. a home stretching program and corticosteroid injection.

Explanation

This patient has idiopathic adhesive glenohumeral stiffness. Most patients with this condition are women between 40 and 60 years of age with no specific mechanism of onset. Patients typically develop pain, at which point the disease is marked by significant inflammation. This patient is likely in the second stage of the disease, marked by inflammation and early fibrosis of the joint capsule, leading to joint stiffness. The most appropriate treatment step at this stage is an intra-articular glenohumeral corticosteroid injection, most often in conjunction with either a supervised or home-based capsular stretching program. Physical therapy that prioritizes rotator cuff strengthening is more appropriate for patients with isolated subacromial impingement syndrome and may worsen symptoms in patients with stiff shoulders.

Question 1712

Topic: Shoulder & Hip Sports

A 22-year-old collegiate rugby player presents with recurrent anterior shoulder instability. A pre-operative CT scan demonstrates a 25% anterior glenoid bone defect. What is the most appropriate surgical treatment to minimize his risk of recurrence?

. Arthroscopic Bankart repair with suture anchors
. Arthroscopic remplissage with Bankart repair
. Open Latarjet procedure
. Iliac crest bone grafting of the humeral head
. Open capsular shift

Correct Answer & Explanation

. Arthroscopic Bankart repair with suture anchors

Explanation

The open Latarjet procedure is the gold standard for patients with recurrent anterior shoulder instability and significant glenoid bone loss (>20-25%), particularly in high-demand contact athletes. Arthroscopic Bankart repair, even with remplissage, has an unacceptably high failure rate in the setting of critical glenoid bone loss.

Question 1713

Topic: Shoulder & Hip Sports

During an arthroscopic osteochondroplasty for a cam-type femoroacetabular impingement, the surgeon must avoid extending the resection too far posterolaterally on the femoral neck to prevent avascular necrosis. The retinacular vessels at risk in this region are terminal branches of which artery?

. Superficial circumflex iliac artery
. Lateral femoral circumflex artery
. Medial femoral circumflex artery
. Obturator artery
. Inferior gluteal artery

Correct Answer & Explanation

. Superficial circumflex iliac artery

Explanation

The primary blood supply to the femoral head is provided by the retinacular branches of the medial femoral circumflex artery (MFCA). These vessels course superiorly and posteriorly along the femoral neck and are at risk if an osteochondroplasty for a cam lesion extends excessively posterolaterally.

Question 1714

Topic: Knee Sports

A lateral extra-articular tenodesis (LET) is frequently added to revision anterior cruciate ligament (ACL) reconstructions to control rotational laxity. The anterolateral ligament (ALL), often the anatomical target of this augmentation, inserts on the tibia at which of the following locations?

. Directly on Gerdy's tubercle
. The apex of the fibular head
. Midway between Gerdy's tubercle and the anterior margin of the fibular head
. Medial to the tibial tuberosity
. The anterior margin of the lateral collateral ligament insertion

Correct Answer & Explanation

. Directly on Gerdy's tubercle

Explanation

The anterolateral ligament (ALL) originates near the lateral epicondyle of the femur and inserts on the proximal lateral tibia, midway between Gerdy's tubercle and the anterior margin of the fibular head, approximately 5 mm distal to the joint line.

Question 1715

Topic: Knee Sports

A 45-year-old female undergoes an MRI of her knee, which demonstrates a complete tear of the posterior root of the medial meniscus. If left untreated, biomechanical studies demonstrate that this injury alters knee joint contact pressures to a level most equivalent to which of the following?

. A normal knee with intact menisci
. A knee after a 25% partial meniscectomy
. A knee after a total meniscectomy
. An ACL-deficient knee
. A PCL-deficient knee

Correct Answer & Explanation

. A normal knee with intact menisci

Explanation

A posterior root tear of the medial meniscus disrupts the circumferential hoop stresses of the meniscus, leading to extrusion of the meniscus during axial loading. Biomechanically, this functional loss is equivalent to a total meniscectomy, severely increasing peak articular contact pressures and accelerating osteoarthritis.

Question 1716

Topic: Knee Sports

A 16-year-old female is undergoing a medial patellofemoral ligament (MPFL) reconstruction. The surgeon uses intraoperative fluoroscopy to identify Schottle's point for the femoral attachment. Which of the following best describes the location of Schottle's point on a perfect lateral radiograph?

. 1 mm anterior to the posterior femoral cortical extension line, and proximal to Blumensaat's line
. 1 mm posterior to the posterior femoral cortical extension line, and distal to Blumensaat's line
. 5 mm anterior to the posterior femoral cortical extension line, exactly on Blumensaat's line
. 5 mm posterior to the posterior femoral cortical extension line, and proximal to Blumensaat's line
. 1 mm anterior to the posterior femoral cortical extension line, and distal to Blumensaat's line

Correct Answer & Explanation

. 1 mm anterior to the posterior femoral cortical extension line, and proximal to Blumensaat's line

Explanation

Schottle's point anatomically approximates the femoral origin of the MPFL. Radiographically, on a true lateral view, it is located 1 mm anterior to the line extending the posterior femoral cortex, 2.5 mm distal to the posterior origin of the medial femoral condyle, and proximal to the level of Blumensaat's line.

Question 1717

Topic: Shoulder & Hip Sports

A 29-year-old elite volleyball player presents with insidious onset right shoulder weakness. Examination reveals isolated profound atrophy of the infraspinatus with preserved supraspinatus strength and bulk. An MRI is most likely to show nerve compression by a paralabral cyst in which anatomic location?

. Suprascapular notch
. Spinoglenoid notch
. Quadrilateral space
. Triangular interval
. Rotator interval

Correct Answer & Explanation

. Suprascapular notch

Explanation

The suprascapular nerve innervates the supraspinatus muscle before passing through the spinoglenoid notch to innervate the infraspinatus. Entrapment at the spinoglenoid notch (commonly by a cyst associated with a posterior labral tear) results in isolated infraspinatus weakness. Entrapment at the suprascapular notch would affect both muscles.

Question 1718

Topic: Knee Sports

The posterior cruciate ligament (PCL) consists of two distinct functional bundles. Which of the following statements correctly describes the biomechanical properties of the anterolateral (AL) bundle?

. It is tight in extension and loose in flexion
. It is tight in flexion and loose in extension
. It is the primary restraint to valgus stress at 30 degrees of flexion
. It is the smaller and weaker of the two bundles
. It originates on the lateral aspect of the lateral femoral condyle

Correct Answer & Explanation

. It is tight in extension and loose in flexion

Explanation

The PCL consists of the larger, stiffer anterolateral (AL) bundle and the smaller posteromedial (PM) bundle. The AL bundle is tight in flexion and loose in extension, whereas the PM bundle is tight in extension and loose in flexion. The PCL originates on the lateral aspect of the medial femoral condyle.

Question 1719

Topic: 5. Sports Medicine

A 42-year-old manual laborer presents with persistent anterior shoulder pain and catching after a lifting injury 6 months ago. MRI and subsequent diagnostic arthroscopy confirm an isolated Type II SLAP tear. Given the patient's age and high physical demands, which procedure is statistically associated with the most reliable return to full work duties and lowest reoperation rate?

. Arthroscopic SLAP repair with suture anchors
. Biceps tenodesis
. Conservative management with intra-articular corticosteroid injection
. Arthroscopic debridement of the superior labrum without fixation
. Open Bankart repair

Correct Answer & Explanation

. Arthroscopic SLAP repair with suture anchors

Explanation

Extensive recent literature indicates that in patients over the age of 35-40 (especially laborers), biceps tenodesis offers more reliable pain relief, significantly lower reoperation rates, and higher return to work satisfaction compared to SLAP repair, which frequently results in postoperative stiffness and persistent pain in this demographic.

Question 1720

Topic: Knee Sports

During a routine ACL reconstruction on a 19-year-old soccer player, the surgeon systematically evaluates the menisci and identifies a 'ramp lesion' utilizing a posteromedial portal. A ramp lesion specifically describes a tear at which of the following anatomic locations?

. The meniscocapsular and meniscotibial attachments of the posterior horn of the medial meniscus
. The radial margin of the medial meniscus mid-body
. The true posterior root attachment of the medial meniscus to the tibial plateau
. The attachments of the meniscofemoral ligaments (Wrisberg and Humphrey)
. The meniscocapsular junction of the anterior horn of the lateral meniscus

Correct Answer & Explanation

. The meniscocapsular and meniscotibial attachments of the posterior horn of the medial meniscus

Explanation

A ramp lesion is a peripheral tear involving the meniscocapsular and meniscotibial attachments of the posterior horn of the medial meniscus. It is highly associated with acute ACL ruptures and is often missed if a systematic evaluation of the posteromedial compartment (via the intercondylar notch or a dedicated posteromedial portal) is not performed.

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