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 1741
Topic: Knee Sports
In a double-bundle posterior cruciate ligament (PCL) reconstruction, the two distinct bundles are tensioned at different angles of knee flexion to restore native biomechanics. In the native knee, the anterolateral bundle is tightest in which of the following positions?
Correct Answer & Explanation
. Full extension
Explanation
The PCL consists of the anterolateral (AL) and posteromedial (PM) bundles. The larger AL bundle is tightest in knee flexion (around 90 degrees), while the smaller PM bundle is tightest in extension.
Question 1742
Topic: Shoulder & Hip Sports
A 24-year-old elite baseball pitcher presents with shoulder pain during the late cocking phase of throwing. MRI reveals a type II SLAP tear. What physical exam finding is most characteristically associated with this pathology due to posteroinferior capsular contracture?
Correct Answer & Explanation
. Glenohumeral internal rotation deficit (GIRD)
Explanation
Overhead throwing athletes frequently develop posteroinferior capsular contracture, clinically presenting as GIRD. This contracture shifts the glenohumeral contact point posterosuperiorly in maximum external rotation, leading to internal impingement and subsequent SLAP tears.
Question 1743
Topic: 5. Sports Medicine
During hip arthroscopy for femoroacetabular impingement, prolonged traction against the perineal post is required to distract the joint. This maneuver most commonly places which of the following nerves at risk for neurapraxia?
Correct Answer & Explanation
. Pudendal nerve
Explanation
Prolonged compression against the perineal post during hip distraction can cause pudendal nerve neurapraxia. This manifests as perineal numbness or sexual dysfunction, which is usually transient if traction time is minimized.
Question 1744
Topic: Knee Sports
A 28-year-old male sustains a traumatic knee dislocation with a high-grade posterolateral corner (PLC) injury. He has a profound foot drop on presentation. Which component of the PLC is most closely associated anatomically with the injured nerve?
Correct Answer & Explanation
. Popliteus tendon
Explanation
The common peroneal nerve is highly susceptible to stretch injuries during PLC disruptions. Anatomically, it courses directly posterior and inferior to the biceps femoris tendon as it wraps around the fibular neck.
Question 1745
Topic: Shoulder & Hip Sports
A 45-year-old weightlifter feels a pop in his anterior shoulder during a heavy bench press. MRI confirms an isolated, full-thickness upper subscapularis tear. Which of the following physical exam tests is considered the most sensitive for a tear of the upper border of the subscapularis?
Correct Answer & Explanation
. Bear hug test
Explanation
The bear hug test is considered the most sensitive examination maneuver for detecting upper subscapularis tears. The lift-off test is better suited for assessing the lower portion of the subscapularis muscle belly.
Question 1746
Topic: Knee Sports
When performing a medial patellofemoral ligament (MPFL) reconstruction, accurate femoral tunnel placement is critical to avoid abnormal graft tension. Radiographically, Schottle's point is located:
Correct Answer & Explanation
. Anterior to the posterior cortical line and proximal to Blumensaat's line
Explanation
Schottle's point defines the radiographic femoral origin of the MPFL. It is located 1 mm anterior to the posterior femoral cortical line, 2.5 mm distal to the posterior origin of the medial femoral condyle, and proximal to Blumensaat's line.
Question 1747
Topic: Knee Sports
The lateral fragment of bone (Segond fracture) associated with an injury of the anterior cruciate ligament is the result of an avulsion of the
Correct Answer & Explanation
. Oblique popliteal ligament
Explanation
The segond fragment is avulsed by three fibers which are under tension to this area at proximal lateral aspect of tibia. These fibers are intimate with lateral capsule consisting of 1) posterior fibers of anterolateral femoratibial ligament 2) the anterior expansion of arcuate ligament 3) biceps tendon expansions from posteriolateral direction.
Question 1748
Topic: 5. Sports Medicine
Figures 1 and 2 are radiographs of a 25-year-old man who has had persistent right hip pain for over a year. There was an acute injury and the pain has progressively worsened and is now 9/10 in severity. The pain interferes with activities of daily living and the patient's capacity to participate in sports. The patient has failed nonsurgical treatment in the form of physical therapy and activity modification. On physical examination, forward flexion is limited to 90°, internal rotation is limited to 10°, and flexion adduction internal rotation examination is positive. The hip pain was relieved on physical examination after intra-articular administration of local anesthetic. The patient had an MRI and CT scan. What is the most appropriate surgical option?
Correct Answer & Explanation
. Hip arthroscopy with labral repair, rim trimming and femoral osteochondroplasty
Explanation
The radiographs show a large cam lesion on the anterosuperior aspect of the femoral head, and this is confirmed by high alpha angle (76). Cam and pincer lesions commonly cause labral tears and lead to femoroacetabular impingement. After failure of nonoperative treatment, surgery involves hip arthroscopy, labral repair or debridement, rim trimming (resection of acetabulum), and femoral osteochondroplasty. A periacetabular osteotomy is the preferred surgery in dysplastic patients. Dysplasia is defined as undercoverage of the femoral head, typically a center-edge angle <25. Reverse periacetabular osteotomy is used for a true retroverted acetabulum. Lastly, open dislocation is the preferred method when the hip deformity is too severe to treat arthroscopically or when the femoral head is significantly overcovered by the acetabulum (center-edge angle >40).
Question 1749
Topic: Shoulder & Hip Sports
Examination of a 4-year-old child with obstetrical palsy reveals weak deltoids, pectoralis major strength of 4-5, and normal hand function. External rotation of the shoulder is limited. What is the most appropriate surgical procedure to restore external rotation?
Correct Answer & Explanation
. Latissimus dorsi and teres major transfer to the posterior rotator cuff
Explanation
Transfer of the latissimus dorsi and teres major to the posterior rotator cuff will restore external rotation and some abduction. The procedure should be performed in children who are approximately age 4 years, following spontaneous recovery and prior to significant stiffness. External rotation osteotomy is more appropriate for an older child. Fusion should not be performed until skeletal maturity. Distal biceps rerouting restores pronation for a supination deformity. Latissimus dorsi and teres major transfer to the subscapularis would accentuate the internal rotation. In younger patients without significant bony deformity, a subscapularis slide or lengthening can restore external rotation.
Question 1750
Topic: 5. Sports Medicine
A 31-year-old high school football coach has right medial knee pain that is made worse with prolonged standing. His knee is minimally painful in the morning but by the end of the school day, he must sit down. The pain often makes sleeping difficult. He states that several years ago he underwent a surgical procedure to "clean out" the cartilage of the knee; however, he only had several months of pain relief. He is noted to be an athletic male (BMI of less than 30). Knee examination is unremarkable except for medial joint line pain that is exacerbated with standing and walking. Radiographs, including a long-leg view, and MRI scans are seen in Figures 153a through 153d. He wishes to remain active and asks whether he would be a candidate for allograft meniscus transplantation. You advise him that Review Topic
Correct Answer & Explanation
. the current literature does not support allograft meniscus transplantation.
Explanation
The patient's history, physical findings, and MRI scans indicate that a complete medial meniscectomy was performed. The meniscus provides an essential function in dissipating forces to the adjacent articular cartilage. Complete or partial meniscectomy has been shown to result in more rapid clinical and radiographic arthritis than if the meniscus is preserved. Allograft meniscal transplantation has been shown to be effective in the young patient with an absent meniscus, no or correctable limb malalignment, and minimal or correctable articular cartilage damage. His age would be appropriate for an allograft meniscus transplant. Based on the patient's long-leg radiograph, a valgus-producing high tibial osteotomy would be appropriate but alone would not address the absent meniscus in this young patient. Viscosupplementation may provide some temporary relief but is not an appropriate long-term solution. A staged valgus-producing osteotomy followed by an allograft meniscus transplant would be the most appropriate treatment.
Question 1751
Topic: 5. Sports Medicine
Which of the following best describes heat stroke? Review Topic
Correct Answer & Explanation
. Transient loss of consciousness with peripheral vasodilation and decreased cardiac output with normal body temperature
Explanation
Heat stroke consists of hyperthermia (greater than 105.8 degrees F [41 degrees C]), central nervous system dysfunction, and cessation of sweating with hot, dry skin. It is a medical emergency that results from failure of the thermoregulatory mechanisms of the body. It has a high death rate and requires rapid reduction in body core temperature. Heat syncope is characterized by a transient loss of consciousness with peripheral vasodilation and decreased cardiac output with normal body temperature. Heat cramps involve painful contractions of large muscle groups because of decreased hydration and a decrease of serum sodium and chloride. Heat exhaustion is distinguished by a core temperature of less than 102.2 degrees F (39 degrees C) and an absence of central nervous system dysfunction. Hypernatremic heat exhaustion results from inadequate water replacement.
Question 1752
Topic: 5. Sports Medicine
A 20-year-old basketball player reports a 6-month history of right groin pain that radiates into his testicles with activities of daily living. He denies any history of trauma. Examination reveals tenderness about the groin, and he has full hip range of motion. The abdomen is soft. Radiographs are normal. Nonsurgical management has consisted of rest and physical therapy, but he continues to have pain. What is the next step in management?
Correct Answer & Explanation
. Bone scan
Explanation
DISCUSSION: Sports hernias may be one of the most common causes of groin pain in athletes. Resisted hip adduction is painful in the case of groin disruption. Radiation of pain into the testicles and/or adductor region is often present. Sports hernias are associated with weakening of the posterior inguinal wall. In contrast with sports hernias, traditional or classic hernias can be readily detected on physical examination. Diagnostic imaging studies are not helpful and only serve to help exclude other diagnoses. Systemic high-dose steroids or sacroiliac joint injections have no role in treatment. High success rates have been reported for laparoscopic hernia repair in athletes.REFERENCES: Kluin J, den Hoed PT, van Linschoten R, et al: Endoscopic evaluation and treatment of groin pain in the athlete. Am J Sports Med 2004;32:944-949.Genitsaris M, Goulimaris I, Sikas N: Laparoscopic repair of groin pain in athletes. Am J Sports Med 2004;32:1238-1242.Meyers WC, Foley DP, Garrett WE, et al: Management of severe lower abdominal or inguinal pain in high-performance athletes: PAIN (Performing Athletes with Abdominal or Inguinal Neuromuscular Pain Study Group). Am J Sports Med 2000;28:2-8.
Question 1753
Topic: Knee Sports
Figure A is the lateral view of a left knee cadaveric specimen that has the extensor mechanism removed. Which two structures labeled provide the most rotational stability in knee flexion?
Correct Answer & Explanation
. C + D
Explanation
The popliteus tendon (C) and the popliteofibular ligament (D) are the lateral knee structures that provide the most rotational stability in knee flexion. The lateral collateral ligament (B) provides varus stability and rotational stability in knee extension. The PT and PFL serve as restraints to rotational instability, the highest forces occurring at knee flexion (60°-90°).
Question 1754
Topic: 5. Sports Medicine
A 16-year-old high school pitcher notes acute pain on the medial side of his elbow during a pitch. Examination that day reveals medial elbow tenderness, pain with valgus stress, mild swelling, and loss of extension. Plain radiographs show closed physes and no fracture. Which of the following diagnostic studies will best reveal his injury?
Correct Answer & Explanation
. Contrast-enhanced MRI
Explanation
The history and findings are consistent with a diagnosis of a sprain of the medial collateral ligament (MCL) of the elbow; therefore, contrast-enhanced MRI is considered the most sensitive and specific study for accurately showing this injury. Arthroscopic visualization of the MCL is limited to the most anterior portion of the anterior bundle only; complete inspection of the MCL using the arthroscope is not possible. CT without the addition of contrast is of no value in this situation. Use of a technetium Tc 99m bone scan is limited to aiding in the diagnosis of occult fracture, a highly unlikely injury in this patient. There are no clinical indications for electromyography.
Question 1755
Topic: 5. Sports Medicine
Which of the following is the most relevant clinical factor in the maturation assessment of an adolescent female athlete contemplating anterior cruciate ligament (ACL) reconstruction?
Correct Answer & Explanation
. Age of menarche
Explanation
Age of menarche is the most accurate clinical factor to assess the degree of skeletal maturity in the female athlete. Such an assessment is necessary prior to ACL reconstruction in a skeletally immature female because of the risk of damage to the distal femoral and proximal tibial physes. Height of an older male sibling is not relevant to the female athlete. Parental height and recent change in shoe size are only moderately useful in predicting final growth, and hence, skeletal maturity. The presence of breast buds occurs early in adolescent development; therefore, its presence suggests a high likelihood of future growth.
Question 1756
Topic: 5. Sports Medicine
A professional baseball team has several pitchers with complaints of velocity loss with their pitches and shoulder pain of their dominant shoulders during spring training. Pitch counts are properly monitored. The average glenohumeral internal rotation deficit (GIRD) on the pitching staff is 45 degrees. What is the best intervention?
Correct Answer & Explanation
. Focused stretches and therapies that address posterior capsular tightness
Explanation
Glenohumeral Internal Rotation Deficit (GIRD) is a phenomenon that occurs in baseball pitchers and is due to posterior capsular tightness. Treatment should begin with a therapy program addressing the pathologic posterior capsule. GIRD is a phenomenon that is frequently found in high-level overhead throwing athletes, predominantly baseball pitchers. It is defined as the measured difference in internal rotation between the non-dominant arm and dominant arm. Worsening range of motion deficits are seen with increased repetitions, both over a single season and a career. GIRD > 25 degrees is associated with development of shoulder pathologies or pain requiring periods of inactivity. Cessation of overhead throwing activities and initiation of a stretching program to address posterior capsular contractures is largely effective.
Question 1757
Topic: 5. Sports Medicine
A patient undergoes a proximal tibial resection that is reconstructed with a fresh frozen osteoarticular allograft. Eleven months later, the graft is retrieved. Histologically, the articular cartilage and subchondral bone retrieved would be expected to show evidence of
Correct Answer & Explanation
. an articular surface covered with a pannus of synovial tissue.
Explanation
Osteoarticular allografts are devoid of host chondrocytes but do contain “mummified” cellular debris left over from donor processing. The cartilage architecture is preserved in the first 2 to 3 years after transplantation. The articular surface is covered with a pannus of fibrocartilage maintaining the joint space radiographically; this pannus later contains islands of fibrocartilage containing host mesenchymal stem cells. Degenerative changes to the joint surface occur earlier and are more severe in joints that are unstable. Only with degenerative changes at the surface is there histologic evidence of subchondral revascularization. Often degenerative changes involving the articular cartilage reach the tidemark, but the tidemark itself remains structurally intact.
Question 1758
Topic: 5. Sports Medicine
A 38-year-old man is being considered for medial meniscus transplantation following an arthroscopic subtotal meniscectomy performed at the time of ACL reconstruction. His body mass index (BMI) is 28 kg/m2. Laboratory tests are shown in Figure A. Standing long-leg radiographs reveal a 4-degree valgus deformity compared with the contralateral side, with the weightbearing line running through the lateral tibial spine. His arthroscopic photos also revealed a 1.7 cm wide Outerbridge II chondral lesion over the lateral femoral condyle and synovitis. What factor in this patient is an absolute contraindication to meniscal transplantation?
Correct Answer & Explanation
. Rheumatoid arthritis
Explanation
This patient has rheumatoid arthritis. Inflammatory arthritis is an absolute contraindication to meniscal transplantation. Besides inflammatory arthritis, other absolute contraindications include diffuse arthritis, Outerbridge grade IV changes, untreated tibiofemoral subluxation, synovial disease, previous joint infection, skeletal immaturity, or marked obesity. Figure A is a table showing this patient's lab results. He has positive RF and anti-CCP antibody. In addition, he has synovial changes on arthroscopy. These findings are significant for active RA.
Question 1759
Topic: Shoulder & Hip Sports
A 52-year-old, right hand dominant man comes for evaluation of right shoulder pain that has been intermittently bothering him for three months. The pain is worse with overhead activities. He denies any history of trauma. His range of forward elevation in the plane of the scapula is painful and is limited to 145 degrees, compared to 170 degrees on his unaffected side. A radiograph is shown in Figure A. He saw another orthopedist a month ago, who ordered an MRI, which showed a small, partial thickness supraspinatus tendon tear. He received a subacromial injection of lidocaine at that time which temporarily relieved 90 percent of the pain he felt with passive forward elevation of his shoulder past 90 degrees. Today he is requesting a subacromial injection of platelet rich plasma (PRP). You tell him that with regard to pain, function and range of motion, subacromial injection of PRP: Review Topic
Correct Answer & Explanation
. Will result in improvement in pain but no difference in function or range of motion compared to therapy alone.
Explanation
At one year, quality of life, pain, disability and shoulder range of motion are the same for patients treated with therapy and placebo versus patients treated with therapy andPRP injection.Platelet rich plasma has been used for the treatment of chronic tendinopathy in different areas with mixed results. No benefit to patients with symptoms of subacromial impingement has been demonstrated for subacromial injection of PRP, when added to a standard therapy program.Kesikburun et al. conducted a randomized controlled trial in which patients with rotator cuff tendinopathy or partial rotator cuff tears were randomized to receive ultrasound-guided subacromial injection of either PRP or lidocaine, followed by a standard six-week therapy program. The authors found no difference in pain, range of motion or validated outcome scores at one year follow up.Hall et al. reviewed sports medicine applications for PRP. At that time (2009), with regard to PRP, they concluded that there was "little clinical evidence for its use."Ketola et al. sought to determine the effectiveness of subacromial decompression for the treatment of subacromial impingement syndrome. They randomized 140 patients to a supervised exercise program or arthroscopic subacromial decompression followed by a supervised exercise program. They found no clinically important differences between the two groups at 24 months follow up.Figure A shows a right shoulder radiograph without osseous pathology. Incorrect answers:
Question 1760
Topic: 5. Sports Medicine
An active 23-year-old man has right groin pain that increases with sports activity. Examination reveals decreased internal rotation of the affected hip. He has a positive impingement test and radiographs reveal no crossover sign. An MRI scan is most likely to reveal which of the following? Review Topic
Correct Answer & Explanation
. Abnormal alpha angle and a chondrolabral tear
Explanation
Young patients with hip pain and a positive impingement test are likely to have femoroacetabular impingement. The triad seen in these patients is a reduced concavity at the femoral head-neck junction, which leads to an increase in alpha angle and a chondrolabral tear. MR-arthrogram is the cross-sectional imaging modality of choice. These patients usually have reduced internal rotation and a positive impingement sign. The other findings, though possible, are not the most likely scenario in this young and active patient.
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