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 1761
Topic: 5. Sports Medicine
A 23-year-old professional baseball pitcher reports shoulder pain and decreased velocity while pitching. Physical examination reveals a side-to-side internal rotation deficit of 25 degrees. The O’Brien sign is negative; Neer and Hawkins signs are negative. Rotator cuff strength is full. Radiographs are unremarkable. What is the next step in management? Review Topic
Correct Answer & Explanation
. MRI-arthrogram to evaluate the rotator cuff
Explanation
Throwing athletes with symptomatic internal rotation deficits often benefit from an intensive posterior capsular stretching program. Patients that fail to respond to nonsurgical management may benefit from an arthroscopic posterior capsular release.
Question 1762
Topic: Shoulder & Hip Sports
A 47-year-old man has acute right shoulder pain after falling off a ladder. The MRI scan shown in Figure 9 reveals
Correct Answer & Explanation
. a full-thickness rotator cuff tear.
Explanation
DISCUSSION: The MRI scan reveals a full-thickness rotator cuff tear with retraction and increased signal in the subacromial space indicating joint fluid. REFERENCES: Herzog RJ: Magnetic resonance imaging of the shoulder. Instr Course Lect 1998;47:3-20. Iannotti JP, Zlatkin MB, Esterhai JL, et al: Magnetic resonance imaging of the shoulder: Sensitivity, specificity, and predictive value. J Bone Joint Surg Am 1991;73:17-29.
Question 1763
Topic: 5. Sports Medicine
You perform an ACL reconstruction with bone-patella tendon-bone (BTB) autograft and are explaining the postoperative rehabilitation protocol to your patient. Which of the following is associated with increased quadriceps volume and improved quadriceps strength at 1 year without a higher risk of knee instability? Review Topic
Correct Answer & Explanation
. Use of a hinged knee brace for 6 weeks postoperatively
Explanation
Early eccentric strengthening following ACL reconstruction has been associated with increased quadriceps volume and improvement in strength at 1 year without a higher risk of knee laxity.Proper rehabilitation following ACL reconstruction is vital to a successful outcome. The cornerstone of ACL rehabilitation is range of motion, strengthening and functional exercises without risk of destabilizing the knee. There are a variety of rehabilitation protocols and recently an effort has been made to standardize the approach to postoperative ACL care. An accelerated protocol starting at 3 weeks postoperatively has been deemed safe and may enhance the speed and safety with which an athlete returns to play.Kruse et al completed a meta-analysis of 29 Level I and II studies focused on the ACL rehabilitation process. The authors concluded that immediate postoperative weightbearing and knee range of motion 0-90 is safe. Early eccentric strengthening appears to accelerate and improve strength gains at 1 year as compared to delayed eccentric strengthening. Home-based rehabilitation programs can be as effective as formal physical therapy. Postoperative bracing and CPM use is neither necessary nor beneficial.Van Grinsven et al conducted a systematic review of ACL rehabilitation programs and physical therapy modalities to develop an evidence-based rehabilitation protocol. The authors demonstrated that an accelerated protocol without postoperative bracing focused on reduction of pain, swelling and inflammation and regaining range of motion, strength and neuromuscular control has significant advantages and does not lead to stability problems.Gerber et al performed a randomized trial comparing two accelerated postoperative rehabilitation protocols – early eccentric (ECC) rehabilitation versus traditional (TRAD) rehabilitation starting at 3 weeks. There were no significant differences in knee pain, effusion or stability. However, quadriceps strength, hopping distance and activity level improved by a significantly greater amount in the ECC group versus the TRAD group at 26 weeks postoperatively. In a separate analysis of these patients, quadriceps and gluteus muscle cross-sectional area and volume in ECC patients were more than twice those in the TRAD group.Illustration A depicts two eccentric ergometers that can be used in postoperative ACL rehabilitation.Incorrect Responses:another Answertype of brace,2:Thereduration isofbracing or no bracing at all.noadvantagetoCPMuse.
Question 1764
Topic: 5. Sports Medicine
For the athlete performing heavy exercise, the magnitude of core temperature and heart rate increase is most proportional to
Correct Answer & Explanation
. water debt at the onset of exercise.
Explanation
DISCUSSION: Studies examining the impact of graded water debt have clearly shown that the magnitude of core temperature and heart rate increase accompanying work are proportional to the magnitude of water debt at the onset of exercise. Though added thermal burden from hot climates is a factor, it appears to be less significant.
Question 1765
Topic: 5. Sports Medicine
Which of the following best describes carbohydrate loading?
Correct Answer & Explanation
. The practice of decreasing training and increasing carbohydrate intake the week before an endurance event
Explanation
DISCUSSION: Carbohydrate loading is the practice of maximizing glycogen stores by decreasing training and increasing carbohydrate intake the week before an endurance event. Nonendurance athletes do not benefit from this because glycogen depletion is not the limiting factor during a normal competition. Potential side effects of carbohydrate loading are water retention, muscle stiffness, and weight gain. REFERENCES: Coyle EF, Hagberg JM, Hurley BF, et al: Carbohydrate feeding during prolonged strenuous exercise can delay fatigue. J Appl Physiol 1983;55:230-235. Costill DL, Sherman WM, Fink WJ, et al: The role of dietary carbohydrates in muscle glycogen resynthesis after strenuous running. Am J Clin Nutr 1981;34:1831-1836. Sherman WM, Doyle JA, Lamb DR, et al: Dietary carbohydrate, muscle glycogen, and exercise performance during 7 d of training. Am J Clin Nutr 1993;57:27-31.
Question 1766
Topic: Knee Sports
Figure 1 is an arthroscopic view of the intercondylar notch of a right knee from an anterolateral portal. What is the main function of the structure delineated by the black asterisks?
Correct Answer & Explanation
. Resist anterior translation during knee flexion
Explanation
The structure shown is the posterolateral bundle of the anterior cruciate ligament (ACL). This bundle is optimally positioned in the knee to resist rotatory forces during terminal knee extension. "Resist anterior translation during knee flexion" best describes the anteromedial bundle. "Resist rotatory loads during knee flexion" is unlikely because the posterolateral bundle is tightest during knee extension. The posterior cruciate ligament, not the ACL, functions to resist posterior translation.
Question 1767
Topic: Shoulder & Hip Sports
A baseball pitcher has intractable posterior and superior shoulder pain. The arthroscopic view shows no Bankart or Hill-Sachs lesion and a negative drive-through sign. There are no signs of ligamentous laxity, but active compression and anterior slide tests are positive. Treatment should consist of:
Correct Answer & Explanation
. arthroscopic repair of the SLAP lesion with suture anchors.
Explanation
According to Morgan and associates, a type II SLAP lesion can create or is associated with a superior instability pattern. They suggest that this can exist without a co-existing anteroinferior instability pattern. They reported that repair of the SLAP lesion alone resulted in satisfactory outcomes in 90% of patients and a return to throwing in more than 90% of pitchers. The arthroscopic findings in this patient do not support a diagnosis of anteroinferior laxity or instability; therefore, thermal capsular shift or capsular placation is not necessary.
Question 1768
Topic: Shoulder & Hip Sports
In the absence of developmental dysplasia of the hip, what is the most common cause of osteoarthritis? Review Topic
Correct Answer & Explanation
. Legg-Calve-Perthes disease
Explanation
Femoroacetabular impingement is a mechanism for the development of early osteoarthritis for most nondysplastic hips. Early surgical intervention for treatment of femoroacetabular impingement, besides providing relief of symptoms, may decelerate the progression of the degenerative process for this group of young patients. There are two general types of femoroacetabular impingement. In cam impingement, the femoral deformity is usually a bump on the head-and-neck junction that impinges on the acetabular rim. The pincer type of impingement is caused by deformity on the acetabular side such as a deep socket or acetabular overcoverage due to retroversion. Both mechanisms create an obstacle for flexion and internal rotation.
Question 1769
Topic: Shoulder & Hip Sports
Figures 36a and 36b show the MRI scans of a patient who has shoulder weakness. What is the most likely diagnosis?
Correct Answer & Explanation
. Suprascapular nerve entrapment
Explanation
DISCUSSION: The sagittal image reveals increased signal and decreased size of the supraspinatus and infraspinatus muscles, indicating muscle atrophy. The rotator cuff tendon signal is normal. The subscapularis and teres minor muscles are unaffected. Muscular dystrophy and thoracic outlet syndrome would be expected to have a more global effect. Although muscular atrophy can occur in the setting of a rotator cuff tear, the coronal image shows an intact supraspinatus. The suprascapular nerve supplies the supraspinatus and infraspinatus muscles. Therefore, suprascapular nerve entrapment would result in atrophy of these muscles with sparing of the surrounding musculature. Any lesion within the suprascapular notch, including neoplastic disease, a venous varix, or neuroma, can place pressure on the suprascapular nerve. Suprascapular nerve entrapment most commonly results from extension of a paralabral cyst or ganglion, often with associated labral pathology. Spinal accessory nerve disruption would show trapezius muscle atrophy.
Question 1770
Topic: Shoulder & Hip Sports
An active 45-year-old man sustained an acute traumatic anteroinferior dislocation. MRI scans and an arthroscopic view are shown in Figures 36a through
Correct Answer & Explanation
. Greater tuberosity
Explanation
During an anteroinferior dislocation, the posterosuperior portion of the humeral head impacts the inferior rim of the glenoid, resulting in an impaction injury. This lesion is classically referred to as a Hill-Sachs lesion.
Question 1771
Topic: Shoulder & Hip Sports
The view from an anterosuperior portal of the right shoulder shown in Figure 12 reveals which of the following findings?
Correct Answer & Explanation
. Humeral avulsion of the glenohumeral ligament (HAGL) lesion
Explanation
The arthroscopic view shows a HAGL lesion. With the arthroscope directed anteroinferiorly, muscular striations of the subscapularis can be visualized through the avulsion site. In vitro strain studies indicate that glenohumeral ligament failure on the humeral side occurs in approximately 25% of patients, while clinically this lesion has been reported in approximately 9% of patients with shoulder instability. Failure to recognize and treat this lesion leads to persistent anterior instability. An ALPSA lesion, a Bankart variant, occurs on the glenoid side and is characterized by a sleeve-like medial retraction and inferior rotation. A Bankart lesion is the classic avulsion of the glenohumeral ligament from the glenoid rim. The subscapularis tendon and the rotator interval are not shown in the figure.
Question 1772
Topic: 5. Sports Medicine
What is the most common cause of the new onset of amenorrhea in a female endurance athlete who is not sexually active?
Correct Answer & Explanation
. Insufficient caloric intake
Explanation
Insufficient caloric intake caused by either a poor diet or an eating disorder is the most common cause for the loss of menses in a female athlete. In the face of adequate caloric intake, stress is unlikely to cause amenorrhea. Oral contraceptives control menses but do not eliminate it. Diabetes mellitus does not cause the new onset of amenorrhea. Pregnancy can be a cause in a sexually active athlete. Chromosomal abnormalities can result in delayed or absent menarche but not the onset of amenorrhea in a postmenarchal female.
Question 1773
Topic: Shoulder & Hip Sports
Figure 1 is the MR image of a 43-year-old man who has left shoulder pain and weakness after a fall. An examination reveals active forward elevation at 120° and positive Yergason and lift-off test examination findings. Arthroscopy reveals that the articular surfaces of the glenohumeral joint have a normal appearance without significant degenerative changes. What is the most appropriate treatment at this time?
Correct Answer & Explanation
. Rotator cuff repair and biceps tenodesis
Explanation
The MR image shows medial subluxation of the biceps tendon, which can be confused with an articular loose body. In the clinical scenario of biceps instability/subluxation, the rationale regarding tenodesis is to address the painful dislocation and subluxation of the biceps tendon from the bicipital groove. Biceps tendon subluxation is most frequently associated with subscapularis tendon pathology, which is indicated by the MRI and by a positive lift-off test. The MR image does not show a loose body or Bankart lesion. Patients with irreparable rotator cuff tears with a severe external rotation deficit and a deficient teres minormay experience a better functional result with latissimus dorsi transfer.
Question 1774
Topic: Shoulder & Hip Sports
Which of the following best describes the recommended treatment for a 13-year-old pitcher with a painful chronic stress injury to the proximal humeral physis as confirmed on an MRI scan? Review Topic
Correct Answer & Explanation
. Brief shoulder immobilization followed by avoidance of pitching and throwing for the remainder of the season
Explanation
Little Leaguer's shoulder is a chronic stress injury to the proximal humerus growth plate. Imaging findings demonstrate widening of the proximal humeral growth plate. Treatment consists of rest and avoidance of pitching for the remainder of the season. Surgery is not indicated.
Question 1775
Topic: 5. Sports Medicine
A 16-year-old boy falls while playing soccer. He reports that his knee buckled when he planted his leg to kick a ball. He noticed an obvious deformity of his knee, which spontaneously resolved with a “clunk.” He could not finish the game but was able to bear weight with a limp. He has had two similar episodes but has never sought medical attention. An initial examination demonstrated an effusion, tenderness at the proximal medial collateral region and medial patellofemoral retinaculum, decreased range of motion, and patella apprehension. A lateral patellar glide performed at 30° of flexion was 3+. He was otherwise ligamentously stable, and there were no other noteworthy findings. What do Figures 1 and 2 reveal?
Correct Answer & Explanation
. Medial femoral condyle physeal widening
Explanation
This patient’s examination and history indicate recurrent patellar dislocations. Radiographs show an osseous or osteochondral loose fragment. There is no evidence of an obvious nondisplaced fracture or physeal changes. In the setting of suspected patella dislocation or subluxation with loose fragment seen on radiograph, an MRI is indicated. Lateral release alone is seldom indicated in a knee that is normal before injury. The examination and MRI do not indicate a need for medial collateral ligament repair. Treatment should consist of arthroscopy or arthrotomy and attempted internal fixation of this fragment. If fixation is not possible, the loose body can be removed. Normal TT-TG values, an increased lateral patellar glide, and a history of recurrent patellar dislocations after trauma suggest MPFL incompetence and the need for reconstruction.
Question 1776
Topic: Shoulder & Hip Sports
A 78-year-old male presents to clinic 4 weeks after left total shoulder arthroplasty. He has not been wearing his sling and reports that he developed increased pain after slipping in the shower. He used the arm to catch himself from falling. On examination, he can flex the shoulder to 70 degrees, limited by pain. Active external rotation with arm at the side is 50 degrees and active internal rotation is 5 degrees. Passive external rotation is to 80 degrees. A radiograph of the left shoulder is shown below in Figure A. What other complaint is the patient most likely to have? Review Topic
Correct Answer & Explanation
. Pain with palpation of the bicipital groove
Explanation
The clinical presentation is consistent with a tear of the subscapularis, which is a well-described complication after total shoulder arthroplasty. The most likely additional complaint this patient will have is anterior shoulder instability, noticeable with external rotation of the shoulder.Total shoulder arthroplasty is the preferred treatment for glenohumeral arthritis in patients with intact rotator cuff and good glenoid bone stock. The surgical approach involves detaching the subscapularis and capsule from the anterior humerus and dislocating the humeral head anteriorly. Post operatively, external rotation is limited to protect the subscapularis repair. If there is suspicion of a postoperative subscapularis tear, and ultrasound can be performed to confirm the diagnosis.Miller et al. reported 7 cases of subscapularis tendon rupture after total shoulder arthroplasty, all of which were subsequently repaired. Decreased functional outcomes were observed in these patients, with lengthening techniques to address internal rotation contractures and prior surgery involving the subscapularis tendon as risk factors for ruptureWestoff et al. performed static and dynamic ultrasounds on 22 patients after total shoulder arthroplasty evaluating for numerous periarticular pathologies. The authors concluded that sonography is a useful tool for evaluation of peri-implant tissues after TSA.Figure A shows an intact left total shoulder arthroplasty without evidence of fracture, dislocation, or hardware loosening. Illustration A shows the incision for the subscapularis tendon during TSA.Incorrect Answers:
Question 1777
Topic: 5. Sports Medicine
Which of the following symptoms are most commonly associated with piriformis syndrome?
Correct Answer & Explanation
. Posterior hip and radiating extremity pain
Explanation
DISCUSSION: Piriformis syndrome is best characterized by localized posterior hip pain and radicular symptoms in the sciatic distribution because of compression of the piriformis muscle on the sciatic nerve. Weakness in hip extension is not a characteristic finding, nor is pain with hip abduction or flexion. Hypesthesia of the lateral thigh would be more characteristic of a lesion of the lateral femoral cutaneous nerve. Radiating medial thigh pain would suggest hip joint pathology or upper lumbar nerve root irritation. Weakness in internal rotation is not a characteristic feature, and hypesthesia of the perineum would suggest possible involvement of the pudendal nerve.
Question 1778
Topic: 5. Sports Medicine
Examination of a 23-year-old female college basketball player who has had anterior knee pain for the past 3 weeks reveals tenderness and fullness over the inferior patella and proximal patellar tendon. There is no patellofemoral crepitus, patella apprehension sign, or anterior or posterior instability. Initial management should include
Correct Answer & Explanation
. ice, rest, avoidance of the offending activity, and rehabilitation.
Explanation
DISCUSSION: The patient has patellar tendinitis (jumper’s knee). It is a common overuse condition seen in runners, volleyball players, soccer players, and jumpers but can be seen in any activity in which repeated extension of the knee is required. In the acute setting, the pain is well localized and there is tenderness and sometimes swelling of the tendon. MRI is recommended for evaluating chronic cases and for surgical planning. In the acute phases, ice, rest, and avoidance of the offending activity are recommended. Weakness of the quadriceps and hamstring muscle are thought to contribute to this problem; therefore, stretching and isometric exercise in a limited range of motion are important. Complete rest and intratendinous injections of steroids are detrimental to tendon physiology.
Question 1779
Topic: 5. Sports Medicine
Which presurgical condition is most commonly associated with a poor outcome after a hip joint salvage procedure?
Correct Answer & Explanation
. Tonnis grade of 2 or higher
Explanation
DISCUSSION: Although age beyond 40 years and body mass index higher than 30 can adversely affect clinical outcomes after joint preservation procedures (PAO, hip arthroscopy, and femoral acetabular impingement surgery), the presence of hip arthritis on presurgical radiographs is the most commonly mentioned cause of failed hip joint preservation surgery. Tonnis grade is a radiographic measure of hip arthritis. A higher Outerbridge score is associated with more frequent poor outcomes after hip arthroscopy; however, the Outerbridge cartilage score is determined by direct visualization at the time of surgery. An Outerbridge score cannot be determined presurgically.
Question 1780
Topic: 5. Sports Medicine
An 18-year-old high school football player sustains a left posterior hip dislocation that is reduced in the emergency department under IV sedation. Postreduction radiographs reveal a concentric reduction with no evidence of fracture or loose bodies within the joint. What is the most common complication of hip dislocations?
Correct Answer & Explanation
. Osteonecrosis of the femoral head
Explanation
DISCUSSION: Traumatic dislocation of the hip in sports injuries is uncommon, and 85% to 92% occur in a posterior direction. In dislocations without fractures, osteonecrosis is the most common complication occurring in 10% to 20% of patients. MRI should be performed at 3 months postreduction to rule out osteonecrosis. Nerve injuries are rare in this setting, and recurrent dislocations are unusual without acetabular fractures. Chondrolysis has been reported as a rare occurrence. REFERENCES: Anderson K, Strickland S, Warren R: Hip and groin injures in athletes. Am J Sports Med 2001;29:521-533. Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 407-416.
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