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5. Sports Medicine MCQs

Practice Set 91 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 1801

Topic: 5. Sports Medicine
Which of the following findings helps to distinguish between stress fractures of the tibia and shin splints?
. With shin splints, a bone scan shows the posterior tibial cortex in a diffuse, longitudinal orientation.
. With tibial shin splints, the bone scan is more intense.
. A more diffuse area of tenderness is seen in tibial stress fractures.
. A three-phase bone scan is positive in all phases with shin splints, but only positive in delayed images with tibial stress fractures.

Correct Answer & Explanation

. With shin splints, a bone scan shows the posterior tibial cortex in a diffuse, longitudinal orientation.

Explanation

After activity, pain persists longer with tibial stress fractures. A bone scan showing the tibial cortex in a diffuse, longitudinal orientation is consistent with shin splints compared to a more discreet, localized uptake more commonly seen with a stress fracture.

Question 1802

Topic: 5. Sports Medicine

What allograft has the highest antigenicity when used for ligament reconstruction about the knee?

. Tibialis anterior used for anterior cruciate ligament (ACL) reconstruction
. Tibialis anterior used for posterolateral reconstruction
. Bone-patellar tendon-bone used for ACL reconstruction
. Semitendinosus used for posterior cruciate ligament reconstruction
. Semitendinosus used for medial collateral ligament reconstruction

Correct Answer & Explanation

. Tibialis anterior used for anterior cruciate ligament (ACL) reconstruction

Explanation

Although theoretically the intra-articular environment is slightly more immune privileged, the role of immunogenicity is related more to bone than soft tissue. Therefore, the bone-patellar tendon-bone used for ACL reconstruction would have the highest risk of immunogenicity if storage techniques and harvest techniques were similar. This also is true for bone plugs associated with meniscal allografts.

Question 1803

Topic: 5. Sports Medicine
A 20-year-old football player has repeated episodes of heat cramps during summer training sessions. A deficiency of what electrolyte is most responsible for heat cramps?
. Potassium
. Magnesium
. Chloride
. Sodium
. Iron

Correct Answer & Explanation

. Sodium

Explanation

DISCUSSION: Sodium deficiency is the cause of heat cramps. It is the principle electrolyte of sweat and is readily lost during training, especially in warmer temperatures. The condition can be avoided by adding extra table salt to food and maintaining good hydration before and after sports activities. Salt tablets are to be avoided when a patient has heat cramps because the high soluble load will cause gastric irritation. REFERENCES: Bergeron MF, Armstrong LE, Maresh CM: Fluid and electrolyte losses during tennis in the heat. Clin Sports Med 1995;14:23-32. Halpern B: Fluid and electrolyte replacement in athletes. Sports Med Digest 1994;16:1-5.

Question 1804

Topic: 5. Sports Medicine

The patient undergoes right hip arthroscopy. During placement of a standard anterior portal, the 2 structures most at risk for iatrogenic injury are the

. femoral neurovascular bundle and superior gluteal neurovascular bundle.
. pudendal nerve lateral femoral cutaneous nerve (LFCN).
. LFCN and femoral neurovascular bundle.
. LFCN and obturator nerve.

Correct Answer & Explanation

. femoral neurovascular bundle and superior gluteal neurovascular bundle.

Explanation

DISCUSSIONThe clinical scenario describes a young man with a painful hip joint related to femoroacetabular impingement (FAI) based on his history of pain with prolonged sitting and the examination findings of pain and limited internal rotation, flexion, and adduction. Plain radiographs confirm the diagnosis and show decreased head-neck offset or a CAM deformity. Epidemiologic studies have shown that the most common abnormal morphology is a combined CAM/pincer deformity. In isolated CAM deformities, the most consistent finding is separation between the acetabular cartilage and labrum. The “alpha angle” is the angle between the midline of the femoral neck and a line from the center of the femoral head to the point at which the femoral head becomes aspherical. It can be measured on either a lateral radiograph of the femoral neck or on an axial cut of cross-sectional imaging (a CT scan or MR image). It is used to quantify the degree of asphericity at the anterior head-neck junction. Cadaveric studies haveshown that placement of a standard anterior portal during hip arthroscopy is closest to the LFCN and femoral neurovascular bundle.

Question 1805

Topic: 5. Sports Medicine
Which of the following statements best describes the anatomy of the sartorial branch of the saphenous nerve during medial meniscal repair?
. The nerve is reliably extrafascial at the joint line.
. The nerve is anterior to the sartorius.
. The nerve becomes extrafascial between the gracilis and the semitendinosus.
. The nerve is anterior to the semitendinosus with the knee in extension.
. The sartorial branch exits the adductor canal and travels to the anteromedial aspect of the knee.

Correct Answer & Explanation

. The nerve is anterior to the semitendinosus with the knee in extension.

Explanation

DISCUSSION: Dunaway and associates reported that the nerve was extrafascial in only 43% of their cadaveric specimens. Therefore, in medial meniscal repair, the nerve may be present during deep dissection. The sartorial branch of the saphenous nerve is posterior to the sartorius; dissection should remain anterior to the sartorius. The branch becomes extrafascial between the gracilis and the sartorius. The nerve is anterior to the semitendinosus with the knee in extension. The infrapatellar branch of the saphenous nerve exits the adductor canal and travels to the anteromedial aspect of the knee. REFERENCES: Dunaway DJ, Steensen RN, Wiand W, et al: The sartorial branch of the saphenous nerve: Its anatomy at the joint line of the knee. Arthroscopy 2005;21:547-551. Rodeo SA: Arthroscopic meniscal repair with use of the outside-in technique. Instr Course Lect 2000;49:195-206.

Question 1806

Topic: 5. Sports Medicine
Figures 80a and 80b are the radiographs of a 21-year-old football player who underwent anterior cruciate ligament (ACL) reconstruction with patellar tendon autograft 1 year ago. He reports mild stiffness in his knee. Upon examination, he has a negative Lachman test result, trace effusion, and range of motion from 0 to 85 degrees of knee flexion. Which factor is most contributory to his examination findings?
. Incorrect graft choice
. Improper tunnel position
. Tibial graft-tunnel mismatch
. Poor femoral fixation

Correct Answer & Explanation

. Improper tunnel position

Explanation

DISCUSSION: Technical failure is the most common reason for ACL reconstruction failure. Tunnel position is the most frequent cause of technical failure. Malpositioning of the tunnel affects the length of the graft, causing either decreased range of motion or increased graft laxity. This patient has anterior and vertical placement of his femoral tunnel, which has been shown to cause stiffness in knee flexion. Although graft choice is an important factor when planning ACL reconstruction, overall outcomes with autograft tissues are fairly similar. Fixation of the graft at the femoral or tibial end is not as important as tunnel position. Fixing the graft in flexion can cause extension loss when isometry is not achieved, but this condition is not touched upon in this scenario.

Question 1807

Topic: Shoulder & Hip Sports

A 22-year-old patient has had severe groin pain for many months and is unable to engage in any physical activity. The AP radiograph of the pelvis shows minimal arthritis. The lateral radiograph of the hip is shown in Figure 33a. An MR-arthrogram is shown in Figure 33b. What is the most appropriate treatment at this stage? Review Topic

. Hip arthroscopy and labral debridement
. Femoroacetabular osteoplasty and labral repair
. Femoral osteotomy
. Hemiarthroplasty
. Total hip arthroplasty

Correct Answer & Explanation

. Hip arthroscopy and labral debridement

Explanation

The patient has femoroacetabular impingement. The prominence on the femoral neck has resulted in a labral tear and detachment. An MR-arthrogram is the most appropriate modality for diagnosis of a labral tear. The diagnosis of a labral tear per se is not an indication for surgical intervention because the natural incidence of this condition is not known. Labral debridement without addressing the underlying anatomic abnormality is likely to result in a suboptimal outcome. The most appropriate treatment, when indicated, is shaving down of the femoral neck to remove the bony prominence and attachment of the labrum. Femoral osteotomy has no role in the treatment of this condition. The patient has minimal arthritis; therefore, arthroplasty is not indicated.

Question 1808

Topic: 5. Sports Medicine
A right-handed 24-year-old professional baseball player injured his left shoulder 6 weeks ago when he dove forward and landed hard with the arm extended. He reports that the shoulder “slipped out” and “went back in.” The shoulder did not need to be reduced. He now reports deep pain in the front of the shoulder when batting on either side and is hesitant to raise his left arm up over his head to catch a ball. Examination reveals no obvious deformities of the shoulder and a somewhat guarded, limited range of motion in all planes. Provocative tests for the rotator cuff and labrum are equivocal. MRI scans are shown in Figures 16a and 16b. What is the best course of action?
. Physical therapy
. Arthroscopic labral repair
. Arthroscopic subscapularis repair
. Arthroscopic thermal capsular shift
. Open Bankart repair

Correct Answer & Explanation

. Physical therapy

Explanation

The MRI scan shows no obvious labral tear or Hill-Sachs lesion to suggest an anterior dislocation. There are no data to support early surgery for anterior labral tears resulting from traumatic subluxation without dislocation. Initial treatment should consist of a short period of rest and immobilization, followed by a physical therapy rehabilitation program designed to restore motion, strength, and dynamic stability to the shoulder.

Question 1809

Topic: 5. Sports Medicine
The patient fails nonsurgical treatment for this condition. What is the best next step?
. Continued nonsurgical care with physical therapy, a brace, and stretching
. Activity restrictions and avoiding painful activity
. Surgical excision of the tibial tubercle ossicle
. Debridement of the ossicle and repair of the patellar tendon

Correct Answer & Explanation

. Surgical excision of the tibial tubercle ossicle

Explanation

Osgood-Schlatter disease is an apophysitis of the tibial tubercle. In fewer than 10% of cases, symptoms persist after skeletal maturity. For these patients, excision of the ossicle will usually resolve symptoms. The ossicle is usually not part of the tendon attachment and can be resected without detaching any of the patellar tendon.

Question 1810

Topic: Shoulder & Hip Sports
  • What location is the primary source of vascular ingrowth for tendon-bone healing with rotator cuff repair?
. Intra-articular bleeding
. Intratendinous layer of the rotator cuff
. Articular surface of the rotator cuff
. Holes in the greater tuberosity
. Bleeding from the decompressed acromion

Correct Answer & Explanation

. Intra-articular bleeding

Explanation

Question 1811

Topic: 5. Sports Medicine

Figure 100 is the MR image of a 19-year-old man who sustains recurrent anterior shoulder dislocations. The lesion shown occupies approximately 10% of the articular surface. What is the most appropriate treatment?

. Open distal tibial allograft reconstruction
. Open reduction and internal fixation (ORIF) with cannulated screws
. Arthroscopic coracoid transfer
. Arthroscopic repair incorporating the bony component

Correct Answer & Explanation

. Open distal tibial allograft reconstruction

Explanation

DISCUSSIONThe MR image shows a bony Bankart lesion involving less than 20% of the glenoid joint surface. One series reported high success rates after arthroscopic treatment when the defect was incorporated into the repair. Anterior bony deficiencies occupying more than 25% to 30% of the glenoid joint surface treated with soft-tissue repair only are associated with highrecurrence rates. In these patients, an open or arthroscopic coracoid transfer or distal tibial allograft reconstruction should be considered. ORIF has been reported for treatment of large acute glenoid rim fractures, but is not recommended for recurrent anterior shoulder instability in the setting of a 10% glenoid rim fracture.

Question 1812

Topic: Shoulder & Hip Sports
A 72-year-old man who underwent total shoulder arthroplasty 2 years ago slipped on ice and fell on his shoulder 3 weeks ago. Immediately after falling he was unable to elevate his arm. Motor examination reveals deltoid 5-/5, subscapularis 5-/5, external rotation 4-/5, and supraspinatus 2/5. Radiographs are shown in Figures 8a and 8b. What is the most likely diagnosis?
. Anterior shoulder dislocation
. Humeral component loosening
. Glenoid component loosening
. Glenoid component catastrophic fracture
. Rotator cuff tear

Correct Answer & Explanation

. Rotator cuff tear

Explanation

The patient has a traumatic rotator cuff tear. The history of the fall, the weakness on examination, and normal radiographic findings make a traumatic rotator cuff tear the most likely diagnosis. An MRI scan can be obtained to further evaluate the integrity of the rotator cuff. The axillary radiograph shows a reduced, nondislocated total shoulder arthroplasty. His radiographs show a well-seated humeral stem and no signs of loosening. The glenoid is a cemented all-polyethylene component with no evidence of radiolucent lines surrounding the cemented pegs. The polyethylene glenoid component is radiolucent; however, the space between the metallic humeral head and the glenoid bone is the thickness of the polyethylene glenoid component.

Question 1813

Topic: Shoulder & Hip Sports

Figure 1 is the T2 coronal MRI scan(Massive atraumatic rotator cuff tear) of a 52-year-old woman with a 6-month history of shoulder pain. She does not recall a history of trauma. Physical therapy is recommended. What is the most significant predictor of failure of nonoperative treatment?

. Tear size
. Pain scale score
. Strength deficit
. Patient expectations

Correct Answer & Explanation

. Tear size

Explanation

The MRI reveals a large full thickness supraspinatus tear. A large, prospective study showed that physical therapy can be effective in the treatment of atraumatic full-thickness rotator cuff tears. Patient expectations regarding the role of rehabilitation were the strongest predictor of surgery. Other factors associated with surgery were higher activity level and not smoking. Anatomic features of the rotatorcuff tear and the severity of patient’s reported pain did not predict failure of nonoperative treatment. Patients who have low expectations regarding the effectiveness of physical therapy are more likely to fail nonoperative treatment.

Question 1814

Topic: 5. Sports Medicine
Initial repair of the large U-shaped rotator cuff tear shown in Figure 12 consists of closing the tear side-to-side to take advantage of margin convergence. The most significant biomechanical consequence of this repair step results in
. increased strength of the rotator cuff repair by creating thicker repair construct.
. decreased size of the defect exposing the humeral head.
. decreased stress in the rotator cuff at the site of the side-to-side repair.
. decreased stress in the rotator cuff at the free margin and greater tuberosity interface.
. decreased stress in the rotator cuff crescent cable.

Correct Answer & Explanation

. decreased stress in the rotator cuff at the free margin and greater tuberosity interface.

Explanation

Margin convergence refers to the phenomenon that occurs with side-to-side closure of large U- or L-shaped rotator cuff tears in which the free margin of the tear converges toward the greater tuberosity as the side-to-side tear progresses. The creation of the converged cuff margin creates decreased strain in the free margin of the repaired cuff, resulting in a decreased strain in the repair sutures.

Question 1815

Topic: 5. Sports Medicine
Images from an MRI scan of this patient’s left hip are shown in Figure 30c through 30e. What is the most likely cause of his acute pain?
. Significant cartilage loss on the acetabulum
. Labral tear
. Femoral neck stress fracture
. Tendonopathy of the rectus femoris

Correct Answer & Explanation

. Labral tear

Explanation

This patient has cam-type femoroacetabular impingement. Decreased internal rotation and a positive impingement test are classic findings. His MRI scan shows a labral tear, which is common in cam impingement.

Question 1816

Topic: Knee Sports

Figure 80a shows an arthroscopic view from an infralateral portal of a right knee. Figure 80b shows a coronal MRI scan, and Figures 80c through 80e show consecutive sagittal images of the knee. The images show what anatomic finding? Review Topic

. Loose body
. Discoid lateral meniscus
. Transverse meniscal ligament
. Displaced lateral meniscus tear
. Displaced medial meniscus tear

Correct Answer & Explanation

. Loose body

Explanation

The arthroscopic view and the coronal MRI scan show a discoid lateral meniscus covering almost the entire lateral tibial plateau. The sagittal views show a contiguous meniscus or "bow tie" sign on three consecutive images, pathognomonic for a discoid meniscus. Lateral discoid menisci are much more common than medial. There is no evidence of abnormal signal to indicate meniscal tearing. A transverse meniscal ligament is best seen anterior to the anterior horn of the lateral meniscus on multiple views. There is no evidence of a loose body on the arthroscopic or MRI images.

Question 1817

Topic: 5. Sports Medicine

A 70-year-old male presents with a complete, chronic rupture of the patellar tendon 3 months after a primary TKA. He cannot actively extend his knee against gravity. Primary repair is impossible due to tissue retraction. What is the most reliable surgical reconstruction technique?

. Primary repair augmented with heavy nonabsorbable sutures
. Extensor mechanism allograft reconstruction
. Hamstring autograft reconstruction
. Medial gastrocnemius rotational flap alone
. Nonoperative management in an extension splint

Correct Answer & Explanation

. Primary repair augmented with heavy nonabsorbable sutures

Explanation

Chronic or irreparable patellar tendon ruptures in the setting of TKA are exceptionally difficult to manage. Extensor mechanism allograft (often utilizing an Achilles tendon with bone block or a whole extensor mechanism) or synthetic mesh reconstruction provides the most reliable restoration of function.

Question 1818

Topic: 5. Sports Medicine
What factor highly correlates with poor outcomes after surgery for femoroacetabular impingement?
. Age <20
. Tonnis grade 2
. Prominence of the femoral head in cam impingement
. The patient is a professional athlete

Correct Answer & Explanation

. Tonnis grade 2

Explanation

A systematic review of case studies looking at the results of surgical treatment for femoroacetabular impingement shows good results for most patients, with the exception of those with preoperative radiographs showing osteoarthritis (such as Tonnis grade 2) or Outerbridge grade III or grade IV cartilage damage noted intraoperatively.

Question 1819

Topic: 5. Sports Medicine
Patients with patellar clunk syndrome are best managed by which of the following methods?
. Rest and nonsteroidal anti-inflammatory drugs
. Surgical debridement
. Patellectomy
. Patellar revision
. Lateral release/patellar realignment

Correct Answer & Explanation

. Surgical debridement

Explanation

Patellar clunk syndrome is usually the result of a fibrous nodule that forms on the undersurface of the distal quadriceps tendon. Nonsurgical management is rarely successful. Surgical debridement is usually curative, with only rare recurrence.

Question 1820

Topic: 5. Sports Medicine
A 38-year-old man sustains a complete avulsion with retraction of the ischial attachment of the hamstring muscles in a fall while water skiing. He indicates that he is an aggressive athlete who participates regularly in multiple running and cutting-type sports, and he strongly desires to continue his athletic competition. Management should consist of
. ultrasound, iontophoresis, and stretching, with an early return to sports.
. a local corticosteroid injection and strengthening, with a delayed return to sports.
. immobilization and rehabilitation, with a delayed return to sports.
. early surgical repair, prolonged rehabilitation, and a return to sports.
. rehabilitation, with delayed surgical repair if the patient is unable to return to sports.

Correct Answer & Explanation

. early surgical repair, prolonged rehabilitation, and a return to sports.

Explanation

DISCUSSION: Several studies have identified a complete proximal avulsion of the hamstring muscles as an injury that leads to significant long-term disability, with a high percentage of athletes who must permanently restrict their activities following nonsurgical management. Early surgical repair and prolonged rehabilitation have yielded consistently better results than nonsurgical management.

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