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 1901
Topic: 5. Sports Medicine
An 18-year-old lacrosse player is diagnosed with infectious mononucleosis. What is the recommendation for return to play? Review Topic
Correct Answer & Explanation
. Full participation 4 weeks after both the onset of illness and findings of a normal-sized spleen
Explanation
Infectious mononucleosis commonly affects adolescents and young adults. It is a febrile illness accompanied by acute pharyngitis. Splenomegaly may occur and predispose the athlete to splenic rupture. Splenic rupture has been reported in nonathletes as well as in patients with normal-sized spleens. Clinical evidence supports a return to all sports 4 weeks after the onset of symptoms provided that the spleen has returned to normal size.
Question 1902
Topic: Shoulder & Hip Sports
A 22-year-old swimmer underwent thermal capsulorrhaphy treatment for recurrent anterior subluxation. Following 3 weeks in a sling, an accelerated rehabilitation program allowed him to return to swimming in 3 1/2 months. While practicing the butterfly stroke, he sustained an anterior dislocation. He now continues to have symptoms of anterior instability and has elected to have further surgery. Surgical findings may include a
Correct Answer & Explanation
. deficient anterior capsule.
Explanation
DISCUSSION: Complications of thermal capsule shrinkage or accelerated rehabilitation include capsule ablation. Since the original surgery did not include labral reattachment, findings of a Bankart lesion or a glenoid fracture from a nontraumatic injury are unlikely. Subscapularis detachment or biceps subluxation is a postoperative complication of open repairs. Failure of early postoperative instability treatment should not produce loose bodies. REFERENCES: Abrams JS: Thermal capsulorrhaphy for instability of the shoulder: Concerns and applications of the heat probe. Instr Course Lect 2001;50:29-36. Hecht P, Hayashi K, Lu Y, et al: Monopolar radiofrequency energy effects on joint capsular tissue: Potential treatment for joint instability. An in vivo mechanical, morphological, and biochemical study using an ovine model. Am J Sports Med 1999;27:761-771.
Question 1903
Topic: Shoulder & Hip Sports
If the site of the pathologic lesion is revealed in Figure 54f and not in Figure 54e after traumatic anterior shoulder dislocation, the mechanism of shoulder injury is likely
Correct Answer & Explanation
. combined hyperabduction and external rotation.
Explanation
DISCUSSION: For patients with anterior shoulder instability, most commonly, a Bankart lesion, or detachment of the anteroinferior labrum with the attached inferior glenohumeral ligament from the glenoid rim is found. A medialized anteroinferior capsulolabral attachment (ALPSA lesion) is a common finding in shoulders with chronic anterior instability. The anterior band of the inferior glenohumeral ligament is tightest with the arm in 90 degrees of abduction with the shoulder externally rotated, creating a โhammockโ that supports the humeral head. At 45 degrees of shoulder abduction, the capsuloligamentous components of the shoulder are at their loosest, resulting in the most total superior-inferior translation. During traumatic anterior glenohumeral dislocation, associated injuries commonly occur. Humeral avulsion of the glenohumeral ligaments (HAGL) has become a well-recognized cause of recurrent shoulder instability and is reported in 1% to 9% of patients. HAGL lesions can result from trauma in the setting of combined hyperabduction and external rotation. This is in contrast to a Bankart lesion, which is a result of trauma when the shoulder is hyperabducted without substantial associated rotation.
Question 1904
Topic: 5. Sports Medicine
Second impact syndrome (SIS) after head injury is characterized by which of the following?
Correct Answer & Explanation
. Preventable by restricting return to play until symptom-free
Explanation
DISCUSSION: SIS is a devastating but preventable complication of head injury. It occurs when return to activities is allowed prior to complete resolution of the symptoms of the first head injury. A second, sometimes trivial, head injury can lead to a devastating series of events that can result in sudden death. The symptoms tend to progress rapidly and often involve the brain stem. The prognosis is poor. REFERENCES: Cantu RC: Second-impact syndrome. Clin Sports Med 1998;17:37-44. Saunders RL, Harbaugh RE: Second impact in catastrophic contact-sports head trauma. JAMA 1984;252:538-539. Stevenson KL, Adelson PD: Pediatric sports-related head injuries, in Delee JC, Drez D (eds): Orthopaedic Sports Medicine: Principles and Practice, ed 2. Philadelphia, PA, WB Saunders, 2003, vol 1, p 781.
Question 1905
Topic: 5. Sports Medicine
A 28-year-old man reports an episode of buckling and giving-way of his right knee. Figure 54a and 54b show a radiograph and sagittal MRI scan. What is the most likely diagnosis? Review Topic
Correct Answer & Explanation
. Patellar tendon rupture
Explanation
The radiograph shows patella alta consistent with a rupture of the patellar tendon. The MRI scan confirms disruption of the patellar tendon from the inferior pole of the patella. The cruciate ligaments are not visualized in this image, and would not result in patella alta. Quadriceps tendon rupture would result in patella baja. There is no evidence of meniscal tearing on these images.
Question 1906
Topic: Shoulder & Hip Sports
Figure 28 shows an arthroscopic view of a right shoulder in the lateral position through a posterior portal. What is the area between structure B (biceps) and SS (subscapularis tendon)?
Correct Answer & Explanation
. Rotator cuff interval
Explanation
The rotator cuff interval is located between the supraspinatus and subscapularis and the biceps tendon is deep to the interval. It is a triangular area where the base is the coracoid process and the apex is the transverse humeral ligament at the biceps sulcus. Closure or tightening of this area is often helpful in patients with shoulder instability. Conversely, this area is often contracted in patients with adhesive capsulitis and may need to be released.
Question 1907
Topic: Knee Sports
A 9-year-old girl, who is an avid soccer player, has intermittent spontaneous snapping in her left knee that has worsened. There is no reported trauma or prior surgeries to her knee. Despite working with her trainer, she has developed anterior-based knee pain and lacks full extension. Her knee skin is unremarkable, but there is fullness to palpation on the lateral aspect of her knee. Her range of motion demonstrates a lack of 15ยฐ of terminal extension and ligamentous examination is unremarkable. Considering possible surgical treatments for this patient, what is the most appropriate surgical treatment?
Correct Answer & Explanation
. Arthroscopic meniscal saucerization
Explanation
Surgical intervention of discoid meniscus is based on symptomatic patients. Complete discoid menisci are typically stable but are expected to have >4.5 times incidence of surgical intervention. Saucerization of symptomatic discoid meniscus is associated with better results with younger patients with increases of poor outcomes in adult-aged patients. Meniscal transplant may be an option, although long-term resultsare unknown.
Question 1908
Topic: 5. Sports Medicine
Figures 94a and 94b show T1 sagittal and coronal MR images of the right shoulder of a 45-year-old woman. She has insidious onset of dull, aching right shoulder pain localized at the superior aspect of her shoulder. The nerve that supplies the atrophied muscle arises from the upper trunk from contributions of which nerve roots?
Correct Answer & Explanation
. C5 and C6 with occasional contribution from C4
Explanation
The suprascapular nerve innervates the supraspinatus muscle. Patients with suprascapular neuropathy usually have insidious onset of dull, aching shoulder pain at the superior or posterior aspect of the shoulder. The suprascapular nerve originates from the upper trunk from predominantly the C5 and C6 nerve roots, with an occasional contribution from the C4 nerve root.
Question 1909
Topic: 5. Sports Medicine
An 18-year-old woman sustains a twisting injury of the knee while skiing. Figures 7a and 7b show the radiograph and coronal MRI scan of the knee. In addition to the injury shown, what is the most likely associated injury? Review Topic
Correct Answer & Explanation
. Anterior cruciate ligament rupture
Explanation
The MRI scan shows a Segond fracture, which is a small avulsion of the lateral joint capsule from the anterolateral aspect of the proximal tibia. It is almost always associated with anterior cruciate ligament rupture and often with a tear of either the medial or lateral meniscus.
Question 1910
Topic: Knee Sports
Figure 1 is the MR image of a 36-year-old athlete who is tackled from behind and falls forward onto his left knee. He has pain, swelling, and stiffness. Examination includes a moderate effusion, positive quadriceps active test, and normal Lachman test finding. If the patient chooses surgical reconstruction, he should be advised that, when compared with a transtibial technique, the tibial inlay technique has been shown to provide
Correct Answer & Explanation
. more graft protection during cyclic loading.
Explanation
The clinical description and MR image point to an injury to the posterior cruciate ligament (PCL). This ligament is thought to be primarily composed of anterolateral and posteromedial bundles, with the former tightening in flexion and the latter in extension. Because of alterations in knee kinematics and increased varus alignment in PCL insufficiency, contact stresses and cartilage loads increase in the patellofemoral and medial compartments. Although good outcomes may be obtained with transtibial, open inlay, and arthroscopic inlay techniques, one major difference is the creation of the โkiller-turnโ during the transtibial approach. This sharp turn in the graft as it emerges from the tibia appears to lead to more pronounced attenuation and thinning of the graft during cyclic loading. The scenario describes a patient with chronic PCL and posterolateral corner (PLC) injury, as evidenced by the varus thrust and abnormal Dial test finding. A valgus-producing osteotomy may be effective, and, in fact, may be the only treatment necessary to address chronic PLC injury. Accordingly, an opening lateral osteotomy would not beappropriate. Of the remaining responses, an osteotomy that increases tibial slope would also address the PCL deficiency by reducing posterior tibial sag. Vascular injury is an uncommon, but potentially devastating, complication associated with PCL surgery and may occur regardless of the technique used. Numerous strategies have been described to reduce the risk, including use of a posteromedial accessory incision to allow finger retraction of the popliteal neurovascular bundle, oscillating drills to prevent excessive soft-tissue entanglement, and tapered (rather than square) drill bits that may minimize cut-out of sharp edges as drilling reaches the posterior tibial cortex. Knee extension lessens, rather than increases, the distance between the posterior tibia and the neurovascular bundle and increases, not lessens, risk forvascular injury.
Question 1911
Topic: 5. Sports Medicine
Which of the following statements best describes the relationship between tissue response to thermal capsulorrhaphy and the type of device used?
Correct Answer & Explanation
. The tissue response is the same regardless of the device.
Explanation
DISCUSSION: Although radiofrequency devices and lasers differ fundamentally in the way they generate heat within a tissue, both classes of devices are capable of producing temperatures within the critical temperature range (65 to 75 degrees C) for collagen denaturation and subsequent tissue shrinkage. When it comes to cell viability and tissue response, heat is heat. Once critical temperatures are reached, cells will die at 45 degrees C, collagen will become denatured at 60 degrees C, and tissue ablation will occur at 100 degrees C no matter what the source of thermal energy. Therefore, claims of a better or different type of heat have little bearing on the biologic response of the tissue. Histologic, ultrastructural, and biomaterial alterations induced by laser and radiofrequency energy have been shown to be similar.
Question 1912
Topic: 5. Sports Medicine
A 16-year-old boy with osteochondritis dissecans of the capitellum has intermittent symptoms of catching and locking. Examination is unremarkable. Radiographs reveal a loose body anteriorly with a diameter of 10 mm. To remove the loose body, elbow arthroscopy is being considered. Which of the following procedures would minimize the risk of neurovascular complication during the procedure?
Correct Answer & Explanation
. Distending the elbow joint capsule prior to establishing the anterolateral portal
Explanation
DISCUSSION: Complications of elbow arthroscopy are usually minor or temporary. However, serious complications include nerve injuries. The deep radial nerve is the closest to any of the portals, resting as close as 1 mm away from the scope inserted in the anterolateral portal. The capsule can be displaced anteriorly by distending the joint with about 25 mL of saline solution, thus moving the deep radial nerve approximately 1 cm anteriorly and decreasing the risk of injuring it while establishing the anterolateral portal. Keeping plastic cannulae in the portals may help to diminish fluid extravasation and swelling, which is more of an impediment than a serious complication. The image intensifier has no documented role in guiding loose body removal. While the proximal anteromedial portal is probably the safest anterior portal to establish, it is actually easier to remove a large loose body from this portal while viewing it from an anterolateral position. There is less tendon and muscle bulk to pass through at the site of the proximal anteromedial portal than at the anterolateral portal, making it less likely for the loose body to get stuck in the soft tissues. Techniques have been developed to permit removal of loose bodies as large as 2 cm in diameter without breaking them up into pieces. If it is possible to remove a large loose body intact, doing so greatly simplifies and shortens the procedure. REFERENCES: Lynch GJ, Meyers JF, Whipple TL, Caspari RB: Neurovascular anatomy and elbow arthroscopy: Inherent risks. Arthroscopy 1986;2:190-197. OโDriscoll S: Loose bodies and synovial conditions, in Green D, Hotchkiss R, Pederson W (eds): Greenโs Operative Hand Surgery. New York, NY, Churchill Livingstone, 1999, pp 235-249.
Question 1913
Topic: 5. Sports Medicine
A 20-year-old collegiate football player who sustained blunt head trauma during the first half of a game is emotional and confused. During the halftime intermission, his affect, memory, and disorientation are totally resolved and have returned to preinjury baseline. The only residual finding is a very mild headache. He wants to play the second half. What is the most appropriate course of action?
Correct Answer & Explanation
. Do not permit return to play until all symptoms have resolved.
Explanation
DISCUSSION: There is almost universal acceptance that an athlete may return to play after blunt head trauma only if he or she is totally asymptomatic. Mild residual symptoms are considered an absolute contraindication for return to play. Returning to play after a cardiovascular challenge or sport-specific activities is permitted on the pretext that the athlete is totally asymptomatic prior to these maneuvers. Neuropsychiatric testing is being used more frequently to monitor residual cognitive effects after head trauma. It has not been used as a return to play criterion. REFERENCES: Garrick J (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 29-48. Guskiewicz KM, McCrea, Marshall SW, et al: Cumulative effects associated with recurrent concussion in collegiate football players: The NCAA Concussion Study. JAMA 2003;290:2549-2555.
Question 1914
Topic: Shoulder & Hip Sports
Figure 76 is the MR image of a 16-year-old high school football player who sustained a traumatic dominant shoulder dislocation during a game. On-field reduction was unsuccessful. The shoulder is reduced in the emergency department, and the player and his family follow up in clinic. Which factor is most associated with failure of surgical treatment in this scenario?
Correct Answer & Explanation
. Age
Explanation
DISCUSSION: The MR image reveals a Bankart lesion. Arthroscopic Bankart repair failure likelihood is increased by numerous factors. Age, number of recurrences, and bony defects are most associated with failure of arthroscopic repair. Shoulder dominance, amount of periosteal stripping, and difficulty of reduction do not correlate with increased recurrence risk following surgery.
Question 1915
Topic: Knee Sports
Figure 1 is the MR image of a 36-year-old athlete who is tackled from behind and falls forward onto his left knee. He has pain, swelling, and stiffness. Examination includes a moderate effusion, positive quadriceps active test, and normal Lachman test finding. Left untreated, injury to this structure most likely will lead to degenerative changes in
Correct Answer & Explanation
. medial and lateral compartments.
Explanation
The clinical description and MR image point to an injury to the posterior cruciate ligament (PCL). This ligament is thought to be primarily composed of anterolateral and posteromedial bundles, with the former tightening in flexion and the latter in extension. Because of alterations in knee kinematics and increased varus alignment in PCL insufficiency, contact stresses and cartilage loads increase in the patellofemoral and medial compartments. Although good outcomes may be obtained with transtibial, open inlay, and arthroscopic inlay techniques, one major difference is the creation of the โkiller-turnโ during the transtibial approach. This sharp turn in the graft as it emerges from the tibia appears to lead to more pronounced attenuation and thinning of the graft during cyclic loading. The scenario describes a patient with chronic PCL and posterolateral corner (PLC) injury, as evidenced by the varus thrust and abnormalDial test finding. A valgus-producing osteotomy may be effective, and, in fact, may be the only treatment necessary to address chronic PLC injury. Accordingly, an opening lateral osteotomy would not be appropriate. Of the remaining responses, an osteotomy that increases tibial slope would also address the PCL deficiency by reducing posterior tibial sag. Vascular injury is an uncommon, but potentially devastating, complication associated with PCL surgery and may occur regardless of the technique used. Numerous strategies have been described to reduce the risk, including use of a posteromedial accessory incision to allow finger retraction of the popliteal neurovascular bundle, oscillating drills to prevent excessive soft-tissue entanglement, and tapered (rather than square) drill bits that may minimize cut-out of sharp edges as drilling reaches the posterior tibial cortex. Knee extension lessens, rather than increases, the distance between the posterior tibia and the neurovascular bundle and increases, not lessens, risk forvascular injury.
Question 1916
Topic: Knee Sports
A 16-year-old boy sustains a twisting injury to the left knee while wrestling. MRI scans are shown in Figures 22a through 22c. What is the most likely diagnosis? Review Topic
Correct Answer & Explanation
. Anterior cruciate ligament rupture
Explanation
The MRI scans show a displaced bucket-handle medial meniscus tear that can be visualized on coronal, sagittal, and axial views. The sagittal view shows the typical โdouble posterior cruciate ligament sign,โ in which the low-signal bucket-handle fragment parallels the normal low-signal posterior cruciate ligament. The coronal and axial images both show the displaced medial meniscus in the notch.
Question 1917
Topic: 5. Sports Medicine
A 42-year-old man sustained a fracture of the distal radius with subsequent stiffness in the ipsilateral shoulder. Despite a 6-month program of range-of-motion exercises, external rotation at the side is limited to 10 degrees. Attempts at closed manipulation are unsuccessful. Treatment should now consist of
Correct Answer & Explanation
. arthroscopic release of the rotator cuff interval.
Explanation
DISCUSSION: When external rotation at the side is limited, the most likely diagnosis is contracture of the rotator cuff interval, including the superior glenohumeral and coracohumeral ligaments. Therefore, the treatment of choice is arthroscopic release of the rotator cuff interval. REFERENCE: Harryman DT II, Matsen FA III, Sidles JA: Arthroscopic management of refractory shoulder stiffness. Arthroscopy 1997;13:133-147.
Question 1918
Topic: Shoulder & Hip Sports
What is the most common arthroscopic finding of internal impingement in an overhead athlete?
Correct Answer & Explanation
. Rotator cuff articular side tear
Explanation
DISCUSSION: Internal impingement occurs when the articular side of the supraspinatus abrades against the posterior superior glenoid in the cocking position. Damage may include a posterior labral tear where the contact occurs, not anteriorly as in a Bankart lesion. Biceps fraying and acromion spurs are more commonly seen in extrinsic impingement. Loose bodies may occur from multiple lesions associated with instability and articular cartilage disorders but are uncommon in internal impingement. REFERENCES: Jobe CM: Posterior superior impingement of the rotator cuff on the glenoid rim as a cause of shoulder pain in the overhead athlete. Arthroscopy 1993;9:697-699. McFarland EG, Hsu C, Neir C, OโNeil O: Internal impingement of the shoulder: A clinical and arthroscopic analysis. J Shoulder Elbow Surg 1999;8:458-460.
Question 1919
Topic: 5. Sports Medicine
Which of the following substances does not have androgenic effects?
Correct Answer & Explanation
. Creatine
Explanation
Growth hormone is the most abundant substance produced by the pituitary gland. Growth hormone has a direct anabolic effect by accelerating the incorporation of amino acids into proteins. It is becoming an increasingly popular anabolic steroid substitute; however, it is expensive and difficult to obtain. Androstenedione is an androgen produced by the adrenal glands and gonads. It acts as a potent anabolic steroid and is converted in the liver directly to testosterone with a resultant increase in levels after administration. DHEA is a naturally occurring hormone made by the adrenal cortex. It is converted to androstenedione, which in turn is converted to testosterone. The beneficial and adverse effects of DHEA can be correlated directly with those of testosterone. Nandrolone is also a potent anabolic steroid. It is commonly taken as 19-norandrostenedione and may be more favored because of its potent anabolic effects with less androgenic effects (no conversion to estrogen compounds). Creatine sales have skyrocketed, and it is a popular nutritional supplement. There is an expectation that creatine can increase strength and power performance; however, direct anabolic effects have not been demonstrated. Creatine serves as a substrate for hydrogen ions and contributes to the resynthesis of ATP (adenosine triphosphate) during maximal exercise. By enhancing ATP production and buffering local pH in muscle, there may be improved tolerance of anaerobic activities. Increases in muscle mass may be related to increased perception of improved training ability or an increase in muscle water content.
Question 1920
Topic: 5. Sports Medicine
Second impact syndrome (SIS) after head injury is characterized by which of the following? Review Topic
Correct Answer & Explanation
. Gradual progression of neurologic symptoms
Explanation
SIS is a devastating but preventable complication of head injury. It occurs when return to activities is allowed prior to complete resolution of the symptoms of the first head injury. A second, sometimes trivial, head injury can lead to a devastating series of events that can result in sudden death. The symptoms tend to progress rapidly and often involve the brain stem. The prognosis is poor.
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