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 1941
Topic: Knee Sports
When compared with the normal anterior cruciate ligament (ACL), placement of an anterior cruciate ligament graft in the over-the-top position on the femoral side has what effect on its function?
Correct Answer & Explanation
. Lax in flexion and tight in extension
Explanation
The placement of an ACL graft with respect to its femoral and tibial attachments has a significant effect on its function. Evidence has shown that if the graft is placed in the over-the-top position, the graft will become lax in flexion and more taut with extension. Conversely, if the graft is placed too anterior on the femoral side, it will tighten in flexion and become lax in extension.
Question 1942
Topic: Knee Sports
An 18-year-old man sustains a twisting injury to the left knee while playing football. An MRI scan is shown in Figure 48. What is the most likely diagnosis? Review Topic
Correct Answer & Explanation
. Anterior cruciate ligament rupture
Explanation
The MRI scan shows a displaced, bucket-handle lateral meniscus tear. The sagittal view shows the typical "large anterior horn" sign, or "double meniscus" sign in which the displaced bucket-handle fragment appears just anterior to the native anterior horn of the lateral meniscus. The presence of the fibula on the sagittal view confirms this as the lateral compartment. The image is lateral and the cruciate ligaments are not visualized. The articular cartilage shown does not demonstrate an osteochondral lesion.
Question 1943
Topic: Shoulder & Hip Sports
The patient has weakness with elbow flexion and has numbness down the anterior lateral aspect of the forearm.
Correct Answer & Explanation
. Excessive retraction and dissection of the medial portion of the conjoint tendon
Explanation
DISCUSSIONThe Latarjet procedure was initially described in 1959 as a modification of the Bristow procedure. It has been used as a primary procedure to address instability, but is used more commonly for patients with instability and glenoid bone loss. In 2000, Burkhart and associates reported a 67% failure rate of the Bankart procedure in patients with an inverted pear-shaped glenoid (glenoid bone loss) or an engaging Hill-Sachs lesion, with a suggestion that a bone graft procedure would be optimal in this population. Complications following the Latarjet procedure have been reported as high as 25%, with the majority attributable to nerve injury, recurrent instability, and arthritis. Many of these complications are likely secondary to surgical technique. A coracoid graft that is placed too laterally or with prominent screws will overhang the glenoid and lead to early degenerative glenohumeral arthritis. A coracoid graft placed too medially can lead to recurrent instability secondary to an ineffective subscapularis sling and bone block. A coracoid graft placed inferiorly indicates dissection close to the axillary nerve, which can place tension on the axillary nerve or cause injury from direct trauma. After harvesting the coracoid graft, the surgeon must find the musculocutaneous nerve as it enters the conjoint tendon on the medial surface about 5 cm distal to the coracoid. Excessive dissection or retraction can lead to musculocutaneous nerve palsy.
Question 1944
Topic: Shoulder & Hip Sports
Which of the following radiographic views best depicts a Hill-Sachs defect?
Correct Answer & Explanation
. Stryker notch
Explanation
The Stryker notch view best shows this type of defect. An outlet view helps evaluate acromial shape, a true AP shows joint space narrowing, a serendipity view evaluates the sternoclavicular joint, and a Zanca view helps evaluate the acromioclavicular joint. An internal rotation AP may also depict a Hill-Sachs defect.
Question 1945
Topic: Shoulder & Hip Sports
In recurrent posterior shoulder instability, what is the recommended approach to the posterior capsule?
Correct Answer & Explanation
. An infraspinatus-splitting approach
Explanation
DISCUSSION: Using an infraspinatus-splitting incision allows for excellent exposure of the posterior capsule and minimizes the risk of injury to the axillary nerve which lies inferior to the teres minor in the quadrilateral space. REFERENCES: Dreese J, D’Alessandro D: Posterior capsulorrhaphy through infraspinatus split for posterior instability. Tech Shoulder Elbow Surg 2005;6:199-207. Shaffer BS, Conway J, Jobe FW, et al: Infraspinatus muscle-splitting incision in posterior shoulder surgery: An anatomic and electromyographic study. Am J Sports Med 1994;22:113-120. Fuchs B, Jost B, Gerber C: Posterior-inferior capsular shift for the treatment of recurrent voluntary posterior subluxation of the shoulder. J Bone Joint Surg Am 2000;82:16-25.
Question 1946
Topic: 5. Sports Medicine
What is the recommended treatment of a skeletally immature 12-year-old boy who has an anterior cruciate ligament-deficient knee?
Correct Answer & Explanation
. Reduced activity, rehabilitation exercises, and functional bracing until the patient is near skeletal maturity
Explanation
Traditional surgeries for anterior cruciate ligament-deficient knees carry the potential risk of premature physeal closure in young athletes. Therefore, most surgeons are reluctant to recommend intra-articular reconstruction using bone tunnels with bone-patellar tendon-bone autografts or hamstring tendons. The current recommendation for young athletes is activity modification, rehabilitation, and functional bracing until the patient is near skeletal maturity. At that time, for the very symptomatic patient, the treatment of choice is intra-articular repair of the anterior cruciate ligament. If a skeletally immature patient continues to have instability despite rehabilitation and bracing, a modification of the femoral tunnel to the over-the-top position will not place the lateral femoral physis at risk for premature closure and deformity. A centrally placed tibial tunnel will minimize the risk of angular deformity and minimize limb-length discrepancy if physeal arrest occurs.
Question 1947
Topic: Shoulder & Hip Sports
A 69-year-old woman has just undergone an uncomplicated total shoulder arthroplasty for glenohumeral osteoarthritis. A press-fit humeral stem and a cemented all-polyethylene glenoid component were placed. At this point, what is the postoperative rehabilitation plan?
Correct Answer & Explanation
. Immediately begin an active assisted range-of-motion program emphasizing forward elevation and external rotation to the side.
Explanation
The patient needs to immediately begin an active assisted range-of-motion program emphasizing forward elevation and external rotation to the side. Sling immobilization without stretching for either 3 or 6 weeks will result in severe stiffness that will compromise her ultimate range of motion. Since she has a good quality subscapularis tendon, there is no need to avoid beginning external rotation to the side. However, starting a strengthening program at 3 weeks risks tearing the subscapularis tendon repair. Active strengthening should not begin for 6 weeks postoperatively to allow the subscapularis tendon repair time to heal.
Question 1948
Topic: 5. Sports Medicine
A 35-year-old man presents with mechanical knee pain after a fall. An arthroscopic picture taken during diagnostic arthroscopy is shown in Figure A. His surgeon considers treatment with Technique B and Technique C, which are shown in Figures B and C, respectively. Which of the following statements is true with respect to Technique B and C?
Correct Answer & Explanation
. A biopsy of the repair site at 3 months will reveal more Type I collagen in Technique B than in Technique C.
Explanation
Microfracture (Technique B) heals with fibrocartilage, predominantly Type I collagen. Mosaicplasty/OAT (Technique C) transfers articular cartilage, containing predominantly Type II collagen. The initial treatment for small articular cartilage defects is rest, NSAIDs, and bracing. For larger defects (<2-4cm2), options include marrow stimulation procedures (abrasion chondroplasty, microfracture, osteochondral drilling) and autograft procedures (Mosaicplasty, a technique of osteochondral autograft transfer (OAT)).
Question 1949
Topic: Knee Sports
What fibers of the anterior cruciate ligament tighten with extension of the knee? Review Topic
Correct Answer & Explanation
. Posterolateral
Explanation
The anterior cruciate ligament consists of two functional bundles: anteromedial and posterolateral. During extension of the knee, the posterolateral bundle becomes taut. In flexion, the anteromedial bundle is tight and the posterolateral bundle relaxes. Traditionally, anterior cruciate ligament reconstruction primarily recreates the anteromedial bundle. Recently, techniques for double bundle reconstruction have been described to recreate the normal anatomic relationship of the two bundles.
Question 1950
Topic: Shoulder & Hip Sports
Figures 1 and 2 are intrasurgical photographs from the posterolateral viewing portal that were taken at the beginning and end of a right shoulder arthroscopic procedure performed on a 54-year-old man. This technique demonstrates superior results compared with traditional arthroscopic techniques when evaluating which outcome?
Correct Answer & Explanation
. Retear rate
Explanation
The images reveal a medium-sized tear of the rotator cuff. As more clinical studies are published comparing double-row with single-row rotator cuff repair, it has become clear that the retear rate is lower with a double-row construct for small and medium-sized tears. This may be attributable to the stronger time-zero repair construct that double-row repair provides. No study to date has demonstrated a significant difference in clinical outcomes (functional and pain scores at any time) or time to healing between the two techniques.
Question 1951
Topic: Shoulder & Hip Sports
A 45-year-old right hand dominant female sustains a left shoulder injury after falling on ice 2 weeks ago. She is brought to the operating room for surgical intervention and positioned upright in a beach chair. Figures A and B are images taken from a posterior viewing portal with a 70-degree arthroscope. Figure C demonstrates the surgically repaired structure. Which of the following physical examination maneuvers would have been most likely abnormal in this patient preoperatively?
Correct Answer & Explanation
. Lift-off test
Explanation
The repaired structure is the subscapularis tendon, tested frequently with the Lift-off test. Figure A as viewed from a posterior portal in the beach chair position of the left shoulder demonstrates a subscapularis tear with Figure B demonstrating medial instability of the long head of the biceps tendon. Figure C shows a repaired subscapularis to its footprint with double loaded screw-in anchors. A biceps tenodesis was concomitantly performed. The key physical exam findings are positive Belly-press and Lift-off maneuvers, as well as weakness in internal rotation and increased passive external rotation.
Question 1952
Topic: 5. Sports Medicine
Figure 20 shows the MRI scan of a 20-year-old athlete who has a painful shoulder. This pathology is most commonly seen in:
Correct Answer & Explanation
. football linemen.
Explanation
The MRI scan reveals a posterior labral detachment. This injury is the result of a posteriorly directed force and is common to football players in blocking positions. Although this injury can occur with trauma in all types of athletes, it is seen with relative frequency in football. Treatment is aimed at labral repair with posterior capsulorrhaphy.
Question 1953
Topic: 5. Sports Medicine
When comparing arthroscopic lavage and knee debridement with placebo in patients with chronic symptomatic osteoarthritis, what outcome has been demonstrated?
Correct Answer & Explanation
. No significant benefit for chronic osteoarthritis
Explanation
DISCUSSION: Excluding a diagnosis of meniscal tear, loose body, or mechanical derangement, treating knee osteoarthritis of indeterminate cause with arthroscopic lavage and debridement has been found to provide no discernable benefit to offset the risk of surgery. The effects of arthroscopy have not been clinically significant in the vast majority of patient-oriented outcomes measures for pain and function at multiple times between 1 week and 2 years after surgery.
Question 1954
Topic: 5. Sports Medicine
A 68-year-old male presents with the inability to perform a straight leg raise 6 weeks after a primary TKA. Ultrasound confirms a complete mid-substance patellar tendon rupture. What is the most reliable surgical management for this complication?
Correct Answer & Explanation
. Primary end-to-end suture repair
Explanation
Primary repair of patellar tendon ruptures after TKA has an unacceptably high failure rate. Extensor mechanism reconstruction using an allograft (e.g., Achilles or whole extensor mechanism) or synthetic mesh is the gold standard for restoration of function.
Question 1955
Topic: Shoulder & Hip Sports
.A 22-year-old collegiate baseball pitcher has had posterior shoulder pain with decreased throwing velocity and accuracy over the past several months. Examination of the abducted shoulder in the supine position reveals 120 degrees of external rotation, 40 degrees of internal rotation on the throwing side, 100 degrees of external rotation, and 70 degrees of internal rotation on the nonthrowing side. The remainder of the clinical examination is unremarkable. An MRI scan shows a small partial articular-sided infraspinatus tear. Initial treatment should consist of
Correct Answer & Explanation
. arthroscopic rotator cuff repair.
Explanation
Question 1956
Topic: Shoulder & Hip Sports
A 67-year-old female presents with shoulder pain for 3 months after falling down stairs. Imaging demonstrates a large rotator cuff tear involving multiple tendons. You perform an arthroscopic rotator cuff repair and biceps tenodesis. At her 2 month follow up, she reports worsening shoulder pain and decreased range of motion. Examination reveals active forward flexion to 80°. Passive range of motion is full. There is a positive external rotation lag sign. An MRI is performed and is pictured in Figure A. Which is the best treatment for this patient? Review Topic
Correct Answer & Explanation
. Revision repair of subscapularis
Explanation
The next best step for this patient's failed rotator cuff repair is a revision repair of the infraspinatus.Failed rotator cuff repair is multifactorial. Structural failure of repair is the result of both intrinsic and extrinsic factors. Intrinsic factors include advancing patient age, increasing tear size, poor tendon and muscle quality, systemic disease and smoking history. Extrinsic factors include inadequate biomechanical construct or repair configuration and overaggressive postoperative rehabilitation.Denard et al authored a review article on revision rotator cuff repair. Indications for revision repair are persistent symptoms despite nonoperative management in whom infection and advanced degenerative changes have been ruled out. Satisfactory results have been reported following revision repair of recurrent rotator cuff tears, particularly with arthroscopic techniques. Female sex and preoperative forward flexion < 135° is associated with poorer outcomes.Lambers Heerspink et al found that increasing age, larger tear size and additional biceps or acromioclavicular (AC) joint procedures have a negative influence on cuff integrity at follow up. Smoking, duration of symptoms, obesity and medical comorbidities were not found to influence cuff integrity in this study. Only AC procedures and workers’ compensation status were associated with worse functional outcomes.Figure A is a coronal T2 MRI demonstrating a failed rotator cuff repair with retear. Incorrect Responses:
Question 1957
Topic: Shoulder & Hip Sports
A 62-year-old man has had worsening pain in the left shoulder for the past 6 weeks without trauma. He participated in physical therapy to "strengthen" his shoulder; however, it failed to provide relief. On examination, his right shoulder motion is 180, 60, and T8 (forward flexion, external rotation, and internal rotation). His left shoulder motion, both active and passive, is 150, 40, and L1. T1- and T2-weighted MRI scans are shown in Figures 106a and 106b with an official diagnosis of partial supraspinatus tendon tear. What is the appropriate treatment? Review Topic
Correct Answer & Explanation
. Physical therapy for rotator cuff strengthening and scapula stabilization
Explanation
The patient lacks both active and passive motion in all planes of shoulder motion; his primary pathology is adhesive capsulitis. Although the MRI scans reveal a partial-thickness rotator cuff tear, this is not uncommon in asymptomatic patients older than age 60 years. Physical therapy for patients with adhesive capulitis should stress shoulder motion rather than rotator cuff strengthening. Because most cases of adhesive capsulitis improve without surgical management, surgical treatment options are not appropriate at this time.
Question 1958
Topic: Shoulder & Hip Sports
Figures 111a and 111b show axial MRI scans of a 24-year-old man who injured his right shoulder several years ago and now reports continued difficulty with the shoulder and has pain with activity. He reports that when the injury occurred, he felt that his shoulder "popped" but he never required closed reduction. He wore a
Correct Answer & Explanation
. Reaching back to hit a forehand in tennis
Explanation
Performing a bench press with large amounts of weight is most likely to cause pain for a patient with a posterior labral tear. A patient who sustains a first-time posterior dislocation is less likely to have recurrent dislocations compared with first-time anterior dislocations. Patients often do have problems with loading the shoulder in a forward flexed position, such as during a bench press. The other activities listed here might be difficult, but are not as likely to be problematic. A biceps curl might bother a person with a SLAP tear. The late cocking/early acceleration phase of throwing, the overhead portion of a tennis serve, and spiking a volleyball places the shoulder in an abduction/external rotation position, which is likely to be problematic for a person with anterior instability.
Question 1959
Topic: 5. Sports Medicine
A 68-year-old man embarks on a 24-week strength training program. He trains at 80% of his single repetition maximum for both the upper and lower extremities. Which of the following changes can be anticipated?
Correct Answer & Explanation
. A significant increase in strength
Explanation
DISCUSSION: Consistent, long-term exercise training in older athletes has proven very beneficial in reversing both endurance and strength losses that traditionally have been seen with aging. This patient’s program will lead to a significant increase in the strength, cross-sectional area, and capillary density of the trained muscles. No major changes in aerobic capacity are anticipated. Strength improvements of up to 5% per day, similar to those for younger athletes, have been identified in this population in one study. REFERENCES: Kirkendall DT, Garrett WE Jr: The effects of aging and training on skeletal muscle. Am J Sports Med 1998;26:598-602. Frontera WR, Meredith CN, O’Reilly KP, Knuttgen HG, Evans WJ: Strength conditioning in older men: Skeletal muscle hypertrophy and improved function. J Appl Physiol 1988;64:1038-1044.
Question 1960
Topic: 5. Sports Medicine
A 25-year-old recreational soccer player has recurrent shoulder dislocations. He first dislocated his shoulder playing football in high school, was treated in a sling for 6 weeks, and returned to play for the remainder of the season. He did well until 2 years later when he reinjured the shoulder. He says that his shoulder dislocates with little injury and always "feels loose." Examination reveals anterior instability and an MR arthrogram reveals an anterior-inferior labral tear and surgical treatment is recommended. He inquires about the benefits of arthroscopic vs open procedure. Which of the following statements reflects an advantage associated with arthroscopic procedures compared to open stabilization? Review Topic
Correct Answer & Explanation
. Range of motion might be slightly better after an arthroscopic procedure.
Explanation
There is much debate in the literature regarding optimal techniques for treatment of shoulder instability. Most studies have suggested a slightly better range of motion of the shoulder after an arthroscopic repair. Recurrent instability rates have been slightly higher with arthroscopic procedures in some studies, while others show the rates are not statistically different. Return to work and/or sports has been shown to be equal or slightly better with open procedures.
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