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5. Sports Medicine MCQs

Practice Set 99 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 1961

Topic: Shoulder & Hip Sports

A 23-year-old right-hand dominant professional baseball pitcher has right shoulder pain when releasing the ball. He has noticed his velocity has decreased over the past 2 months. Examination reveals supine abducted external rotation of 110 degrees compared to 100 degrees on the left side. His internal rotation is 30 degrees on the right compared to 70 degrees on the left side. Rotator cuff strength is normal. All other clinical tests are normal. MRI with contrast reveals no intra-articular lesions. What is the best course of treatment? Review Topic

. Arthroscopic capsular plication
. Arthroscopic thermal shift
. Arthroscopic subacromial decompression
. Posterior capsular stretching
. Selective external rotation stretching

Correct Answer & Explanation

. Arthroscopic capsular plication

Explanation

The examination reveals that the patient has posterior capsular tightness. Surgery should not be considered until the patient has failed to respond to nonsurgical management. The internal rotation contracture (GIRD - glenohumeral internal rotation deficit) should be addressed with appropriate posterior capsular stretching. Thisshould then be followed by appropriate rotator cuff and scapular stabilization exercises. Only if this management fails to relieve the patient's symptoms should surgery be considered. This patient clearly does not need external rotation stretching given the fact that he has normal external rotation.

Question 1962

Topic: 5. Sports Medicine
Which of the following best describes athletic pubalgia?
. A syndrome of lower abdominal and adductor pain
. Painful symptoms emanating from the symphysis pubis
. Painful symptoms associated with dysfunction of the iliopsoas tendon
. Stress fracture of the pubic ramus
. Entrapment of the pudendal nerve

Correct Answer & Explanation

. A syndrome of lower abdominal and adductor pain

Explanation

DISCUSSION: Athletic pubalgia refers to a distinct syndrome of lower abdominal and adductor pain that is mostly commonly seen in high performance male athletes. This condition must be distinguished from others such as painful inflammation of the symphysis pubis, referred to as osteitis pubis. Symptoms attributable to the iliopsoas tendon are most commonly associated with snapping of the tendon. Stress fracture of the pubic ramus may cause symptoms in this area, but it is usually confirmed by imaging studies. Neurapraxia of the pudendal nerve is associated with pressure from the seat in cycling sports and also as a complication associated with traction during surgical procedures. REFERENCES: Meyers WC, Foley DP, Garrett WE, Lohnes JH, Mandlebaum BR: 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. Albers SL, Spritzer CE, Garrett WE Jr, Meyers WC: MR findings in athletes with pubalgia. Skeletal Radiol 2001;30:270-277.

Question 1963

Topic: 5. Sports Medicine
A 20-year-old basketball player has tenderness and bruising after sustaining a blow to the knee. A radiograph is shown in Figure 15. What is the most likely diagnosis?
. Patellar fracture
. Patellar dislocation
. Bipartite patella
. Vastus lateralis tear
. Tumor

Correct Answer & Explanation

. Bipartite patella

Explanation

DISCUSSION: The patient has a bipartite patella. The line between the fragment and the main patella is smooth and sclerotic, indicating a chronic, not acute, entity. The location is classic for a bipartite patella, not a tumor. REFERENCES: Schmidt DR, Henry JH: Stress injuries of the adolescent extensor mechanism. Clin Sports Med 1989;8:343-355. Weaver JK: Bipartite patellae as a cause of disability in the athlete. Am J Sports Med 1977;5:137-143.

Question 1964

Topic: Shoulder & Hip Sports

-Figures a through c are the MRI scans of a 21-year-old woman with recurrent shoulder instability and pain after an open anterior stabilization procedure. Positive belly-press test findings were positive.At surgery she was found to have an irreparable tear of the tendon injury identified preoperatively. The procedure to address the dynamic stabilizer deficit places which nerve at most risk?

. Ulnar
. Radial
. Axillary
. Median
. Musculocutaneous

Correct Answer & Explanation

. Ulnar

Explanation

Question 1965

Topic: Shoulder & Hip Sports

A patient has multidirectional instability of the shoulder that has not responded to nonsurgical management. Successful surgical treatment will most likely include which of the following? Review Topic

. Abrasion arthroplasty of the anterior glenoid rim
. Posterior capsular advancement into a Hill-Sachs defect
. Repair of an inferior glenohumeral ligament detachment
. Repair of an unstable SLAP tear
. Closure of the rotator interval

Correct Answer & Explanation

. Abrasion arthroplasty of the anterior glenoid rim

Explanation

Published reports establish the importance of the rotator interval in shoulder stability and improvements achieved through suture closure of the interval. Multidirectionalinstability treated surgically following failure to respond to nonsurgical management has been shown to be associated with classic Bankart lesions, Hill-Sachs defects, glenoid chondral lesions, and even SLAP lesions (Werner). However, these lesions were seen in a lower percentage than that found for unidirectional anterior dislocations. Likewise, these lesions do not appear to be significant in influencing treatment in the majority of patients.

Question 1966

Topic: 5. Sports Medicine
What is the most common behavioral effect of anabolic steroid use in athletes?
. Increased aggression
. Psychosis
. Drug dependence
. Depression
. Mania

Correct Answer & Explanation

. Increased aggression

Explanation

Users of anabolic steroids often display increased feelings of hostility and aggression. Although reports of psychotic, depressive, and manic behavior have been reported with the use of steroids, they are rare. Drug dependence, such as seen with narcotics, is not a feature of steroid use.

Question 1967

Topic: Shoulder & Hip Sports
Figure 30 shows an axial T1-weighted MRI scan of a patient’s right shoulder. The arrows are pointing to what normal structure?
. Deltoid insertion
. Subscapularis tendon
. Latissimus dorsi tendon
. Short head of the biceps tendon
. Pectoralis major tendon

Correct Answer & Explanation

. Pectoralis major tendon

Explanation

Tears of the pectoralis major tendon are frequently missed during examination. MRI provides excellent visualization of the tendon if the study extends low enough down the arm. The pectoralis major tendon inserts on the crest of the greater tubercle of the humerus, just lateral to the long head of the biceps tendon. The latissimus dorsi tendon inserts medial to the long head of the biceps tendon on the lesser tubercle. The subscapularis tendon inserts on the lesser tuberosity more proximally. The deltoid insertion is more distal.

Question 1968

Topic: Shoulder & Hip Sports

Which of the follow scenarios is most likely to be amenable to a complete repair of a massive rotator cuff tear? Review Topic

. year-old woman with rheumatoid arthritis
. year-old man with a tear associated with an anterior shoulder dislocation
. year-old man who underwent repair of an ipsilateral rotator cuff 3 years ago
. year-old male laborer with superior humeral migration on radiographs
. year-old woman with muscular atrophy noted in the supraspinatus fossa

Correct Answer & Explanation

. year-old woman with rheumatoid arthritis

Explanation

Whereas a rotator cuff tear associated with an acute anterior dislocation in 45-year old patient may be massive, its acute nature typically means that significant retraction and atrophy of the musculature has not occurred. Therefore, repair is often complete and tension-free. A massive tear associated with rheumatoid arthritis is likely one of chronic attrition with poor tendon tissue because of the underlying disease and chronic corticosteroid use. Repairs of massive chronic rotator cuff tears have been reported to have a 50% rate of retear and this rate would be expected to be higher in the revision setting and with evident supraspinatus atrophy on physical examination. Superior humeral migration on static upright radiographs indicates loss of the superior glenoid rim, leading to rotator cuff tear arthropathy.

Question 1969

Topic: 5. Sports Medicine
A 40-year-old woman reports the atraumatic onset of severe knee pain and swelling after undergoing an uncomplicated elective cholecystectomy 1 week ago. She denies any history of diabetes mellitus or HIV but has had occasional episodes of mild knee pain and swelling that have always responded to nonsteroidal anti-inflammatory drugs. Radiographs are shown in Figures 5a and 5b. A knee aspiration yields a WBC count of 35,000/mm³. The aspirate should also yield which of the following findings?
. Strongly negative needle-shaped crystals
. Weakly positive birefringent rhomboid-shaped crystals
. Gross blood
. Gram-positive cocci
. Gram-negative rods

Correct Answer & Explanation

. Weakly positive birefringent rhomboid-shaped crystals

Explanation

DISCUSSION: The radiographs reveal chondrocalcinosis of the menisci. This is caused by calcium pyrophosphate crystals, which are weakly positive birefringent rhomboid-shaped crystals. Frequently, this condition is asymptomatic; however, routine abdominal surgery may cause precipitation of these crystals and pain. Gout, which is caused by strongly negative birefringent needle-shaped sodium urate crystals, is not associated with chondrocalcinosis and is rare in younger women. Gross blood is uncommon without trauma. Infection is not likely in a healthy patient who underwent uncomplicated surgery. REFERENCES: Fisseler-Eckhoff A, Muller KM: Arthroscopy and chondrocalcinosis. Arthroscopy 1992;8:98-104. Hough AJ Jr, Webber RJ: Pathology of the meniscus. Clin Orthop 1990;252:32-40.

Question 1970

Topic: Shoulder & Hip Sports
A patient reports pain in the hip with functional positioning. With the patient supine, pain in which of the following positions would be typical for femoral acetabular impingement?
. Hip is internally rotated, passively flexed to 90 degrees, and adducted
. Hip is internally rotated, passively flexed to 90 degrees, and abducted
. Hip is externally rotated, maximally flexed to 90 degrees, and adducted
. Hip is externally rotated, passively flexed to 90 degrees, and abducted
. Hip is externally rotated, maximally flexed, and abducted

Correct Answer & Explanation

. Hip is internally rotated, passively flexed to 90 degrees, and adducted

Explanation

DISCUSSION: Patients with dysplasia often have a hypertrophic labrum. Abnormal contact between the femoral neck and the acetabular rim leads to labral injury, especially in the anterior-superior acetabular zone. Typically, young patients with the condition report pain with activity or long periods of sitting or driving. The hips often have limited motion, in particular in internal rotation and flexion. Forceful adduction with the maneuver causes pain. REFERENCES: Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 411-424. Beck M, Leunig M, Parvizi J, et al: Anterior femoroacetabular impingement: Part II. Midterm results of surgical treatment. Clin Orthop 2004;418:67-73. McCarthy JC, Noble PC, Schuck MR, et al: The role of labral lesions to development of early degenerative hip disease. Clin Orthop 2001;393:25-37.

Question 1971

Topic: Shoulder & Hip Sports
A 60-year-old right hand-dominant woman fell on her outstretched arm and sustained an anterior shoulder dislocation. The shoulder is reduced in the emergency department and she is seen for follow-up 1 week later wearing a sling. Examination reveals that she has significant difficulty raising her arm in forward elevation and has excessive external rotation compared to the contralateral shoulder. What is the next most appropriate step in management?
. MRI
. Electromyography
. Open repair of the supraspinatus
. Arthrography
. Arthroscopic labral repair

Correct Answer & Explanation

. MRI

Explanation

DISCUSSION: In patients older than age 40 years, a high suspicion of a rotator cuff tear should be kept in those patients with weakness after shoulder dislocation. Both posterior rotator cuff and subscapularis injuries have been documented. The next most appropriate step in management should be MRI. If the findings are negative, suspicion of nerve injury should lead to electromyography. REFERENCES: Stayner LR, Cumming J, Andersen J, et al: Shoulder dislocations in patients older than 40 years of age. Orthop Clin North Am 2000;31:231-239. Neviaser RJ, Neviaser TJ, Neviaser JS: Concurrent rupture of the rotator cuff and anterior dislocation of the shoulder in the older patient. J Bone Joint Surg Am 1988;70:1308-1311.

Question 1972

Topic: 5. Sports Medicine
Figure 94 is an arthroscopic view of the intercondylar notch of a right knee from an anterolateral portal. After injury to the structure as indicated by the asterisks, which examination test most likely will demonstrate an abnormal finding?
. Lachman test
. Pivot-shift test
. Posterior drawer test
. Posterolateral (PL) drawer test

Correct Answer & Explanation

. Pivot-shift test

Explanation

The structure shown is the PL bundle of the anterior cruciate ligament (ACL), which is tight near terminal knee extension. Biomechanical analysis suggests the PL bundle provides a greater degree of rotational stability than the anteromedial bundle. The pivot-shift test evaluates for rotational instability of the ACL, while the Lachman test assesses anterior-posterior stability. The posterior drawer and PL drawer test findings are positive after a posterior cruciate ligament tear and PL corner injury, respectively.

Question 1973

Topic: 5. Sports Medicine
Figure 1 is the MRI scan of a 15-year-old boy who has had knee pain with running for 5 months. What is the most appropriate treatment?
. Arthroscopic or open reduction and internal fixation
. Arthroscopic loose body removal
. Activity restriction for up to 9 months
. Subchondral drilling

Correct Answer & Explanation

. Arthroscopic or open reduction and internal fixation

Explanation

The MRI reveals an osteochondritis dissecans (OCD) lesion that is unstable and has a large osseous component. OCDs are acquired lesions of the subchondral bone. Patients with OCD initially report nonspecific pain and variable amounts of swelling. Initial radiographs help identify the lesion and establish the status of the physes. An MRI scan is useful for assessing the potential for the lesion to heal with nonsurgical treatment. Nonsurgical treatment is appropriate for small, stable lesions in patients with open physes and focuses on activity restriction for 3 to 9 months. Surgical treatment is necessary for unstable or detached lesions. Stable lesions with intact articular cartilage can be treated with subchondral drilling to stimulate vascular ingrowth, with radiographic healing at an average of 4.4 months. Fixation is indicated for unstable or hinged lesions, and stabilization of the fragment can be achieved using a variety of implants through an arthroscopic or open approach. The fragment should be salvaged, and the normal articular surface restored whenever possible. In this patient, the fragment is unstable and therefore stabilization of the fragment with internal fixation would be the best treatment option.

Question 1974

Topic: Shoulder & Hip Sports

Recent randomized controlled trials comparing early passive range of motion to 6 weeks of immobilization after successful arthroscopic rotator cuff repair concluded that, compared to immobilization, early passive range of motion resulted in: Review Topic

. Higher Constant scores at 12 months
. Increased rates of re-rupture as determined by ultrasound
. Equivalent functional outcomes
. Less pain at 6 months
. Inceased range of motion at 12 months

Correct Answer & Explanation

. Higher Constant scores at 12 months

Explanation

A series of high-quality RCTs have demonstrated that early passive range of motion has equivalent functional outcomes when compared to 6 weeks of immobilization after arthroscopic rotator cuff surgery.Traditionally, most surgeons recommended early post-operative range of motion exercises for their patients in order to prevent adhesions and ultimately stiffness. However, recent evidence has found that there is no difference in the healing rate, range of motion or functional outcome between patients who undergo early versus delayed (i.e. initial 6 weeks of immobilization) passive range of motion exercises after arthroscopic rotator cuff repair.Kim et al. conducted a randomized controlled trial comparing early passive range of motion vs. immobilization in 106 patients who underwent arthroscopic repair for full-thickness rotator cuff tears. They found that there was no clinically or statistically significant difference between the two groups in pain, healing or function.Keener et al. also conducted a randomized controlled trial of 124 patients who were undergoing arthroscopic repair of a full-thickness rotator cuff tear and found no difference between early and delayed range of motion in healing and functional outcome.Cuff & Pupello also compared early vs. delayed range of motion during the postoperative rehabilitation phase in a randomized controlled trial of 68 individuals undergoing arthroscopic rotator cuff repair and found no significant difference in range of motion or healing.Incorrect Answers:

Question 1975

Topic: 5. Sports Medicine

An otherwise healthy 31-year-old man has had right knee pain for the past 9 months. His former physician administered a cortisone injection and ordered 6 months of physical therapy. The patient later had an arthroscopy with debridement of the right knee by another physician and completed another course of physical therapy. The patient received minimal relief from these treatments and still is not able to walk longer distances or go on hikes. On examination, he is a healthy appearing male with a body mass index of 24 kg/m 2 . He has a small effusion, minimal quadriceps atrophy, no tenderness about the knee, full range of motion, stable to varus and valgus stress at 30° of flexion, a grade 1 Lachman test, and a normal posterior drawer. Figures 1 through 4 are his arthroscopic views, radiograph and MRI scan from his prior surgical procedure. What is the next most appropriate step in treatment?

. Bracing with physical therapy focusing on quadriceps/vastus medialis obliquus (VMO) and hamstring strengthening
. Osteotomy
. Osteochondral allograft to femoral condyle
. Arthroscopy with femoral condyle microfracture

Correct Answer & Explanation

. Bracing with physical therapy focusing on quadriceps/vastus medialis obliquus (VMO) and hamstring strengthening

Explanation

The patient has a symptomatic cartilage lesion of his medial femoral condyle, which has not responded to nonsurgical measures, and he failed a prior arthroscopy with debridement. Based on his examination and imaging, he is ligamentously stable, has normal mechanical alignment, and has intact menisci, making him a candidate for a cartilage restoration procedure. The accompanying MRI also indicates subchondral bone involvement with increased T2 signal underlying the cartilage defect. Osteochondral allograft is the only choice that addresses both the cartilage defect, as well as compromised subchondral bone. Depending on lesion size, osteochondral autograft transfer may also be considered, but this is not presented as an answer choice.Given the radiographic finding of neutral mechanical alignment, bracing would be less effective, and the patient has already tried extensive physical therapy. Lack of malalignment also excludes tibial osteotomy as a preferred answer choice. Microfracture is best for small cartilage lesions withoutsignificant bone marrow involvement.

Question 1976

Topic: 5. Sports Medicine
A 36-year-old skier sustains a grade III posterior cruciate ligament (PCL) tear. Where will increased contact pressures develop over time?
. Ligament of Humphrey
. Patellar ligament
. Quadriceps tendon
. Lateral compartment
. Medial compartment

Correct Answer & Explanation

. Medial compartment

Explanation

DISCUSSION: Complete rupture of the PCL leads to increased contact pressures in the patellofemoral and medial compartments of the knee. However, whether degenerative arthritis will develop and in which compartments still remains controversial. REFERENCE: Garrett WE, Speer KP, Kirkendall DT (eds): Principles & Practice of Orthopaedic Sports Medicine. Philadelphia, PA, Lippincott Williams & Wilkins, 2000, p 767.

Question 1977

Topic: Shoulder & Hip Sports
A patient reports persistent anterior shoulder pain following a forceful external rotation injury to the shoulder. An MRI scan is shown in Figure 4. The patient remains symptomatic despite 3 months of nonsurgical management. Treatment should now consist of:
. repair of the superior labrum.
. isolated supraspinatus repair.
. biceps recentering.
. subscapularis repair and biceps tenodesis.
. subscapularis repair and recentering of the biceps tendon.

Correct Answer & Explanation

. subscapularis repair and biceps tenodesis.

Explanation

DISCUSSION: The MRI scan reveals a subscapularis tear with a biceps that is out of the groove. Treatment in this patient is most predictable if the subscapularis is repaired. The biceps should either be tenodesed or tenotomized since it is unstable. Recentering of the biceps has been found to be unpredictable. Treatment of these lesions has been shown to have better results if the biceps is either released or tenodesed. This prevents recurrent biceps symptoms that can be a source of surgical failure. REFERENCES: Edwards TB, Walch G, Sirvenaux F, et al: Repair of tears of the subscapularis: Surgical technique. J Bone Joint Surg Am 2006;88:1-10. Deutsch A, Altcheck DW, Veltri DM, et al: Traumatic tears of the subscapularis tendon: Clinical diagnosis, magnetic resonance imaging findings, and operative treatment. Am J Sports Med 1997;25:13-22. Walch G, Nove-Josserand L, Boileau P, et al: Subluxations and dislocations of the tendon of the long head of the biceps. J Shoulder Elbow Surg 1998;7:100-108.

Question 1978

Topic: Shoulder & Hip Sports
A patient who sustained a cerebrovascular accident (CVA) 18 months ago has a long-standing spastic adduction contracture of the shoulder with a rigid block to passive external rotation. Significant hygiene problems exist with maceration and continued skin breakdown. Management should consist of:
. a percutaneous pectoralis tenotomy.
. a modified L’Episcopo procedure.
. serial lidocaine nerve blocks.
. pectoralis tenotomy and subscapularis tendon lengthening.
. phenol nerve blocks.

Correct Answer & Explanation

. pectoralis tenotomy and subscapularis tendon lengthening.

Explanation

DISCUSSION: Following a CVA, the muscular imbalance often leads to a fixed contracture of the shoulder in adduction, internal rotation, and flexion. The responsible muscles include the pectoralis major, subscapularis, teres major, and latissimus dorsi. If stretching cannot produce enough improvement for axillary hygiene, then surgery is an option. If the shoulder resists external rotation during examination with the arm at the side, as in this patient, then the subscapularis is spastic and contributing to the deformity as well and needs to be released along with the pectoralis. Phenol nerve blocks are most effective and best given within 6 months of the initial CVA to be effective. Lidocaine blocks may be helpful in determining whether a deformity is caused by a fixed soft-tissue contracture or by spasticity but play no role once the contracture is present. The modified L’Episcopo procedure is indicated in patients with contracture secondary to brachial plexus birth palsies. REFERENCES: Braun RM, Botte MJ: Treatment of shoulder deformity in acquired spasticity. Clin Orthop 1999;368:54-65. McCollough NC III: Orthopaedic evaluation and treatment of the stroke patient. Instr Course Lect 1975;24:45-55.

Question 1979

Topic: 5. Sports Medicine

Figures below show the radiographs, MRI, and MR arthrogram obtained from a 25-year-old collegiate soccer player who has new-onset left groin pain. He played competitive soccer from a young age and has competed or practiced 5 to 6 times per week since the age of 10. He denies any specific hip injury that necessitated treatment, but his trainer contends that he had a groin pull. He reports groin pain with passive flexion and internal rotation of the left hip, and his hip has less internal rotation than his asymptomatic right hip. He is otherwise healthy. What is the primary cause of a cam deformity?

. A genetic problem
. Repetitive activities involving an open proximal femoral physis
. Early closure of the proximal femoral physis
. Hip dysplasia

Correct Answer & Explanation

. Repetitive activities involving an open proximal femoral physis

Explanation

Multiple studies have confirmed that cam or pincer anatomy is commonly present in asymptomatic hips. According to a large systematic review, cam deformities are present in approximately one-third of asymptomatic hips in young adults, and the proportion is higher than 50% in the subgroup of athletes. Ganz and associates proposed that femoral acetabular impingement is the root cause of osteoarthritis in most nontraumatic, nondysplastic hips, and functional improvement with surgical correction of the deformity has been demonstrated. Despite the link between cam deformity and hip osteoarthritis, a corresponding link between the correction of the deformity and prevention of osteoarthritis has never been proven. The results of cam deformity correction, typically including repair of the degenerative labral tear, are much poorer when substantial joint space loss is present. A typical joint space cutoff of 2 mm or less is used to recommend against hip preservation surgery.

Question 1980

Topic: Shoulder & Hip Sports

Biomechanical in vitro studies of double-row anchor fixation of rotator cuff tears show what initial advantage over single-row anchor fixation? Review Topic

. Increased peak-to-peak elongation
. Decreased stiffness
. Higher ultimate tensile load
. Decreased contact area
. Increased conditioning elongation

Correct Answer & Explanation

. Higher ultimate tensile load

Explanation

Biomechanical in vitro studies of double-row fixation of rotator cuff tears during cyclic loading and tensile loading to failure have demonstrated that double-row fixation results in a higher ultimate tensile load when compared to single-row fixation. Peak-to-peak elongation, stiffness, and conditioning elongation for double-row fixation were all similar to single-row fixation. These initial findings, however, may or may not lead to improved clinical outcomes.

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