Orthopedic Sports Medicine 2026 MCQs: Board Review

Question 1

Figure 24 shows the radiograph of a 10-year-old boy who sustained a valgus injury to the knee. Examination reveals grade III medial laxity. Initial management should consist of

Explanation

Based on the mechanism of injury and findings of medial laxity, the most likely diagnosis is injury to either the growth plate or the medial collateral ligament. With the open physeal plate, this area of injury is presumed present until proven otherwise; therefore, stress radiographs should be obtained before implementing any treatment or ordering more extensive and expensive tests. DeLee JC: Ligamentous injury of the knee, in Stanitski CL, DeLee JC, Drez D Jr (eds): Pediatric and Adolescent Sports Medicine. Philadelphia, PA, WB Saunders, 1994, vol 3, pp 406-432. Clanton TO, DeLee JC, Sanders B, Neidre A: Knee ligament injuries in children. J Bone Joint Surg Am 1979;61:1195-1201.

Question 2

A right-handed 14-year-old pitcher has had a 3-month history of shoulder pain while pitching. Examination reveals full range of motion, a mildly positive impingement sign, pain with rotational movement, and no instability. Plain AP radiographs of both shoulders are shown in Figures 25a and 25b. Management should consist of

Explanation

25b The patient has the classic signs of Little Leaguer's shoulder, with findings that include pain localized to the proximal humerus during the act of throwing and radiographic evidence of widening of the proximal humeral physis. Examination usually reveals tenderness to palpation over the proximal humerus, but the presence of any swelling, weakness, atrophy, or loss of motion is unlikely. The treatment of choice is rest from throwing for at least 3 months, followed by a gradual return to pitching once the shoulder is asymptomatic. Carson WG Jr, Gasser SI: Little Leaguer's shoulder: A report of 23 cases. Am J Sports Med 1998;26:575-580.

Question 3

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

Explanation

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. Orava S, Kujala UM: Rupture of the ischial origin of the hamstring muscles. Am J Sports Med 1995;23:702-705.

Question 4

What mechanism contributes to strength gains during conditioning of the preadolescent athlete?

Explanation

Prepubescent athletes gain strength through neurogenic adaptations, including recruitment of motor units, reduced inhibition, and learned motor skills. Myogenic adaptations (muscle hypertrophy) occur after puberty and include increased contractile proteins, thickening of the connective tissue, and increased short-term energy sources such as creatine phosphate. Grana WA: Strength training, in Stanitski CL, DeLee JC, Drez D Jr (eds): Pediatric and Adolescent Sports Medicine. Philadelphia, PA, WB Saunders, 1994, pp 520-526.

Question 5

Following an episode of transient quadriplegia in contact sports, an athlete's return to play is absolutely contraindicated when

Explanation

Return to play decisions after traumatic spinal or spinal cord injury are not always clear-cut and often must be made on a patient-by-patient basis. The Torg ratio has been found to have low sensitivity in patients with large vertebral bodies. Abnormal electromyographic studies can persist in the face of normal function and do not define spinal injury. Duration of quadriplegia is not related to anatomic pathology. Findings on MRI scans or contrast-enhanced CT scans consistent with stenosis include lack of a significant cerebrospinal fluid signal around the cord, bony or ligament hypertrophy, or disk encroachment. Based on these findings, return to play should be avoided. Cantu RC, Bailes JE, Wilberger JE Jr: Guidelines for return to contact or collision sport after a cervical spine injury. Clin Sports Med 1998;17:137-146. Herzog RJ, Wiens JJ, Dillingham MF, Sontag MJ: Normal cervical spine morphometry and cervical stenosis in asymptomatic professional football players: Plain film radiography, multiplanar computer tomography, and magnetic resonance imaging. Spine 1991;16:178-186.

Question 6

A 16-year-old snowboarder has significant pain and is still unable to bear weight after sustaining a lateral ankle injury in a fall 1 week ago. Examination reveals swelling and tenderness in the sinus tarsi. AP, lateral, and mortise radiographs of the ankle are unremarkable. Management should consist of

Explanation

Because there is a significant possibility that the patient may have a fracture of the lateral process of the talus, there is some disagreement as to the best radiographic study to identify this injury. A CT scan is an appropriate diagnostic tool to visualize the fracture and identify any displacement. Displaced lateral process fractures are best treated surgically. Kirkpatrick DP, Hunter RE, Janes PC, Mastrangelo J, Nicholas RA: The snowboarder's foot and ankle. Am J Sports Med 1998;26:271-277.

Question 7

A 24-year-old man who plays golf noted the immediate onset of pain on the ulnar side of his hand and has been unable to swing a club for the past 6 weeks after striking a tree root with his club during his golf swing. Examination reveals full motion of the wrist, diminished grip strength, and tenderness over the hypothenar region. A CT scan of the hand and wrist is shown in Figure 26. Management should consist of

Explanation

Fractures of the hook of the hamate frequently are not identified in the acute phase. Because the fracture can be difficult to see on plain radiographs, the lack of findings can lead to a painful nonunion. A carpal tunnel view may show the fracture, but a CT scan will best detect the injury. Immobilization is the treatment of choice and will result in union in most patients unless the diagnosis is delayed. However, excision of the fragment may be necessary for patients who have nonunion, persistent pain, or ulnar nerve palsy. Carroll RE, Lakin JF: Fracture of the hook of the hamate: Acute treatment. J Trauma 1993;34:803-805.

Question 8

An 18-year-old football player sustains a contact injury to his right lower leg, and radiographs show a closed transverse fracture of the middle third of the tibia. Based on the clinical examination, a compartment syndrome is suspected. When measuring compartment pressures, the highest tissue pressure is recorded how many centimeters proximal or distal to the fracture site?

Explanation

Measurements of compartment pressures in patients with tibial fractures and compartment syndrome reveal that the highest tissue pressures are recorded at the level of the fracture or within 5 cm of the fracture. Tissue pressures show a statistically significant decrease when they are recorded at increasing distances proximal and distal to the site of the highest pressure recorded. To reliably determine the location of the highest tissue pressure in patients with tibial fractures, measurements should be obtained, at a minimum, in both the anterior and deep posterior compartments at the level of the fracture, as well as at locations proximal and distal. The highest tissue pressure recorded should serve as a basis for determining the need for fasciotomy. Heckman MM, Whitesides TE Jr, Grewe SR, Rooks MD: Compartment pressure in association with closed tibial fractures: The relationship between tissue pressure, compartment, and the distance from the site of the fracture. J Bone Joint Surg Am 1994;76:1285-1292.

Question 9

A 50-year-old patient who plays tennis sustained the deformity shown in Figure 27 following a high volley. Further diagnostic work-up should include

Explanation

The patient has a rupture of the long head of the biceps; however, patients older than age 45 years are at greater risk of having an associated rotator cuff tear. An MRI scan should be ordered to avoid missing concomitant rotator cuff pathology. While patients may report pain radiating down the arm at the time of the tendon rupture, an EMG is not indicated. The short head of the biceps is intact and needs no further work-up, even though the muscle descends in most cases. The anterior labrum can be injured but is not associated with this deformity. Neer CS II, Bigliani LU, Hawkins RJ: Rupture of the long head of the biceps related to the subacromial impingement. Orthop Trans 1977;1:114.

Question 10

A 16-year-old ice hockey player is struck on the chest by the puck. He skates a few strides and then collapses. What is the most likely diagnosis?

Explanation

Sudden cardiac arrest following a blow to the chest in young athletes has been termed "commotio cordis." It is most common in Little League and other youth projectile sports (eg, ice hockey, lacrosse). The cause, although not completely determined, is most likely an arrhythmia related to the impact in a vulnerable time in the cardiac cycle. Resuscitation has proven to be exceedingly difficult, resulting in a high mortality rate. Maron BJ, Strasburger JF, Kugler JD, Bell BM, Brodkey FD, Poliac LC: Survival following blunt chest impact-induced cardiac arrest during sports activities in young athletes. Am J Cardiol 1997;79:840-841.

Question 11

A 24-year-old dancer sustains the injury shown in Figure 28. Management should consist of

Explanation

The patient has a moderately displaced distal diaphyseal fracture of the fifth metatarsal, and the most appropriate treatment is brief immobilization and symptomatic management. Attempts at closed reduction are unlikely to appreciably alter the position of the fracture. Surgical techniques for either reduction of the fracture or fixation have not been shown to result in improved functional outcomes. O'Malley MJ, Hamilton WG, Munyak J: Fractures of the distal shaft of the fifth metatarsal: "Dancer's Fracture." Am J Sports Med 1996;24:240-243. DeLee JC: Fractures and dislocations of the foot, in Mann RA, Coughlin MJ (eds): Surgery of the Foot and Ankle, ed 6. St Louis, MO, CV Mosby, 1993, pp 1465-1703.

Question 12

A 22-year-old volleyball player has atrophy of the infraspinatus muscle. This deficit is the result of entrapment of what nerve?

Explanation

Suprascapular deficits, as the result of repetitive forceful internal rotation with overhead ball striking, occur in the spinoglenoid notch. Compression interferes with distal suprascapular nerve innervation to the infraspinatus, while allowing the supraspinatus to function normally. A scapular notch entrapment of this nerve would involve both the supraspinatus and the infraspinatus. The axillary, dorsal scapular, and subscapular nerves do not affect the infraspinatus. Ferretti A, Cerullo G, Russo G: Suprascapular neuropathy in volleyball players. J Bone Joint Surg Am 1987;69:260-263.

Question 13

Figure 29 shows the radiograph of a 25-year-old woman who has had a 3-month history of ankle pain after sustaining an inversion injury to the ankle. She reports occasional catching, but no sense of instability. Examination reveals ligament stability. Management should consist of

Explanation

Osteochondral lesions of the talar dome can have a traumatic or nontraumatic etiology. Most authors site a probable traumatic etiology for lateral lesions. Stage I and II lesions, which are composed of compressed subchondral bone or a partial detached osteochondral fragment, can be treated initially in a non-weight-bearing short leg cast for 6 weeks. Stage III medial lesions can also be treated in the same manner. If symptoms persist, the treament of choice is debridement of the fracture, curettage of the lesion, and drilling of the subchondral bone. This treatment also applies to lateral stage III and all stage IV lesions. If the fragment is at least one third of the size of the talar dome, management should consist of open reduction and internal fixation. In patients with more chronic lesions (4 to 6 months of persistent pain), the threshold to proceed with surgery is lower, even in a stage II lesion. Lutter LD, Mizel MS, Pfeffer GB (eds): Orthopaedic Knowledge Update: Foot and Ankle. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 205-226.

Question 14

A 19-year-old college cross-country runner is amenorrheic and has recurrent stress fractures. Long-term management should consist of

Explanation

The triad of menstrual dysfunction, disordered eating, and stress fracture is well recognized in women who participate in endurance sports. The best treatment remains to be determined, but at present, the combination of oral contraceptives to regulate menses, an increased intake of calcium and vitamin D, as well as nutritional counseling, is the recommended treatment for decreased bone mass related to exercise-induced amenorrhea. Nattiv A, Armsey TD Jr: Stress injury to bone in the female athlete. Clin Sports Med 1997;16:197-224.

Question 15

A 47-year-old male tennis player has pain in his nondominant shoulder that has failed to respond to 4 months of nonsurgical management. Examination reveals acromial tenderness and pain at the supraspinatus tendon insertion. He has a positive impingement sign, pain on forward elevation, and minimal cuff weakness. The MRI scans are shown in Figures 30a and 30b. To completely resolve his symptoms, treatment should consist of

Explanation

30b The MRI scans show a mesoacromion with tendonopathy of the supraspinatus. The history and physical findings indicate that the patient has a symptomatic os acromiale. Simple excision of the unstable os acromiale has not yielded consistently good results. Meticulous internal fixation using tension banding with cannulated screws and autologous bone grafting has shown good results for this problem. Hutchinson MR, Veenstra MA: Arthroscopic decompression of shoulder impingement secondary to os acromiale. Arthroscopy 1993;9:28-32.

Question 16

A 39-year-old competitive cyclist sustains an injury to her left hip in a fall. Gadolinium arthrography, with an accompanying MRI scan, is shown in Figure 31. A cleft, or defect, identified by the arrow, indicates a detachment of the

Explanation

The area indicated by the arrow represents gadolinium contrast extending into a separation between the lateral labrum and its acetabular attachment. This can be a traumatic detachment, but occasionally a cleft may be present as a normal variant of the labral morphology. The capsular attachment of the iliofemoral ligament is peripheral to the labrum. The pulvinar is the common name applied to the fat and overlying synovium contained within the acetabular fossa above the ligamentum teres. The zona orbicularis is a circumferential thickening of the capsule around the femoral neck, and the retinacular vessels travel within the capsular synovium up the femoral neck to supply the femoral head. Petersilge CA, Haque MA, Petersilge WJ, Lewin JS, Lieberman JM, Buly R: Acetabular labral tears: Evaluation with MR arthrography. Radiology 1996;200:231-235. Czerny C, Hofmann S, Neuhold A, et al: Lesions of the acetabular labrum: Accuracy of MR imaging and MR arthrography in detection and staging. Radiology 1996;200:225-230.

Question 17

A cortisone injection in the subacromial space will most likely result in

Explanation

A cortisone injection in the subacromial space will most likely result in elevated blood glucose levels in patients with type I diabetes mellitus. Patients should be warned of this potential complication. Cortisone does not have an effect on instability or proprioception, and a single injection would not affect osteoporosis. Repetitive injections or injection into the tendon itself could accelerate rupture of the biceps tendon. Matsen FA III, Arntz CT: Subacromial impingement, in Rockwood CA, Matsen FA III (eds): The Shoulder. Philadelphia, PA, WB Saunders, 1990, pp 623-646.

Question 18

A high school athlete reports the sudden onset of low back pain while performing a dead lift. Examination reveals a lumbar paraspinal spasm and a positive straight leg raising test. The deep tendon reflexes, motor strength, and sensation in the lower extremeties are normal. The radiographs are normal. If symptoms persist for more than a few weeks, management should consist of

Explanation

In adolescents, a lumbar herniated disk is characterized by a paucity of clinical findings; a positive straight leg raising test may be the only consistent positive finding. This may result in a long period of nonsurgical management that fails to provide relief. Activities that place a significant shear load on the lumbar spine, such as the dead lift, are associated with an increased risk of central disk herniation. When an adolescent who lifts weights has a history of low back pain that fails to respond to a short period of active rest, an MRI scan is the study of choice to evaluate for a lumbar herniated disk. Epstein JA, Epstein NE, Marc J, Rosenthal AD, Lavine LS: Lumbar intervertebral disk herniation in teenage children: Recognition and management of associated anomalies. Spine 1984;9:427-432.

Question 19

A 22-year-old skier reports painful range of motion in the left thumb after falling forward on his outstretched hand while holding his ski pole. Examination of the left thumb reveals increased AP laxity and 45 degrees of valgus laxity at the metacarpophalangeal (MCP) joint. Examination of the right thumb shows 25 degrees of valgus laxity at the MCP joint. Radiographs are normal. Management should consist of

Explanation

The patient has a complete tear of the ulnar collateral ligament as defined by MCP joint laxity of greater than 30 degrees (or 15 degrees greater laxity compared with the opposite side). Primary repair is the treatment of choice because displacement of the ligament superficial to the adductor aponeurosis (Stener lesion) must be corrected. Any volar plate injury can be addressed during repair of the ulnar collateral ligament.

Question 20

Which of the following structures is most commonly involved in lateral epicondylitis?

Explanation

The most common specific site of involvement is the origin of the extensor carpi radialis brevis. It is usually caused by overuse activities, such as the eccentric overload exhibited during a backhand in tennis. In most patients, the characteristic friable, grayish tissue described as angiofibroblastic hyperplasia or hyaline degeneration is seen at the extensor carpi radialis brevis origin. Nirschl RP: Elbow tendinosis/tennis elbow. Clin Sports Med 1992;11:851-870.

Question 21

When comparing surgical and nonsurgical extremities in patients who underwent anterior cruciate ligament (ACL) reconstruction using patellar tendon or hamstrings autografts, isokinetic strength measurements obtained 6 months after the surgery would most likely reveal

Explanation

Follow-up examination at 6 months revealed no statistically significant differences in quadricep or hamstring strength when comparing surgical versus nonsurgical extremities isokinetically. Therefore, the selection of autogenous hamstring or patellar tendon for ACL reconstruction should not be based solely on the assumption of the graft tissue source altering the recovery of quadricep and/or hamstring strength. Carter TR, Edinger S: Isokinetic evaluation of anterior cruciate ligament reconstruction: Hamstring versus patellar tendon. Arthroscopy 1999;15:169-172 Howell SM, Taylor MA: Brace-free rehabilitation, with early return to activity, for knees reconstructed with a double-looped semitendinosus and gracilis graft. J Bone Joint Surg Am 1996;78:814-825.

Question 22

A quarterback sustains a rough tackle after which he appears confused, has a dazed look on his face and an unsteady gait on standing. He denies loss of consciousness. Reexamination within 10 minutes is normal, the patient is lucid, and he wants to return to play. The coach and the player should be advised that he may

Explanation

The patient has a grade I (mild) concussion that can result in confusion and disorientation, without loss of consciousness. This concussion syndrome is completely reversible, with no long-term sequelae. Athletes who sustain a grade I concussion may return to play after 15 minutes if there are no lingering symptoms, such as headache or vertigo. A grade II concussion is characterized by loss of consciousness of less than 5 minutes. With this type of injury, the athlete can return to play in 1 week, if asymptomatic. If a grade III (severe) concussion is sustained, the athlete should avoid contact for a minimum of 1 month before considering a return to competition. A grade III concussion is characterized by a loss of consciousness of greater than 5 minutes or posttraumatic amnesia of greater than 24 hours. A CT scan is not indicated in a grade I injury. An athlete who sustains three grade I or grade II concussions, or two grade III concussions may not return to play for the season. Torg JS, Gennarelli TA: Head and cervical spine injuries, in DeLee JC, Drez D Jr (eds): Orthopaedic Sports Medicine Principles & Practice. Philadelphia, PA, WB Saunders, 1994, vol 1, pp 417-462.

Question 23

The bone avulsion shown in Figure 32 has a high correlation with tearing of the

Explanation

As described by Segond in 1987, an avulsion fracture of the lateral tibial plateau is commonly referred to as a Segond fracture. Subsequent to 1987, several authors have also found that the lateral capsular sign represents, but is not limited to, a disruption of the middle third of the lateral capsule and a tear of the anterior cruciate ligament. Bach BR, Warren RF: Radiographic indicators of anterior cruciate ligament injury, in Feagin JA (ed): The Crucial Ligaments. New York, NY, Churchill Livingston, 1988, pp 301-327. Segond P: Recherches cliniques et experimentales sur les epanchements sanguins du genou par entorse. Prog Med (Paris) 1987;7:297.

Question 24

A 21-year-old college defensive lineman sustains a minimally displaced (less than 1 mm) midthird scaphoid fracture during the first game of the season. Management should consist of

Explanation

The union rate for minimally displaced midthird scaphoid fractures is quite high with cast immobilization while allowing a return to sports. Inadequate immobilization results in a much higher nonunion rate. Early fixation and rehabilitation have been proposed for sports or positions that are not amenable to cast immobilization. While immobilization of a nondisplaced fracture results in an acceptably high union rate, there is no advantage to fixation in conjunction with immobilization in the course of healing. With adequate immobilization and protection, play restrictions until healing has occurred are unnecessary. Rettig AC, Kollias SC: Internal fixation of acute stable scaphoid fractures in the athlete. Am J Sports Med 1996;24:182-186. Rettig AC, Weidenbener EJ, Gloyeske R: Alternative management in midthird scaphoid fractures in the athlete. Am J Sports Med 1994;22:711-714.

Question 25

A 16-year-old football player sustains a direct blow to the anterior aspect of his flexed right knee. Examination reveals a contusion over the anterior tibial tubercle and a small effusion. MRI scans are shown in Figures 33a through 33c. What is the most likely diagnosis?

Explanation

33b 33c The MRI scans show disruption of the fibers of the PCL. Patients sustaining an isolated acute PCL injury can present with only minimal discomfort and have full range of motion. When examination reveals a contusion over the tibial tubercle and discomfort with the posterior drawer examination, with or without instability, a possible injury to the PCL should be considered. In acute injuries, the reported accuracy of MRI imaging for diagnosing PCL tears ranges from 96% to 100%. Resnick D, Kang HS: Internal Derangement of Joints: Emphasis on MRI Imaging. Philadelphia, PA, WB Saunders, 1997, pp 699-700. Harner CD, Hoher J: Evaluation and treatment of posterior cruciate ligament injuries. Am J Sports Med 1998;26:471-482.

Question 26

A 25-year-old professional soccer player undergoes ACL reconstruction with a bone-patellar tendon-bone autograft. During the procedure, the femoral tunnel is drilled through the anteromedial portal rather than transtibial. Which of the following is the most likely biomechanical advantage of this technique?

Explanation

Drilling the femoral tunnel independently via an anteromedial portal allows for more anatomic placement of the ACL footprint compared to the transtibial technique, which often results in a more vertical graft that primarily controls AP translation but is less effective for rotational instability.

Question 27

A 19-year-old collegiate football running back presents with an acute knee injury after being tackled. MRI demonstrates a complete, isolated PCL rupture. He has no gross instability with varus or valgus stress and a Grade II posterior drawer. What is the most appropriate initial management?

Explanation

Isolated Grade I and II PCL tears are highly amenable to non-operative treatment. Management typically involves bracing in extension to counteract the posterior pull of the hamstrings, followed by aggressive quadriceps strengthening.

Question 28

In Medial Patellofemoral Ligament (MPFL) reconstruction, placing the femoral tunnel too proximal will result in which of the following kinematic abnormalities?

Explanation

Proximal placement of the femoral tunnel in MPFL reconstruction causes the graft to overtighten during knee flexion. This non-anatomic placement increases patellofemoral contact pressures and can restrict terminal range of motion.

Question 29

A 22-year-old baseball pitcher presents with medial elbow pain during the late cocking phase of throwing and a decrease in velocity. Physical examination reveals a positive moving valgus stress test. An MRI arthrogram demonstrates a partial thickness tear of the UCL. Which bundle of the UCL is the primary restraint to valgus stress at 90 degrees of flexion?

Explanation

The anterior bundle of the UCL is the primary restraint to valgus stress. Within it, the anterior band is tightest in extension, whereas the posterior band is the primary restraint at 60 to 90 degrees of flexion.

Question 30

A 35-year-old heavy laborer sustains an acute distal biceps tendon rupture. During a single-incision anterior repair using cortical button fixation, the surgeon must be particularly careful to protect which of the following nerves as it pierces the supinator muscle?

Explanation

The posterior interosseous nerve (PIN) courses through the arcade of Frohse into the supinator muscle. It is at significant risk during the drilling and placement of a cortical button in single-incision distal biceps repairs.

Question 31

A 28-year-old rock climber presents with chronic shoulder pain. An MRI reveals a type II SLAP lesion. He fails conservative management and undergoes arthroscopic repair. Postoperatively, what is the most common complication following SLAP repair in this patient demographic?

Explanation

Postoperative stiffness, particularly a loss of external rotation, is the most common complication following SLAP repair. This risk is minimized by avoiding overtensioning of the capsulolabral complex.

Question 32

A 45-year-old avid runner presents with deep gluteal pain and posterior thigh radiation that worsens with prolonged sitting. Examination shows tenderness over the ischial tuberosity and pain with resisted knee flexion while the hip is flexed. Which of the following conditions is most likely responsible for his symptoms?

Explanation

Proximal hamstring tendinopathy classically presents with deep, localized buttock pain at the ischial tuberosity. Symptoms are exacerbated by prolonged sitting and activities requiring repetitive deep hip flexion, such as running uphill.

Question 33

A 16-year-old female gymnast presents with an insidious onset of anterior knee pain. Imaging reveals an open proximal tibial physis. Which of the following findings on a lateral radiograph indicates patella alta using the Caton-Deschamps index?

Explanation

The Caton-Deschamps index measures the distance from the lower articular margin of the patella to the anterior edge of the tibial plateau, divided by the patellar articular length. A ratio greater than 1.2 is indicative of patella alta.

Question 34

A 21-year-old collegiate swimmer complains of anterior shoulder pain. On examination, there is a positive O'Brien's test. During arthroscopy, an anterosuperior labral variant is noted where the labrum is absent from the 1 to 3 o'clock position with a cord-like middle glenohumeral ligament. What is the appropriate management of this anatomic variant?

Explanation

The described finding is a Buford complex, a normal anatomic variant. It should be left alone, as attempting to repair the cord-like middle glenohumeral ligament to the glenoid will severely restrict external rotation.

Question 35

During an arthroscopic rotator cuff repair, a massive, retracted, U-shaped tear involving the supraspinatus and infraspinatus is identified. Margin convergence sutures are utilized. What is the primary biomechanical goal of margin convergence?

Explanation

Margin convergence side-to-side suturing acts to close a U-shaped tear into a more manageable crescent shape. Biomechanically, this significantly reduces tension and strain at the tendon-to-bone repair site on the greater tuberosity.

Question 36

A 10-year-old boy (Tanner stage 1) sustains a mid-substance complete tear of his anterior cruciate ligament (ACL) while playing soccer. Non-operative management has failed due to recurrent instability. Which of the following surgical techniques is most appropriate?

Explanation

In prepubescent children with significant remaining growth (Tanner 1 or 2), a physeal-sparing technique, such as an extraphyseal IT band reconstruction (e.g., MacIntosh/Kocher technique), minimizes the risk of growth arrest and angular deformity.

Question 37

A 22-year-old male rugby player presents with recurrent anterior shoulder instability. Advanced imaging reveals 25% anterior glenoid bone loss and an engaging Hill-Sachs lesion.

Which of the following is the most appropriate surgical management?

Explanation

The Latarjet procedure is indicated for recurrent anterior shoulder instability associated with critical glenoid bone loss (>20-25%). Soft tissue repairs alone in this setting have an unacceptably high failure rate.

Question 38

When reconstructing the medial patellofemoral ligament (MPFL) for recurrent patellar instability, identifying the correct femoral attachment (Schöttle's point) is critical. Where is this anatomic point located radiographically?

Explanation

The MPFL femoral origin is located in a saddle-like depression situated between the medial epicondyle distally and the adductor tubercle proximally.

Question 39

A 28-year-old professional volleyball player is diagnosed with a posterior labral tear and an associated paralabral cyst located strictly at the spinoglenoid notch. Which of the following clinical exam findings is most expected?

Explanation

A paralabral cyst at the spinoglenoid notch selectively compresses the distal suprascapular nerve branch to the infraspinatus. This spares the supraspinatus (innervated prior to the notch), resulting in isolated external rotation weakness.

Question 40

A 30-year-old male sustains a severe knee injury. On physical examination, the Dial test demonstrates 15 degrees of increased external rotation of the tibia compared to the contralateral leg at 30 degrees of flexion, and 18 degrees of increased external rotation at 90 degrees of flexion. This pattern most strongly suggests injury to which structures?

Explanation

The Dial test evaluates external tibial rotation. Increased rotation (>10 degrees compared to the normal side) at 30 degrees only indicates an isolated PLC injury. Increased rotation at both 30 and 90 degrees indicates combined PLC and PCL injuries.

Question 41

A 24-year-old hockey player presents with chronic groin pain. Imaging reveals femoroacetabular impingement (FAI) with a cam lesion. Which radiographic view is best utilized to measure the alpha angle to quantify the cam deformity?

Explanation

The Dunn lateral or cross-table lateral views provide the best visualization of the anterolateral femoral head-neck junction, which is where cam deformities most commonly occur and the alpha angle is most accurately measured.

Question 42

A medial meniscus posterior root tear is diagnosed in a 45-year-old active female. If left untreated, biomechanical studies demonstrate that this injury alters knee contact pressures most similarly to which of the following scenarios?

Explanation

A complete posterior root tear results in loss of hoop stresses, leading to medial meniscal extrusion. Biomechanically, this increases tibiofemoral peak contact pressures to levels equivalent to a total medial meniscectomy.

Question 43

A 21-year-old cross-country runner is evaluated for chronic exertional compartment syndrome (CECS) of the lower legs. According to the modified Pedowitz criteria, which of the following intramuscular pressure measurements is diagnostic for CECS?

Explanation

Diagnostic criteria for CECS include a pre-exercise resting pressure > 15 mmHg, a 1-minute post-exercise pressure > 30 mmHg, or a 5-minute post-exercise pressure > 20 mmHg.

Question 44

Histological evaluation of surgical specimens from patients undergoing operative management for chronic lateral epicondylitis (tennis elbow) most characteristically demonstrates which of the following?

Explanation

Lateral epicondylitis is a tendinosis, not a true tendinitis. Histopathology characteristically shows angiofibroblastic hyperplasia, disorganized collagen, and an absence of acute inflammatory cells.

Question 45

During an ulnar collateral ligament (UCL) reconstruction in a baseball pitcher, understanding elbow biomechanics is crucial. Which anatomical band of the UCL is the primary restraint to valgus stress between 30 and 120 degrees of elbow flexion?

Explanation

The anterior bundle of the UCL is the primary restraint to valgus stress. Specifically, the anterior band of the anterior bundle is tight in extension and early flexion, while the posterior band tightens in deeper flexion.

Question 46

An 11-year-old Little League baseball pitcher presents with vague, gradual onset shoulder pain in his throwing arm. Radiographs reveal widening of the proximal humeral physis compared to the contralateral shoulder. What is the most appropriate initial management?

Explanation

Little Leaguer's shoulder is an epiphysiolysis of the proximal humerus caused by repetitive rotational microtrauma. The gold standard treatment is complete rest from throwing until symptoms resolve and the physis appears normal on radiographs.

Question 47

A 32-year-old male bodybuilder feels a tearing sensation in his anterior chest wall while performing a heavy bench press. Examination shows bruising and loss of the anterior axillary fold contour. During surgical repair, where should the sternal head of the pectoralis major be reattached?

Explanation

The sternal head of the pectoralis major most commonly ruptures and inserts on the lateral lip of the bicipital groove, crossing deep to the clavicular head at its insertion site.

Question 48

A professional American football player sustains a 'turf toe' injury. Which of the following mechanisms is the primary cause of this condition?

Explanation

Turf toe is a sprain of the first MTP joint plantar capsuloligamentous complex. It is typically caused by an axial load applied to a foot fixed in equinus, resulting in hyperdorsiflexion (hyperextension) of the first MTP joint.

Question 49

A 20-year-old female dancer complains of a deep, audible clicking in her groin area when she brings her hip from flexion into extension. The phenomenon is reproducible and mildly painful. This specific form of 'snapping hip' syndrome involves which of the following structures?

Explanation

Internal snapping hip syndrome (coxa saltans interna) occurs when the iliopsoas tendon snaps over the iliopectineal eminence or the femoral head during hip extension.

Question 50

A healthy 30-year-old professional athlete sustains an acute, mid-substance Achilles tendon rupture. When discussing operative versus non-operative treatment with modern functional rehabilitation protocols, operative management is primarily associated with which of the following outcomes?

Explanation

While modern functional rehabilitation has minimized the differences, operative treatment of Achilles tendon ruptures historically and consistently demonstrates a lower re-rupture rate compared to non-operative treatment, albeit with a higher risk of wound complications.

Question 51

A 22-year-old collegiate basketball player sustains a Zone 2 fifth metatarsal base fracture (Jones fracture). He desires to return to play as safely and quickly as possible. What is the most appropriate management?

Explanation

In high-level athletes with a Zone 2 (Jones) fracture, early intramedullary screw fixation is recommended. It significantly decreases the rate of nonunion and reduces the time to return to play compared to non-operative management.

Question 52

Comparing quadriceps tendon ruptures to patellar tendon ruptures, which of the following demographic or clinical statements is most accurate?

Explanation

Quadriceps tendon ruptures typically occur in patients older than 40, while patellar tendon ruptures are more common in patients younger than 40. A patellar tendon rupture yields patella alta, whereas a quadriceps rupture results in patella baja (or neutral).

Question 53

A 19-year-old soccer player presents with anterior ankle pain after a twisting injury. Physical examination raises suspicion for a syndesmotic sprain (high ankle sprain). Which of the following physical examination tests has the highest inter-observer reliability and sensitivity for diagnosing a syndesmotic injury?

Explanation

The external rotation stress test is considered one of the most reliable and sensitive clinical tests for diagnosing syndesmotic ankle sprains. The squeeze test is highly specific but lacks sensitivity.

Question 54

A 14-year-old female gymnast complains of insidious onset, mechanical low back pain exacerbated by extension. Plain radiographs of the lumbar spine are normal. What is the preferred next imaging modality to diagnose an early, pre-radiographic pars interarticularis stress reaction while avoiding ionizing radiation?

Explanation

MRI is the preferred advanced imaging modality to detect marrow edema associated with an early pars stress reaction (spondylolysis), as it offers excellent sensitivity without exposing the pediatric patient to ionizing radiation.

Question 55

A 25-year-old recreational basketball player is diagnosed with chronic patellar tendinopathy. He has failed a 4-week course of rest and NSAIDs. What is the most evidence-based physical therapy intervention for this condition?

Explanation

Eccentric strengthening, specifically utilizing a decline squat protocol, has the highest level of evidence for effectively treating chronic patellar tendinopathy (Jumper's knee) and promoting collagen remodeling.

Question 56

A 19-year-old female soccer player undergoes an anterior cruciate ligament (ACL) reconstruction using a bone-patellar tendon-bone autograft. Which of the following is the most frequently reported complication specific to this graft choice compared to a hamstring autograft?

Explanation

Bone-patellar tendon-bone (BTB) autograft is historically associated with a higher incidence of anterior knee pain and donor site morbidity compared to hamstring autograft. Graft rupture rates are comparable or slightly lower for BTB in young, active patients.

Question 57

A 25-year-old male sustains a direct blow to the proximal tibia with the knee flexed. Examination reveals a posterior sag sign and posterior translation of 8 mm at 90 degrees of flexion with a firm endpoint. What is the most appropriate initial management?

Explanation

This represents a Grade II isolated posterior cruciate ligament (PCL) injury (5-10 mm translation). Isolated Grade I and II PCL injuries are best managed non-operatively with brief immobilization in extension to reduce the posterior sag, followed by progressive quadriceps strengthening.

Question 58

A 22-year-old college football player suffers a multiligament knee injury (KD-III). During the initial emergency department evaluation, his ankle-brachial index (ABI) is measured at 0.85. What is the most appropriate next step in management?

Explanation

An ABI of less than 0.9 in the setting of a knee dislocation or multiligament knee injury is highly suspicious for a vascular injury. CT angiography is the gold standard next step to confirm, localize, and characterize the arterial injury before surgical intervention.

Question 59

A 24-year-old male presents with recurrent anterior shoulder instability. CT scan with 3D reconstruction reveals a 25% anteroinferior glenoid bone loss. Which of the following is the most appropriate surgical treatment?

Explanation

In patients with recurrent anterior shoulder instability and significant glenoid bone loss (typically >20-25%), isolated soft-tissue repair (Bankart) has an unacceptably high failure rate. The Latarjet procedure (coracoid transfer) is the standard of care for restoring stability.

Question 60

A 36-year-old recreational weightlifter complains of persistent deep anterior shoulder pain. MRI arthrogram demonstrates a Type II SLAP tear. Non-operative management has failed. What is the most appropriate surgical intervention for this patient?

Explanation

In older patients or those not participating in overhead throwing sports, primary biceps tenodesis provides superior pain relief and functional outcomes with lower complication rates compared to SLAP repair for Type II SLAP tears.

Question 61

A 45-year-old tennis player presents with shoulder pain. MRI shows a partial articular-sided supraspinatus tendon avulsion (PASTA) involving 60% of the tendon thickness. What is the recommended surgical management if conservative treatment fails?

Explanation

For partial articular-sided rotator cuff tears involving greater than 50% of the tendon thickness, standard treatment involves taking down the remaining intact tendon and performing a formal full-thickness repair, or completing a transtendon (in situ) repair.

Question 62

During a physical examination for a suspected meniscal tear, the examiner flexes the knee, internally rotates the tibia, and applies a varus stress while bringing the knee into extension. Which specific test is being described?

Explanation

The McMurray test for the lateral meniscus involves flexing the knee, internally rotating the tibia, and applying a varus stress while extending the knee. Testing the medial meniscus requires external rotation and valgus stress.

Question 63

A 28-year-old male hockey player presents with insidious onset groin pain. Radiographs demonstrate a pistol-grip deformity and an alpha angle of 65 degrees. What is the primary pathoanatomy in this condition?

Explanation

An increased alpha angle (>55 degrees) and pistol-grip deformity indicate Cam-type femoroacetabular impingement (FAI). This is characterized by an aspherical femoral head-neck junction that impinges against the anterosuperior acetabular rim during hip flexion.

Question 64

A 55-year-old woman experiences a sudden pop in the back of her knee while descending stairs. MRI shows a medial meniscus posterior root tear with 4 mm of meniscal extrusion. If left untreated, this condition most closely simulates the biomechanical effects of:

Explanation

A complete meniscal root tear disrupts the hoop stresses of the meniscus, causing it to extrude and fail to distribute weight. Biomechanically, the contact pressures in the tibiofemoral compartment become equivalent to those following a total meniscectomy, leading to rapid chondrolysis.

Question 65

During medial patellofemoral ligament (MPFL) reconstruction, identifying the correct femoral attachment is crucial. According to Schöttle's method, where is the radiographic femoral footprint located on a strict lateral radiograph?

Explanation

The Schöttle point for MPFL femoral insertion is located radiographically 1 mm anterior to the posterior femoral cortical line, 2.5 mm distal to the posterior origin of the medial femoral condyle, and proximal to the level of the posterior portion of Blumensaat's line.

Question 66

A 29-year-old male cyclist falls on his shoulder. Radiographs show superior displacement of the clavicle with a coracoclavicular (CC) distance increased by 120% compared to the contralateral side. What Rockwood classification does this represent and what is the typical management?

Explanation

A CC distance increased by 100-300% denotes a Rockwood Type V acromioclavicular joint injury. Because this severe disruption includes the deltotrapezial fascia, surgical reconstruction of the CC ligaments is typically indicated.

Question 67

A 34-year-old male suffers an acute mid-substance Achilles tendon rupture. He is treated non-operatively with a functional rehabilitation protocol. Compared to historical rigid cast immobilization, early functional rehabilitation demonstrates:

Explanation

Modern non-operative management using early weight-bearing and functional rehabilitation protocols has shown re-rupture rates comparable to operative treatment. This avoids surgical complications while improving early functional outcomes compared to prolonged cast immobilization.

Question 68

A 21-year-old cross-country runner reports bilateral lower leg pain that occurs 15 minutes into a run and resolves with rest. Intracompartmental pressure testing is performed. Which of the following values is diagnostic for chronic exertional compartment syndrome?

Explanation

Modified Pedowitz criteria for chronic exertional compartment syndrome include: pre-exercise pressure >= 15 mm Hg, 1-minute post-exercise >= 30 mm Hg, or 5-minute post-exercise >= 20 mm Hg. A 5-minute pressure of 25 mm Hg meets diagnostic criteria.

Question 69

A 22-year-old collegiate football player sustains a multiligamentous knee injury resulting in a knee dislocation. Upon reduction, he has an asymmetric, diminished dorsalis pedis pulse compared to the contralateral side. An ankle-brachial index (ABI) is measured at 0.85. What is the most appropriate next step in management?

Explanation

An ABI less than 0.9 after a knee dislocation raises high suspicion for a popliteal artery injury. CT angiography is the gold standard next step to rapidly define the vascular injury before surgical intervention.

Question 70

A 26-year-old professional baseball pitcher complains of vague posterior shoulder pain during the late cocking phase of throwing. Physical examination reveals a loss of 25 degrees of internal rotation compared to the non-throwing shoulder, with a positive O'Brien test. What is the initial recommended treatment for this condition?

Explanation

The patient presents with Glenohumeral Internal Rotation Deficit (GIRD) and possible internal impingement. The initial management for GIRD in overhead athletes is a supervised posterior capsular stretching program, such as sleeper stretches.

Question 71

During a medial patellofemoral ligament (MPFL) reconstruction for recurrent patellar instability, identifying the anatomic femoral footprint is critical. According to Schottle's method on a true lateral radiograph, where is the femoral attachment of the MPFL located?

Explanation

The Schottle point indicates the anatomic femoral origin of the MPFL. It is located 1 mm anterior to the posterior cortical line of the femur and proximal to the level of the posterior Blumensaat line.

Question 72

A 16-year-old female high school soccer player is planning to undergo an anterior cruciate ligament (ACL) reconstruction. Which of the following graft choices is associated with the highest risk of graft failure in this specific patient population?

Explanation

Multiple studies demonstrate that allografts have a significantly higher failure rate in young, active athletes (especially under 20 years old) compared to autograft options.

Question 73

A 30-year-old weightlifter feels a sudden pop and pain in his anterior shoulder/chest while performing a heavy bench press. Examination reveals ecchymosis and loss of the anterior axillary fold. MRI confirms a complete rupture of the pectoralis major tendon. Which portion of the muscle is most commonly injured in this mechanism?

Explanation

Pectoralis major ruptures typically occur during eccentric contraction, such as the lower phase of the bench press. The sternal head is most commonly injured at its humeral insertion because it is maximally stretched in this position.

Question 74

A 24-year-old gymnast presents with chronic lateral elbow pain. She has pain with valgus stress and a 15-degree extension deficit. Radiographs demonstrate a radiolucent lesion in the capitellum with a sclerotic margin. MRI shows a 12mm osteochondral defect with a detached fragment and fluid behind the fragment. What is the most appropriate definitive management?

Explanation

This patient has an unstable osteochondritis dissecans (OCD) of the capitellum, indicated by fluid behind the fragment. For small to moderate unstable lesions that are chronic, arthroscopic debridement and marrow stimulation (microfracture) is indicated.

Question 75

A 45-year-old weekend warrior sustains an acute Achilles tendon rupture. He discusses operative versus non-operative management with you. Based on recent high-level evidence utilizing modern functional rehabilitation protocols, non-operative management compared to operative management is associated with:

Explanation

Recent evidence shows that when early functional rehabilitation is employed, non-operative management of Achilles ruptures yields similar re-rupture rates compared to surgical repair, while successfully avoiding surgical risks such as infection.

Question 76

A 20-year-old collegiate rugby player sustains an anterior shoulder dislocation. After reduction, a CT scan shows a glenoid bone loss of 25%. He is indicated for a Latarjet procedure. The primary stabilizing mechanism of the Latarjet procedure in this setting is:

Explanation

The primary stabilizing mechanism of the Latarjet procedure is the 'sling effect' of the conjoint tendon compressing the anteroinferior capsule during abduction and external rotation. The osseous expansion plays a secondary role.

Question 77

A 50-year-old male presents with acute severe pain in the posterior knee after stepping off a curb. MRI demonstrates a complete radial tear of the posterior root of the medial meniscus with 4 mm of meniscal extrusion. If left untreated, this injury biomechanically behaves most similarly to:

Explanation

A posterior root tear of the medial meniscus disrupts the circumferential hoop stresses, leading to functional incompetence and meniscal extrusion. Biomechanically, it is equivalent to a total medial meniscectomy.

Question 78

A 19-year-old male sustains a complete distal biceps tendon rupture during a wrestling match. He undergoes an anatomic surgical repair. Which of the following complications is most frequently associated with a single-incision anterior approach using a cortical button?

Explanation

The single-incision anterior approach for distal biceps repair is most commonly associated with lateral antebrachial cutaneous nerve (LABCN) neurapraxia due to traction and its superficial proximity to the surgical window.

Question 79

A 21-year-old collegiate soccer player presents with a high ankle sprain (syndesmotic injury) confirmed by an increased tibiofibular clear space. He undergoes dynamic fixation using a suture-button construct. Compared to traditional syndesmotic screw fixation, the suture-button construct has been shown to:

Explanation

Suture-button constructs for syndesmosis injuries offer dynamic stabilization mimicking physiologic motion. They demonstrate a faster return to sport and a lower need for routine hardware removal compared to rigid screw fixation.

Question 80

A 28-year-old professional dancer undergoes hip arthroscopy for a symptomatic cam-type femoroacetabular impingement (FAI). Postoperatively, she reports numbness over the perineum and labia majora. This complication is most likely related to:

Explanation

Pudendal nerve neurapraxia is a known complication of hip arthroscopy due to prolonged compression against the perineal post during traction. It typically presents as transient numbness in the groin and perineal area.

Question 81

A 17-year-old male baseball pitcher complains of chronic medial elbow pain and decreased throwing velocity. Valgus stress testing reproduces pain at the medial epicondyle. MRI shows a high-grade partial tear of the ulnar collateral ligament (UCL). He is scheduled for UCL reconstruction. What is the optimal placement of the graft to best recreate the primary restraint to valgus stress?

Explanation

The anterior bundle of the UCL is the primary restraint to valgus stress at the elbow between 30 and 120 degrees of flexion. Reconstruction techniques aim to anatomically recreate this specific bundle.

Question 82

A 35-year-old water skier falls forcefully while accelerating and sustains an avulsion of the proximal hamstring origin. MRI demonstrates a complete avulsion of the conjoined tendon and semimembranosus with 4 cm of distal retraction. During the surgical exposure, which of the following nerves is at greatest risk of injury and must be carefully protected?

Explanation

The sciatic nerve lies immediately lateral to the ischial tuberosity and the proximal hamstring origin. In cases of significant tendon retraction and scarring, the nerve is at high risk of iatrogenic injury.

Question 83

A 25-year-old athlete sustains a posterolateral corner (PLC) injury of the knee. During a surgical reconstruction of the PLC using a fibular-based technique, care must be taken to avoid injury to the common peroneal nerve. Where does the common peroneal nerve typically cross in relation to the fibular head?

Explanation

The common peroneal nerve courses posterior to the long head of the biceps femoris tendon and wraps around the fibular neck from posterior to anterior, making it highly vulnerable during PLC reconstruction.

Question 84

Which of the following statements regarding the anatomy and biomechanics of the posterior cruciate ligament (PCL) is true?

Explanation

The PCL consists of the larger anterolateral bundle (tight in flexion) and the smaller posteromedial bundle (tight in extension). The anterolateral bundle provides the primary restraint to posterior tibial translation at 90 degrees of knee flexion.

Question 85

A 45-year-old woman presents with acute posterior knee pain after a deep squat. MRI reveals a medial meniscus posterior root tear. Which of the following is the most likely consequence if this injury is left untreated?

Explanation

Posterior root tears of the medial meniscus disrupt circumferential hoop stresses, functionally equating to a total meniscectomy. This biomechanical failure leads to meniscal extrusion and rapid acceleration of medial compartment osteoarthritis if left un repaired.

Question 86

A 21-year-old collegiate rugby player with a history of recurrent anterior shoulder instability presents for surgical evaluation. A 3D CT scan reveals 26% anterior glenoid bone loss. What is the most appropriate surgical management?

Explanation

In collision athletes with critical anterior glenoid bone loss (typically greater than 20-25%), isolated soft-tissue repair has an unacceptably high failure rate. The Latarjet procedure (coracoid transfer) is required to restore the bony arc and provide a dynamic sling effect.

Question 87

A 28-year-old male is brought to the trauma bay after a motorcycle accident. He has a grossly unstable knee with a suspected multi-ligamentous injury (KD-III). His dorsalis pedis pulse is palpable, but the ankle-brachial index (ABI) is 0.85. What is the most appropriate next step in management?

Explanation

An ABI < 0.9 in the setting of a knee dislocation indicates a high risk for popliteal artery injury, even if distal pulses are palpable. CT angiography is the gold standard next step to rapidly and non-invasively evaluate for a vascular injury requiring surgical intervention.

Orthopedic Board Review Mock Exam #603: 100 High-Yield MCQs

Orthopedic Sports Medicine 2026 MCQs: Board Review Questions & Answers (Part 3)

Key Takeaway

Orthopedic Sports Medicine 2026 MCQs: Board Review Questions & Answers (Part 3)

Chapter Index