Orthopedic Sports Medicine 2026 MCQs: Board Review

Question 1

A 21-year-old collegiate wrestler sustains a blow to his right eye during a match. Examination reveals anisocoria with a dilated right pupil. The globe is properly formed, and extra-occular movements and the visual field are grossly intact. What is the most likely diagnosis?

Explanation

Traumatic mydriasis occurs from a contusion to the iris sphincter. This is a transient phenomenon during which the iris fails to constrict properly, resulting in a dilated pupil. More severe trauma can result in a tear of the sphincter and permanent pupillary deformity. In association with head injury, traumatic anisocoria would be a concerning indicator of the severity of injury. Retinal detachment, lens dislocation, corneal abrasion, and traumatic hyphema are all potential results of eye injury but are not reflected by this clinical description. Brucker AJ, Kozart DM, Nichols CW, Irving MR: Diagnosis and management of injuries to the eye and orbit, in Torg JS (ed): Athletic Injuries to the Head, Neck, and Face, ed 2. St Louis, MO, Mosby Year Book, 1991, pp 650-670.

Question 2

After making a tackle, a football player is found prone and unconscious without spontaneous respirations. Initial management should consist of

Explanation

The on-field evaluation and management of a seriously injured athlete requires that health care teams have a game plan in place and proper equipment that is readily available. The initial step, which consists of stabilizing the head and neck by manually holding them in a neutral position, is then followed by assessment of breathing, pulses, and level of consciousness. If the athlete is breathing, management should consist of mouth guard removal and airway maintenance. If the athlete is not breathing, the face mask should be removed, with the chin strap left in place. The airway must be established, followed by initiation of assisted breathing. CPR is instituted only when breathing and circulation are compromised. In the unconscious athlete or if a cervical spine injury is suspected, the helmet must not be removed until the athlete has been transported to an appropriate facility and the cervical spine has been completely evaluated. McSwain NE, Garnelli, RL: Helmet removal from injured patients. Bull of Am Coll Surg 1997;82:42-44.

Question 3

A 23-year-old baseball pitcher who has diffuse pain along the posterior deltoid reports pain during late acceleration and follow-through. Examination of his arc of motion from external rotation to internal rotation at 90 degrees of shoulder abduction reveals a significant deficit in internal rotation when compared to the nonthrowing shoulder. Initial management should consist of

Explanation

Loss of internal rotation is common among overhead throwers and tennis players. Posterior capsular stretching can improve symptoms when accompanied by rest and gradual resumption of throwing. To avoid a false impression of improvement, cortisone injection is not recommended. Pitching through pain can cause further damage to the labrum and capsule. A sling and external rotator strengthening will not improve internal rotation. Kibler WB: Biomechanical analysis of the shoulder during tennis activities. Clin Sports Med 1995;14:79-85.

Question 4

A 54-year man has left shoulder pain and weakness after falling while skiing 4 months ago. Examination reveals full range of motion passively, but he has a positive abdominal compression test and weakness with the lift-off test. External rotation strength with the arm at the side and strength with the arm abducted and internally rotated are normal. MRI scans are shown in Figures 1a and 1b. Treatment should consist of

Explanation

1b The examination findings are consistent with subscapularis muscle weakness but normal supraspinatus and infraspinatus strength. The lift-off test and abdominal compression test are specific for subscapularis function. The MRI scan reveals a chronic avulsion and retraction of the subscapularis. The transverse image reveals a normal infraspinatus muscle, and the sagittal image reveals an atrophic subscapularis. Surgical repair of the isolated subscapularis tendon is indicated. Iannotti JP, Williams GR: Disorders of the Shoulder: Diagnosis and Management, ed 1. Philadelphia, PA, Lippincott Williams & Wilkins, 1999, pp 31-56.

Question 5

A 17-year-old high school long distance runner is seeking advice before running a marathon for the first time. What advice should be given regarding his fluid, carbohydrate, and electrolyte intake around the time of the race?

Explanation

The goal of fluid replenishment should be to replace the sweat that has been lost. Sweat is mostly water, with a small concentration of salts and other electrolytes. Absorption is enhanced by solutions of low osmolality. Scientific research has also shown that adding carbohydrates to the drink improves athletic performance. Carbohydrates such as glucose and maltodextrins (glucose polymers) stimulate fluid absorption by the intestines. Fructose slows intestinal absorption of fluids. Drinks that are high in fructose, such as orange juice, can lead to gastrointestinal distress and osmotic diarrhea. Kirkendall D: Fluids and electrolytes, in The U.S. Soccer Sports Medicine Book. Baltimore, MD, Williams and Wilkins, 1996.

Question 6

Figure 2 shows the radiograph of a 26-year-old auto mechanic who injured his right dominant elbow in a fall during a motocross race. Examination reveals pain and catching that limits his range of motion to 45 degrees of supination and 20 degrees of pronation. The interosseous space and distal radioulnar joint are stable. Management should consist of

Explanation

The radial head is an important secondary stabilizer of the elbow, helping to resist valgus forces. There has been a movement toward open reduction and internal fixation of the radial head when technically feasible, especially in a relatively high-demand athlete or laborer. The examination and radiograph suggest that displacement of the fragment is great enough to create a mechanical block. Extended splinting would only serve to encourage arthrofibrosis. Early range of motion is appropriate if there is minimal displacement of the radial head fragement, it is stable, and there is no mechanical block to motion. Fragments larger than one third of the joint surface should be excised only if it is not possible to reduce and repair the fragment. Primary excision of the radial head should be avoided if possible. Complications after excision of the radial head include muscle weakness, wrist pain, valgus elbow instability, heterotopic ossification, and arthritis. Hotchkiss RN: Displaced fractures of the radial head: Internal fixation or excision? J Am Acad Orthop Surg 1997;5:1-10.

Question 7

Figure 3 shows the clinical photograph of a wrestler who has an acute mass in his ear. He does not wear protective headgear. The area is mildly tender and without erythema. Management should consist of

Explanation

The patient has an auricular hematoma. This injury is typically related to blunt trauma, occuring in wrestlers who do not use protective headgear. The goal of treatment is to remove the fluid, reapproximate the perichondrium to the underlying articular cartilage, and limit reaccumulation of the fluid in attempt to prevent cartilage necrosis. Aspiration and application of a compressive dressing offers the best chance to achieve this goal. There are no signs of infection such as marked tenderness, erythema, or surrounding edema to justify antibiotic use or irrigation and debridement. The mass does not warrant excision. Kaufman BR, Heckler FR: Sports-related facial injuries. Clin Sports Med 1997;16:543-562.

Question 8

A patient with no history of patellar instability sustains a traumatic lateral patellar dislocation. What structure most likely has been torn?

Explanation

Any of the above structures may be involved in a lateral patellar dislocation. However, biomechanic studies have found that the medial patellofemoral ligament is the major soft-tissue static restraint of lateral patellar displacement, providing at least 50% of this function. Desio SM, Burks RT, Bachus KN: Soft tissue restraints to lateral patellar translation in the human knee. Am J Sports Med 1998;26:59-65. Conlan T, Garth WP Jr, Lemons JE: Evaluation of the medial soft-tissue restraints of the extensor mechanism of the knee. J Bone Joint Surg Am 1993;75:682-693.

Question 9

A 22-year-old swimmer underwent thermal capsulorrhaphy treatment for recurrent anterior subluxation. Following 3 weeks in a sling, an accelerated rehabilitation program allowed him to return to swimming in 3 1/2 months. While practicing the butterfly stroke, he sustained an anterior dislocation. He now continues to have symptoms of anterior instability and has elected to have further surgery. Surgical findings may include a

Explanation

Complications of thermal capsule shrinkage or accelerated rehabilitation include capsule ablation. Since the original surgery did not include labral reattachment, findings of a Bankart lesion or a glenoid fracture from a nontraumatic injury are unlikely. Subscapularis detachment or biceps subluxation is a postoperative complication of open repairs. Failure of early postoperative instability treatment should not produce loose bodies. Abrams JS: Thermal capsulorrhaphy for instability of the shoulder: Concerns and applications of the heat probe. Instr Course Lect 2001;50:29-36.

Question 10

A 12-year-old boy reports knee discomfort after prolonged strenuous activities. He denies knee swelling or catching and has no pain with activities of daily living. A radiograph is shown in Figure 4. Prognosis for the pathology shown is most influenced by

Explanation

While many factors play a role in the outcome of osteochondritis dissecans, ample evidence has shown that the prognosis is most influenced by the growth status of the plates. If the growth plates are open, the chance of a successful outcome is significantly greater than if they are closed. Federico DJ, Lynch JK, Jokl P: Osteochondritis dissecans of the knee: A historical review of etiology and treatment. Arthroscopy 1990;6:190-197.

Question 11

A 70-year-old golfer has pain in her dominant shoulder. She reports that initially the pain was at night but now she is unable to play. Examination reveals weakness in external rotation and shoulder abduction. Radiographs reveal the humeral head articulating with a thin acromion. Management should consist of

Explanation

Chronic rotator cuff tears should be nonsurgically managed initially with a strengthening program. A cortisone injection may reduce inflammation. Surgery is reserved for patients who continue to have pain and lose sleep despite the use of physical therapy. Blood tests for infection or inflammation are nonspecific. Arthroscopy may play a role, but surgical replacement is reserved for advanced cases. Bokor DJ, Hawkins RJ, Huckell GH, et al: Results of nonoperative management of full-thickness tears of the rotator cuff. Clin Orthop 1993;294:103-110.

Question 12

Which of the following structures is the most important restraint to posterior subluxation of the glenohumeral joint when positioned in 90 degrees of flexion and internal rotation?

Explanation

The posterior band of the inferior glenohumeral ligament is the most important restraint to posterior subluxation of the glenohumeral ligament with the shoulder in 90 degrees of flexion and internal rotation. With the shoulder in external rotation, the subscapularis is an important stabilizer to posterior subluxation. When the shoulder is in neutral rotation, the coracohumeral ligament is the primary stabilizer. The middle glenohumeral ligament functions primarily to resist anterior translation of the shoulder in the midrange of abduction. The supraspinatus muscle and tendon have relatively little contribution to anterior and posterior translation of the glenohumeral joint. Blasier RB, Soslowsky LJ, Malicky DM, Palmer ML: Posterior glenohumeral subluxation: Active and passive stabilization in a biomechanical model. J Bone Joint Surg Am 1997;79:433-440.

Question 13

A 50-year-old competitive tennis player sustained a shoulder dislocation after falling on his outstretched arm 3 weeks ago. He now reports that he has regained motion but continues to have painful elevation and weakness in external rotation. A subacromial cortisone injection provided 3 weeks of relief, but the pain has returned. Which of the following studies will best aid in diagnosis?

Explanation

Based on these findings, the most likely diagnosis is a rotator cuff injury and probable tear; therefore, MRI is the study of choice. CT is preferred for articular fractures. A bone scan is nonspecific and can identify inflammation or occult fracture. Joint aspiration is not likely to identify an effusion. Physical therapy and a functional capacity examination are used to identify weakness during recovery prior to a return to work or sports. Hawkins RJ, Bell RH, Hawkins RH, Koppert GJ: Anterior dislocation of the shoulder in the older patient. Clin Orthop 1986;206:192-195.

Question 14

In the arthroscopic photograph shown in Figure 5, the structure labeled "A" functions primarily as a restraint to translation of the humeral head in what direction?

Explanation

The superior glenohumeral ligament identified as "A" in the figure functions primarily as a restraint to inferior glenohumeral translation of the adducted arm. The middle glenohumeral ligament is highly variable and pooly defined in up to 40% of the population and functions to restrain anterior translation of the externally rotated arm in the midrange of abduction. The anterior band of the inferior glenohumeral ligament is the primary restraint to anterior/inferior translation of the head with the shoulder abducted to 90 degrees and in maximum external rotation. Ticker JB, Bigliani LU, Soslowskiy LJ, et al: Inferior glenohumeral ligament: Geometric and strain-rate dependent properties. J Shoulder Elbow Surg 1996;5:269-279.

Question 15

During the anterior approach for repair of a distal biceps tendon rupture, what structure, shown under the scissors in Figure 6, is at risk for injury?

Explanation

The most commonly injured neurovascular structure during an anterior approach for the repair of a distal biceps tendon rupture is the lateral antebrachial cutaneous nerve. This structure is located lateral to the biceps tendon and in a superficial location just deep to the subcutaneous layer. The antecubital vein is medial and superficial with the brachial artery and median nerve also medial to the biceps tendon but deep to the common flexors. The posterior interosseous nerve is deep within the supinator muscle and can be injured in the deep dissection or through the posterior approach when using a two-incision approach. Kelly EW, Morrey BF, O'Driscoll SW: Complications of repair of the distal biceps tendon with the modified two-incision technique. J Bone Joint Surg Am 2000;82:1575-1581.

Question 16

Which of the following variables has been shown to have the greatest influence on the higher rate of anterior cruciate ligament (ACL) tears in women when compared to men for similar sports?

Explanation

All of the variables have been proposed as possible causes for the increased incidence of ACL tears in women versus men. The general differences in the level of neuromuscular training however, specifically conditioning and muscle strength, have been shown to play the greatest role. Harmon KJ, Ireland ML: Gender differences in noncontact anterior cruciate ligament injuries. Clin Sports Med 2000;19:287-302. Arendt EA: Knee injury patterns among men and women in collegiate basketball and soccer. Am J Sports Med 1995;23:694-701.

Question 17

Figure 7 shows the MRI scan of a 23-year-old competitive rugby player who has anterior ankle pain and swelling. He states that he has been playing for many years and has sprained his ankle several times. Examination will reveal what specific hallmark feature?

Explanation

The history and MRI findings indicate the presence of anterior tibiotalar osteophytes. This is frequently observed in soccer, rugby, and football athletes who play on grass or turf surfaces and repetitively push off and change directions. Examination may reveal an effusion but no loss of subtalar motion. A positive external rotation (Klieger) test is described as pain at the distal ankle with external rotation of the foot and is observed in patients with syndesmosis sprains. This patient may have an increased anterior drawer because of a history of sprains; however, this finding is not specific for anterior impingement of tibiotalar osteophytes. The most specific finding on physical examination is pain with forced dorsiflexion. Ogilvie-Harris DJ, Mahomed N, Demaziere A: Anterior impingement of the ankle of the ankle treated by arthroscopic removal of bony spurs. J Bone Joint Surg Br 1993;75:437-440.

Question 18

A 21-year-old collegiate female cross-country athlete reports right hip pain that begins about 12 miles into a run, followed by pain resolution when she discontinues running. However, each time she tries to resume a running program, she experiences recurrence of pain deep in the anterior groin. A plain radiograph and MRI scan are shown in Figures 8a and 8b. Management should consist of

Explanation

8b The history is consistent with a stress fracture. Findings on the plain radiograph are marginal, but the MRI scan shows evidence of stress reaction in the medial neck of the femur (compression side). A lesion on the compression side is not normally at risk for displacement and usually can be managed nonsurgically. A bone scan would further identify the lesion but is not necessary. A skeletal survey and chest radiograph are used in staging a tumor. Radioisotope injection and guided biopsy are sometimes used for osteoid osteomas. Boden BP, Osbahr DC: High-risk stress fractures: Evaluation and treatment. J Am Acad Orthop Surg 2000;8:344-353.

Question 19

A 21-year-old football player who sustained a direct blow to the posterior hindfoot while making a cut is unable to bear weight on the injured foot. Examination reveals tenderness and swelling of the great toe metatarsophalangeal (MTP) joint. Radiographs are shown in Figures 9a and 9b. What is the most likely diagnosis?

Explanation

9b Turf toe occurs in collision and contact sports in which the athlete pushes off to accelerate or change direction and there is hyperextension of the great toe MTP joint. Typically, there is also axial loading of the posterior hindfoot, which increases the hyperextension of the MTP joint. The most common presentation is pain and swelling of the MTP joint and inability to hyperextend the joint without significant symptoms. With significant force, fractures of the sesmoids and plantar soft tissues can occur. The radiographs do not show a dislocation of the great toe MTP joint because it is concentrically located on both radiographs. However, the radiographs show a fracture of the lateral sesamoid or a diastasis of a bipartite lateral sesamoid. The medial sesamoid is also proximal indicating a rupture of the plantar (volar) plate. Therefore, the most likely diagnosis is a fracture of the lateral sesamoid with rupture of the plantar plate leading to proximal migration of the proximal fragment of the lateral sesamoid and the medial sesamoid. Rodeo SA, et al: Diastasis of bipartite sesamoids of the first metatarsophalangeal joint. Foot Ankle 1993;l4:425-434.

Question 20

Examination of an 18-year-old professional soccer player who was forcefully kicked across the shin while attempting a slide tackle reveals a marked effusion and limited motion of the knee. The tibia translates 12 mm posterior to the femoral condyles when the knee is held in 90 degrees of flexion. There is no posteromedial or posterolateral instability. Management should consist of

Explanation

The patient has an acute grade III posterior cruciate ligament injury. The majority of grade I and II injuries can be treated with protected weight bearing and quadriceps rehabilitation, and most patients can return to sports within 2 to 4 weeks. In contrast, grade III injuries require immobilization in full extension for 2 to 4 weeks to protect the posterior cruciate ligament and the other posterolateral structures presumed to be damaged. The mainstay of postinjury rehabilitation for all posterior cruciate ligament injuries is quadriceps strengthening exercises, which have been shown to counteract posterior tibial subluxation. Miller MD, Bergfeld JA, Fowler PJ, Harner CD, Noyes FR: The posterior cruciate ligament injured knee: Principles of evaluation and treatment. Instr Course Lect 1999;48:199-207.

Question 21

What type of injury is considered the major mechanism of cervical fracture, dislocation, and quadriplegia in contact sports and diving?

Explanation

A compression or burst injury occurs with vertical loading of the spine, such as from a blow to the vertex with the neck flexed (eg, spear tackling in football). This leads to vertebral end plate fractures before disk injury. At higher forces, the entire vertebra and disk may explode into the spinal canal. Analysis has shown this to be the major mechanism of cervical fracture, dislocation, and quadriplegia. With the normal head-up posture, the cervical spine has a gentle lordotic curve, and forces transmitted to the head are largely dissipated in the cervical muscles. When the neck is flexed, the cervical spine becomes straight, with the vertebral bodies lined up under one another. This allows for minimal dissipation of the impact forces to be absorbed by the neck muscles. Cantu RC: Head and spine injuries in youth sports. Clin Sports Med 1995;14:517-532. Proctor MR, Cantu RC: Head and neck injuries in young athletes. Clin Sports Med 2000;19:693-715.

Question 22

A 17-year-old high school football player injures his right ankle during a game. Examination reveals swelling and a closed ankle deformity, with normal foot circulation and sensation. Radiographs are shown in Figures 10a and 10b. In addition to closed reduction, management should include

Explanation

10b The examination and radiographs reveal a closed fracture-dislocation of the ankle with tibiofibular diastasis. Immediate fixation of the medial malleolus and plating of the fibula are indicated. If residual tibiofibular diastasis occurs with lateral translation of the fibula after plating, a syndesmotic screw is placed to stabilize the syndesmosis. Ankle fracture-dislocations associated with a proximal fibular fracture (Maisonneuve fracture) require syndesmotic fixation, but the fibula is not plated. Unstable ankle fractures require surgical treatment. If swelling is severe (fracture blisters, loss of skin wrinkling), a compressive splint is applied and surgery is delayed for 5 to 7 days. Browner BD, Jupiter JB, Levine AM, Trafton PG: Skeletal Trauma. Philadelphia, PA, WB Saunders, 1992, pp 1887-1957.

Question 23

Figure 11 shows a consecutive sequence of MRI scans obtained in a 12-year-old boy who has had increasing lateral knee pain and catching for the past 6 months. Examination reveals pain localized to the lateral joint line. Range-of-motion testing reveals a 5-degree lack of full extension on the involved side. Plain radiographs and laboratory values are within normal limits. What is the most appropriate management?

Explanation

Discoid menisci are rare causes of lateral knee pain in children. Various etiologies have been proposed, including failure of central absorption of the developing meniscus and hereditary transmission. Patients with discoid menisci have pain, clicking, and locking with a loss of active extension on range-of-motion testing. Classification of discoid menisci according to the Watanabe classification include complete, incomplete, and Wrisberg ligament type. The Wrisberg variant contains an abnormal posterior meniscal attachment. MRI is the diagnostic tool of choice, revealing a thick, flat meniscus generally seen in three consecutive MRI images. Symptomatic knees are often associated with a meniscal tear or degeneration and are managed with arthroscopic partial excision to a more normal shape (saucerization). Vandermeer RD, Cunningham FK: Arthroscopic treatment of the discoid lateral meniscus: Results of long-term follow-up. Arthroscopy 1989;5:101-109.

Question 24

A collegiate football player who sustained a blow to the head during the first quarter of a game is confused for several minutes after the hit but does not lose consciousness. He had two similar episodes in games earlier in the season. When should he be allowed to return to play?

Explanation

Using the traditional concussion grading scale, the patient sustained a grade I concussion because he did not lose consciousness and his abnormal cognitive level lasted less than 1 hour. If this was the player's first concussion, theoretically he could return to play later in the game provided that he had no confusion, headache, or associated symptoms. However, because it was the third concussion for the year, participation in contact sports should be terminated for the season. Guskiewwicz KM, Barth JT: Head injuries, in Schenk RC Jr (ed): Athletic Training and Sports Medicine. Rosemont, IL, American Academy of Orthopedic Surgeons, 1999, pp 143-167.

Question 25

For the athlete performing heavy exercise, the magnitude of core temperature and heart rate increase is most proportional to

Explanation

Studies examining the impact of graded water debt have clearly shown that the magnitude of core temperature and heart rate increase accompanying work are proportional to the magnitude of water debt at the onset of exercise. Though added thermal burden from hot climates is a factor, it appears to be less significant. Latzka WA, Montain SJ: Water and electrolyte requirements for exercise. Clin Sports Med 1999;18:513-524. Montain SJ, Sawka MN, Latzka WA, et al: Thermal and cardiovascular strain from hypohydration: Influence of exercise intensity. Int J Sports Med 1998;19:87-91.

Question 26

A 16-year-old female gymnast undergoes an anterior cruciate ligament reconstruction with a hamstring autograft. Which of the following accurately describes a known biomechanical or clinical consequence of choosing a hamstring autograft compared to a bone-patellar tendon-bone (BTB) autograft in this specific demographic?

Explanation

Hamstring autografts in young, high-activity female athletes have a significantly higher revision rate and graft rupture risk compared to BTB autografts. BTB is more frequently associated with higher anterior knee pain but offers better graft survivorship in this high-risk group.

Question 27

A 45-year-old male presents with acute medial knee pain and a "pop" felt while deep squatting. MRI reveals a medial meniscal posterior root tear with 4 mm of meniscal extrusion. If left untreated, this injury alters knee biomechanics most similarly to which of the following?

Explanation

A complete posterior root tear of the medial meniscus eliminates hoop stresses, resulting in tibiofemoral contact pressures equivalent to a total medial meniscectomy. This biomechanical failure leads to rapid progression of osteoarthritis if not surgically repaired.

Question 28

A 22-year-old rugby player presents with recurrent anterior shoulder dislocations. CT scan demonstrates an engaging Hill-Sachs lesion and 27% anterior glenoid bone loss. Which of the following is the most appropriate surgical management?

Explanation

Critical glenoid bone loss (>20-25%) in a collision athlete with recurrent anterior instability is an absolute indication for a bony augmentation procedure, such as the Latarjet procedure. Arthroscopic soft tissue stabilization has unacceptably high failure rates in this setting.

Question 29

A 25-year-old ice hockey player reports chronic anterior groin pain exacerbated by hip flexion and internal rotation. Radiographs demonstrate a crossover sign and an alpha angle of 70 degrees. During hip arthroscopy, addressing the femoral head-neck junction abnormality aims primarily to prevent which of the following?

Explanation

Cam morphology (alpha angle >55-60 degrees) causes abnormal shear forces on the anterosuperior acetabular cartilage during hip flexion and internal rotation. This repetitive impingement characteristically leads to chondral delamination and subsequent labral tears.

Question 30

A 28-year-old male strikes his knee on the dashboard during a motor vehicle collision. Examination reveals a grade III posterior drawer at 90 degrees of knee flexion. Which bundle of the torn ligament normally provides the primary restraint to posterior tibial translation at this flexion angle?

Explanation

The anterolateral bundle of the posterior cruciate ligament (PCL) is tightest in flexion and serves as the primary restraint to posterior tibial translation at 90 degrees. The posteromedial bundle is tightest in extension.

Question 31

A 22-year-old collegiate baseball pitcher presents with vague, deep posterior shoulder pain during the late cocking phase of throwing. Physical examination demonstrates a 25-degree deficit in internal rotation at 90 degrees of abduction compared to the contralateral side. What is the most appropriate initial management for this patient?

Explanation

Glenohumeral internal rotation deficit (GIRD) is a primary driver of internal impingement and secondary SLAP tears in overhead athletes due to a posterior peel-back mechanism. The cornerstone of initial management is a targeted stretching program (e.g., sleeper stretches) for the posterior capsule.

Question 32

A 25-year-old professional rugby player sustains an acute knee dislocation resulting in combined ACL and posterolateral corner (PLC) tears. On examination, he exhibits a complete foot drop. What is the most appropriate surgical management for the neurological deficit during his concurrent ligament reconstruction?

Explanation

Common peroneal nerve palsy associated with acute knee dislocation and PLC injury is a stretch injury rather than a transection. It is initially managed with exploration, neurolysis, and observation. Tendon transfers are reserved for patients with lack of functional recovery at 1 year.

Question 33

A 21-year-old hockey player presents with chronic groin pain exacerbated by hip flexion. A frog-leg lateral radiograph reveals an alpha angle of 65 degrees. Physical exam yields a positive FADIR test. The bony deformity associated with this condition is most likely caused by an abnormality located at which of the following sites?

Explanation

This patient has Cam-type femoroacetabular impingement (FAI), characterized by a reduced femoral head-neck offset. The aspherical bone formation is most commonly located at the anterolateral femoral head-neck junction.

Question 34

A 19-year-old collegiate pitcher fails conservative management for a full-thickness proximal ulnar collateral ligament (UCL) tear. He is indicated for surgical reconstruction. Which surgical technique has been shown to minimize the risk of postoperative ulnar neuropathy?

Explanation

The docking technique utilizes a muscle-splitting approach that avoids routine handling and transposition of the ulnar nerve. This significantly reduces the incidence of postoperative ulnar neuropathy compared to the classic figure-of-8 (Jobe) technique.

Question 35

A 45-year-old active female feels a "pop" in her posterior knee while descending stairs. MRI shows medial meniscus extrusion of 4 mm and a radial cleft at the posterior horn root. What are the biomechanical consequences of this specific injury if left untreated?

Explanation

A posterior medial meniscus root tear completely disrupts circumferential hoop stresses, rendering the meniscus functionally equivalent to a total meniscectomy. This drastically decreases tibiofemoral contact area and increases peak contact pressures, leading to rapid chondrolysis.

Question 36

A 24-year-old soccer player sustains an external rotation injury to his ankle. He has a positive squeeze test and radiographs show increased medial clear space on external rotation stress views. What is the primary ligamentous stabilizer of the distal tibiofibular syndesmosis that has been compromised?

Explanation

While the AITFL is the most commonly injured ligament in syndesmotic sprains, the posterior inferior tibiofibular ligament (PITFL) is the strongest. The PITFL contributes over 40% of the resistance to diastasis and is the primary stabilizer of the syndesmosis.

Question 37

A 26-year-old athlete undergoes a single-bundle posterior cruciate ligament (PCL) reconstruction for chronic symptomatic instability. To best recreate the primary functional bundle, where should the femoral tunnel be positioned?

Explanation

Single-bundle PCL reconstruction aims to recreate the larger and stronger anterolateral (AL) bundle. The anatomic femoral footprint for the AL bundle is located high on the anterolateral aspect of the medial femoral condyle.

Question 38

A 20-year-old collegiate football lineman presents with recurrent anterior shoulder dislocations. A 3D CT scan reveals 27% anterior glenoid bone loss and an "off-track" Hill-Sachs lesion. What is the most appropriate surgical intervention?

Explanation

Critical anterior glenoid bone loss (typically >20-25%) combined with an off-track Hill-Sachs lesion carries an unacceptably high failure rate with soft tissue stabilization alone. A bony augmentation procedure, such as the Latarjet procedure, is indicated.

Question 39

A 14-year-old gymnast complains of lateral elbow pain, clicking, and mechanical catching. Radiographs reveal a radiolucent lesion in the capitellum. MRI demonstrates fluid behind an osteochondral fragment, with an associated loose body. What is the recommended management?

Explanation

Unstable osteochondritis dissecans (OCD) lesions of the capitellum (indicated by fluid behind the lesion or loose bodies) in throwing athletes or gymnasts require surgical intervention. Excision of the fragment with microfracture of the bed is the standard treatment for smaller lesions.

Question 40

An 18-year-old hockey player sustains a concussion during a game. He rests for 3 days and becomes completely asymptomatic. According to current consensus guidelines (e.g., Berlin/Zurich), what is the prerequisite before he can begin a physical step-wise return-to-play protocol?

Explanation

Current concussion guidelines mandate a "return to learn before return to play" approach. The student-athlete must be able to tolerate full academic school activities without symptom exacerbation before initiating the physical step-wise return-to-sport protocol.

Question 41

A 17-year-old female soccer player is 9 months post-ACL reconstruction. Which of the following sets of objective criteria is most significantly associated with a reduced risk of graft rupture upon return to sport?

Explanation

Functional testing is paramount for assessing return-to-play readiness. A limb symmetry index (LSI) >90% on single-leg hop tests and isokinetic quadriceps strength correlates strongly with successful return to sport and drastically reduces re-injury risk compared to timeframes or static exams alone.

Question 42

A 25-year-old professional soccer player reports chronic, debilitating groin pain exacerbated by kicking, sprinting, and sit-ups. Pain radiates into the perineum. Resisted hip adduction reproduces the pain. MRI shows no intra-articular hip pathology. What is the most common anatomical pathology associated with this condition?

Explanation

The patient's presentation is classic for athletic pubalgia (core muscle injury). This condition most commonly involves tearing or attenuation of the conjoined tendon (internal oblique/transversus abdominis) and the rectus abdominis insertion at the pubic symphysis.

Question 43

A 30-year-old cyclist falls directly onto his shoulder. A Zanca view radiograph shows superior displacement of the distal clavicle measuring 200% compared to the contralateral side. The axillary view demonstrates the distal clavicle displaced posteriorly into the trapezius fascia. What is the Rockwood classification and appropriate treatment?

Explanation

Posterior displacement of the distal clavicle into or through the trapezius fascia defines a Rockwood Type IV acromioclavicular (AC) joint injury. Type IV injuries are universally recommended for operative stabilization.

Question 44

A 21-year-old collegiate basketball player complains of acute lateral foot pain after a pivot maneuver. Radiographs reveal a transverse fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal. What is the optimal initial management for this elite athlete?

Explanation

Acute Jones fractures (metaphyseal-diaphyseal junction of the 5th metatarsal) in elite athletes are optimally treated with early intramedullary screw fixation. This provides the highest union rates and fastest return to sport, minimizing the high nonunion risk seen with conservative care.

Question 45

A 28-year-old powerlifter feels a sharp "pop" in his anterior axilla while performing a one-rep max bench press. Examination reveals loss of the anterior axillary fold contour and marked weakness in internal rotation. At what location does the classic distal tear of this muscle typically occur?

Explanation

The patient has sustained a pectoralis major rupture. The most common site of injury in weightlifters performing the bench press is an avulsion of the tendon from its insertion site on the lateral lip of the bicipital groove of the humerus.

Question 46

A 16-year-old female experiences an acute lateral patellar dislocation while dancing, which spontaneously reduces. MRI demonstrates a complete, isolated tear of the medial patellofemoral ligament (MPFL). At what anatomical location does the MPFL most frequently tear in acute, primary patellar dislocations?

Explanation

In acute primary lateral patellar dislocations, the medial patellofemoral ligament (MPFL) most commonly fails at its femoral origin. This attachment is located in the anatomic saddle region between the adductor tubercle and the medial epicondyle.

Question 47

Six months following an ACL reconstruction using a bone-patellar tendon-bone autograft, a 22-year-old female athlete presents with a 15-degree extension deficit and an audible 'clunk' at terminal extension. MRI demonstrates a localized nodular soft-tissue mass anterior to the tibial tunnel within the intercondylar notch. What is the most appropriate definitive management?

Explanation

The clinical presentation and imaging are classic for a cyclops lesion (localized anterior arthrofibrosis). Arthroscopic excision is the definitive treatment to restore terminal extension.

Question 48

A 22-year-old collegiate rugby player with a history of multiple anterior shoulder dislocations presents for surgical evaluation. A 3D CT scan reveals 26% anterior glenoid bone loss. Which of the following surgical procedures is most appropriate to minimize his recurrence risk?

Explanation

Critical anterior glenoid bone loss (>20-25%) in a collision athlete results in a high failure rate with soft tissue stabilization alone. The Latarjet procedure (coracoid transfer) is the gold standard to restore the bony arc and provide a dynamic sling.

Question 49

A 28-year-old male presents with knee pain after sustaining a blow to the anteromedial tibia. Physical examination reveals a positive dial test showing 15 degrees of increased external rotation at 30 degrees of knee flexion compared to the contralateral knee. At 90 degrees of flexion, the external rotation normalizes to match the uninjured side. Which structure(s) is/are injured?

Explanation

Increased external rotation at 30 degrees of flexion that normalizes at 90 degrees indicates an isolated posterolateral corner (PLC) injury. Combined PCL and PLC injuries typically show increased external rotation at both 30 and 90 degrees.

Question 50

A 45-year-old male develops acute posterior knee pain after a deep squat. MRI reveals a complete radial tear at the posterior root of the medial meniscus with 4 mm of meniscal extrusion. What is the primary biomechanical consequence of leaving this injury untreated?

Explanation

A complete posterior root tear disrupts the circumferential hoop stresses of the meniscus. Biomechanically, this is equivalent to a total meniscectomy and leads to rapid deterioration of the medial compartment cartilage.

Question 51

A 19-year-old collegiate baseball pitcher complains of medial elbow pain during the late cocking and early acceleration phases of throwing. Valgus stress testing reproduces pain but reveals a firm endpoint. MRI demonstrates high-grade partial tearing of the ulnar collateral ligament (UCL). What is the most appropriate initial management?

Explanation

Initial management for partial UCL tears in throwing athletes is a period of rest (typically 6 weeks) to allow ligament healing, followed by physical therapy and a graduated return-to-throwing program. Surgery is reserved for complete tears or failed nonoperative management.

Question 52

During a medial patellofemoral ligament (MPFL) reconstruction for recurrent patellar instability, the surgeon uses fluoroscopy to identify Schöttle's point for the femoral tunnel. Where is this anatomic origin located radiographically?

Explanation

Schöttle's point describes the radiographic isometric origin of the MPFL. It is located just proximal and posterior to the medial epicondyle and slightly distal to the adductor tubercle.

Question 53

A 24-year-old professional hockey player presents with chronic groin pain exacerbated by hip flexion and internal rotation. Radiographs demonstrate an alpha angle of 75 degrees. Which of the following is true regarding this patient's pathomorphology?

Explanation

An elevated alpha angle (>50-55 degrees) is diagnostic of Cam-type femoroacetabular impingement (FAI). This pathomorphology indicates a loss of normal anterior femoral head-neck offset, leading to anterosuperior labral and chondral damage.

Question 54

A 21-year-old cross-country runner presents with severe, bilateral anterolateral leg pain that consistently occurs 15 minutes into running and resolves after 30 minutes of rest. Intracompartmental pressure testing reveals post-exercise pressures of 38 mmHg in the anterior compartment. What is the most definitive treatment?

Explanation

The patient has chronic exertional compartment syndrome (CECS) confirmed by elevated post-exercise pressures (>30 mmHg). Surgical release (fasciotomy) of the affected compartments provides the most definitive relief and allows return to sport.

Question 55

A 30-year-old downhill mountain biker crashes onto his shoulder. Radiographs reveal a 150% superior displacement of the distal clavicle relative to the acromion, with a significantly widened coracoclavicular interval. What is the correct Rockwood classification for this injury?

Explanation

A Rockwood Type V acromioclavicular separation involves disruption of the AC and CC ligaments along with the deltotrapezial fascia, leading to >100% to 300% superior displacement of the clavicle.

Question 56

A wide receiver sustains an ankle injury during a tackle. He is tender over the anterior inferior tibiofibular ligament and has pain with the external rotation stress test. Routine radiographs are negative for fracture. Which specific imaging finding would best dictate the need for surgical stabilization?

Explanation

Widening of the medial clear space (>4-5 mm) under external rotation stress indicates incompetence of the deep deltoid ligament and dynamic syndesmotic instability. This unstable 'high ankle sprain' warrants surgical fixation.

Question 57

A 65-year-old patient presents with a massive, chronically retracted tear of the supraspinatus and infraspinatus tendons. Electromyography demonstrates denervation potentials in the infraspinatus muscle. What is the predominant anatomic mechanism for this associated neuropathy?

Explanation

Massive, medially retracted posterosuperior rotator cuff tears alter the resting tension on the suprascapular nerve. The tethering effect primarily causes a traction neuropathy at the suprascapular notch due to 'bowstringing'.

Question 58

A 13-year-old female gymnast complains of vague lateral elbow pain. Radiographs show a radiolucency of the capitellum. MRI demonstrates a 1 cm osteochondral lesion with an intact overlying articular cartilage, no subchondral fluid, and open physes. What is the most appropriate initial management?

Explanation

Stable osteochondritis dissecans (OCD) lesions of the capitellum in patients with open physes have a high potential for healing. Nonoperative management with strict rest and cessation of loading is the standard initial treatment.

Question 59

A 35-year-old bodybuilder experiences a sharp pop in his anterior elbow during a heavy deadlift, followed by ecchymosis and weakness in forearm supination. He undergoes a single-incision anterior surgical repair of the distal biceps tendon. Which nerve is at greatest risk of iatrogenic injury during this specific surgical approach?

Explanation

The lateral antebrachial cutaneous nerve (LABC) is superficially located in the antecubital fossa and is the most commonly injured nerve during a single-incision anterior approach for distal biceps repair. The PIN is more at risk in the two-incision technique.

Question 60

A 16-year-old male diver reports 3 months of central low back pain that worsens with back extension. Oblique lumbar radiographs reveal a radiolucent line across the pars interarticularis of L5 (the 'collar on the Scotty dog'). Neurologic exam is normal. What is the recommended initial management?

Explanation

This adolescent athlete has symptomatic spondylolysis. First-line management is strictly nonoperative, emphasizing activity restriction, bracing (e.g., TLSO) to limit extension, and core-strengthening physical therapy.

Question 61

A 29-year-old male weightlifter felt a 'tearing' sensation in his anterior chest while attempting a maximal bench press. On examination, there is loss of the normal anterior axillary fold contour and significant weakness in internal rotation. Which anatomical location is most common for a complete pectoralis major rupture in this scenario?

Explanation

Pectoralis major ruptures typically occur during eccentric loading, such as the bottom phase of a bench press. The sternal head is placed under maximum tension in extension and external rotation, making it most susceptible to avulsion at or near its humeral insertion.

Question 62

A 25-year-old is brought to the emergency department after a severe hyperextension injury to his right knee during a motor vehicle collision. The knee is grossly unstable. The foot is pale and pulseless, and the Ankle-Brachial Index (ABI) is 0.6. Following a successful closed reduction of the knee, the pedal pulses remain absent. What is the critical next step?

Explanation

The patient exhibits 'hard signs' of vascular injury (pulselessness, pallor) and an ABI < 0.9 that persist after knee reduction. Immediate surgical exploration by vascular surgery is mandated to prevent limb ischemia; delaying for advanced imaging is contraindicated.

Question 63

A collegiate wide receiver sustains a forceful hyperextension injury to his first metatarsophalangeal (MTP) joint on artificial turf. He has severe plantar ecchymosis and a positive Lachman test of the MTP joint. MRI reveals a complete tear of the plantar plate with 1 cm proximal migration of the sesamoids. What is the most appropriate management?

Explanation

A Grade III turf toe injury involves complete disruption of the plantar plate with proximal sesamoid migration. In competitive athletes, surgical repair is indicated to restore push-off strength and prevent progressive hallux deformity.

Question 64

A 32-year-old recreational athlete undergoes minimally invasive repair of an acute mid-substance Achilles tendon rupture. Which postoperative rehabilitation protocol provides the best balance of minimizing re-rupture risk while optimizing functional outcomes?

Explanation

Modern evidence supports early functional rehabilitation protocols following Achilles tendon repair. Protected weight-bearing and controlled early range of motion improve tendon healing and functional scores without increasing the re-rupture rate compared to prolonged immobilization.

Question 65

A 16-year-old female presents with recurrent lateral patellar instability and is scheduled for a medial patellofemoral ligament (MPFL) reconstruction. During the procedure, the femoral tunnel is inadvertently placed too proximal and anterior to Schöttle's point. What is the primary biomechanical consequence of this malpositioning?

Explanation

Placing the femoral tunnel for MPFL reconstruction too proximal and anterior to Schöttle's point results in non-isometric behavior. This specifically causes increased graft tension during knee flexion, which can lead to postoperative stiffness, graft failure, or medial patellofemoral cartilage overload.

Question 66

A 19-year-old elite female soccer player undergoes primary anterior cruciate ligament (ACL) reconstruction. Which of the following clinical scenarios is considered the strongest indication for adding a concomitant lateral extra-articular tenodesis (LET) or anterolateral ligament (ALL) reconstruction?

Explanation

Indications for concomitant LET or ALL reconstruction during ACL reconstruction include a high-grade pivot shift, chronic ACL deficiency, young age (<20 years) with high-level pivot-shift sports participation, and revision ACL reconstruction.

Question 67

A 21-year-old collegiate baseball pitcher presents with medial elbow pain and decreased pitching velocity. MRI demonstrates a high-grade partial tear of the distal ulnar collateral ligament (UCL). During UCL reconstruction using a docking technique, where must the ulnar bone tunnel be placed to accurately recreate the native ligament footprint?

Explanation

The anterior bundle of the native UCL is the primary restraint to valgus stress, and its distal insertion is located along the sublime tubercle of the ulna. The ulnar bone tunnels in UCL reconstruction should be placed precisely at this anatomical footprint to restore joint kinematics.

Question 68

A 25-year-old rugby player sustains an acute, ultra-low velocity knee dislocation. After emergent closed reduction, the patient has palpable but diminished pedal pulses. An ankle-brachial index (ABI) is measured at 0.85. What is the most appropriate next step in management?

Explanation

An ABI less than 0.90 in the setting of a knee dislocation is highly suggestive of a vascular injury, even if pulses are palpable. CT angiography is immediately indicated to definitively evaluate the popliteal artery and plan potential surgical or endovascular intervention.

Question 69

A 19-year-old female collegiate cross-country runner presents with an insidious onset of right groin pain. Plain radiographs are negative. An MRI reveals a tension-sided stress fracture extending 30% across the superior aspect of the right femoral neck. What is the most appropriate management?

Explanation

Tension-sided (superior) femoral neck stress fractures are mechanically unstable and carry a high risk of catastrophic displacement, which can lead to avascular necrosis of the femoral head. Prophylactic percutaneous in situ screw fixation is the standard of care to prevent displacement.

Question 70

A 22-year-old marathon runner complains of progressive bilateral anterolateral leg pain that reliably occurs after running 3 miles and resolves within 30 minutes of rest. Resting anterior compartment pressure is 18 mmHg. Which of the following post-exercise pressure measurements would confirm a diagnosis of chronic exertional compartment syndrome (CECS)?

Explanation

According to the Pedowitz criteria, CECS is confirmed by a resting pressure ≥ 15 mmHg, a 1-minute post-exercise pressure ≥ 30 mmHg, or a 5-minute post-exercise pressure ≥ 20 mmHg. A 1-minute pressure of 35 mmHg meets the diagnostic threshold.

Question 71

A 24-year-old professional football player sustains an acute ACL tear. MRI also demonstrates an avulsion of the posterior horn of the lateral meniscus directly from its tibial root attachment. If left completely untreated, the biomechanical consequence of this meniscal injury most closely mimics that of:

Explanation

A meniscal root tear disrupts the crucial hoop stresses of the meniscus, leading to radial extrusion under axial load. Biomechanically, an untreated root tear results in tibiofemoral contact pressures that are nearly equivalent to those seen after a total meniscectomy.

Question 72

A 20-year-old male collegiate hockey player presents with recurrent anterior shoulder instability. A 3D CT scan reconstruction demonstrates 25% anterior glenoid bone loss and a small off-track Hill-Sachs lesion. What is the most appropriate surgical management?

Explanation

In a collision athlete with critical anterior glenoid bone loss (>20-25%), isolated soft tissue repair has an unacceptably high failure rate. A bone-block augmentation procedure, such as the Latarjet procedure, is indicated to restore glenoid tracking and anterior stability.

Question 73

A 23-year-old wide receiver sustains an external rotation injury to his right ankle. Examination reveals tenderness extending 5 cm proximally over the anterior inferior tibiofibular ligament (AITFL). A gravity stress radiograph demonstrates 6 mm of medial clear space widening. What is the most appropriate treatment?

Explanation

Medial clear space widening greater than 4-5 mm on stress radiographs indicates dynamic syndesmotic instability combined with deltoid ligament incompetence. Operative stabilization of the syndesmosis (via screws or suture button) is required to restore joint congruity and prevent post-traumatic arthritis.

Question 74

A 45-year-old male competitive water skier sustains a forced hyperflexion injury of the hip with the knee fully extended. He experiences severe deep buttock pain, extensive posterior thigh ecchymosis, and a palpable defect at the ischial tuberosity. MRI reveals a complete 3-tendon proximal hamstring avulsion with 4 cm of distal retraction. What is the recommended management?

Explanation

Acute surgical repair (ideally within 3-4 weeks) is strongly indicated for complete, 3-tendon proximal hamstring avulsions, particularly those retracted more than 2 cm in active individuals. Early repair restores strength and prevents chronic sciatic nerve tethering.

Question 75

A 28-year-old NFL running back sustains a severe hyperextension injury to his great toe. Examination reveals marked ecchymosis, profound swelling, and frank instability of the first metatarsophalangeal (MTP) joint with dorsal translation during Lachman testing. MRI confirms a complete tear of the plantar plate. What is the optimal treatment?

Explanation

This clinical picture describes a Grade 3 turf toe injury, characterized by complete disruption of the plantar plate and joint instability. In an elite athlete whose position demands explosive push-off, primary surgical repair is indicated to restore anatomy and function.

Question 76

A 20-year-old collegiate basketball player sustains an acute, non-displaced fracture at the metaphyseal-diaphyseal junction of the 5th metatarsal (Zone 2). To minimize the risk of nonunion and expedite his return to competitive play, what is the most appropriate intervention?

Explanation

Zone 2 fractures of the fifth metatarsal (Jones fractures) occur in a vascular watershed area and have a high propensity for delayed union or nonunion. In elite athletes, early intramedullary screw fixation is recommended to significantly decrease healing time and expedite return to sport.

Question 77

A 14-year-old male competitive gymnast presents with lateral elbow pain and mechanical catching. Radiographs show a radiolucent lesion of the capitellum. An MRI demonstrates a 12 mm osteochondral defect with a rim of high T2 signal fluid tracking completely behind the lesion. What is the recommended treatment?

Explanation

The presence of fluid tracking completely behind an osteochondral lesion of the capitellum on a T2-weighted MRI indicates an unstable fragment. Since the patient is symptomatic and the lesion is structurally unstable, surgical intervention (fixation or OATS) is required.

Question 78

A 32-year-old recreational basketball player sustains an acute mid-substance Achilles tendon rupture. He elects to pursue nonoperative management. Which of the following rehabilitation protocols is associated with a re-rupture rate that most closely approaches that of surgical repair?

Explanation

Modern evidence demonstrates that early functional rehabilitation—incorporating early protected weight-bearing in a functional brace—significantly reduces the re-rupture rate in nonoperatively managed Achilles tendon ruptures, making the outcomes comparable to operative repair.

Question 79

A 15-year-old female gymnast complains of an insidious onset of mechanical lower back pain that is notably exacerbated by lumbar extension. Oblique lumbar radiographs reveal a lucency at the pars interarticularis of L5. What is the recommended initial management?

Explanation

The patient presents with symptomatic spondylolysis. The standard initial treatment for uncomplicated spondylolysis in a young athlete consists of cessation of the offending activity, temporary bracing, and a physical therapy regimen focused on core and pelvic stabilization.

Question 80

A 45-year-old active male presents with acute medial knee pain after a deep squat. MRI reveals a complete radial tear at the posterior root of the medial meniscus with 4 mm of meniscal extrusion. What is the primary biomechanical consequence if this injury is left untreated?

Explanation

A complete posterior root tear of the medial meniscus disrupts hoop stresses, rendering the meniscus nonfunctional. Biomechanically, this results in peak tibiofemoral contact pressures equivalent to those seen after a total meniscectomy.

Question 81

A 22-year-old rugby player has recurrent anterior shoulder instability. A 3D CT scan demonstrates a 25% anterior glenoid bone loss and a non-engaging Hill-Sachs lesion. Which of the following is the most appropriate surgical intervention for this athlete?

Explanation

In high-demand collision athletes with critical anterior glenoid bone loss (typically >20-25%), isolated soft tissue repairs have an unacceptably high failure rate. The Latarjet procedure (coracoid transfer) is the gold standard to restore stability.

Question 82

A 10-year-old Tanner stage 1 male sustains a complete midsubstance ACL tear. His physes are widely open. What is the most appropriate graft choice and surgical technique to minimize the risk of growth arrest?

Explanation

In prepubescent children (Tanner stage 1 or 2) with widely open physes, transphyseal drilling risks growth arrest. A physeal-sparing technique, such as an IT band autograft routed over-the-top, safely restores stability while protecting the growth plates.

Question 83

A 20-year-old collegiate baseball pitcher presents with medial elbow pain and decreased pitching velocity. MRI arthrogram shows a partial tear of the ulnar collateral ligament (UCL) at its distal attachment. After failure of non-operative management, UCL reconstruction is planned. Which nerve is most at risk during this surgical procedure?

Explanation

The ulnar nerve courses immediately posterior to the medial epicondyle in the cubital tunnel and is highly vulnerable during UCL reconstruction. Surgeons must carefully protect it, often requiring neurolysis or anterior transposition.

Question 84

A 26-year-old ice hockey player presents with insidious onset of anterior groin pain exacerbated by hip flexion and internal rotation. Radiographs demonstrate a crossover sign and an alpha angle of 70 degrees. What is the predominant pathomorphology causing his symptoms?

Explanation

The crossover sign indicates acetabular retroversion (Pincer morphology), while an alpha angle greater than 50-55 degrees indicates femoral head-neck junction asphericity (Cam morphology). Therefore, this patient has combined Cam and Pincer impingement.

Question 85

A 30-year-old female skier sustains a high-energy knee dislocation. Examination reveals absent ACL, PCL, and posterolateral corner (PLC) function. She has palpable but slightly diminished distal pulses. Which of the following is the most crucial step in her immediate post-injury management prior to any operative planning?

Explanation

Vascular injury (specifically the popliteal artery) is a limb-threatening complication of knee dislocations. Measurement of ABI is mandatory; an ABI less than 0.9 necessitates a CT angiogram or immediate vascular surgery consultation.

Question 86

A 28-year-old mountain biker falls directly onto his shoulder and sustains a type V acromioclavicular (AC) joint separation. Which of the following best describes the structural disruption seen in this specific injury pattern?

Explanation

A Rockwood Type V AC joint injury involves complete disruption of the AC ligaments, the coracoclavicular (CC) ligaments, and extensive tearing of the deltotrapezial fascia. This results in greater than 100% superior displacement of the clavicle.

Question 87

A 35-year-old male presents with acute posterior ankle pain and a palpable gap in the Achilles tendon. If non-operative management is chosen, which rehabilitation protocol yields re-rupture rates most comparable to operative repair?

Explanation

Recent high-quality evidence shows that early functional rehabilitation protocols (early weight-bearing and ROM in a functional brace) for non-operatively managed Achilles ruptures yield re-rupture rates statistically similar to surgical repair.

Question 88

A 60-year-old male presents with a massive, irreparable posterosuperior rotator cuff tear and pseudoparalysis. He has minimal glenohumeral arthritis. Superior capsular reconstruction (SCR) is planned. The graft used in SCR primarily acts to prevent which of the following kinematic abnormalities?

Explanation

Superior capsular reconstruction (SCR) utilizes a graft attached from the superior glenoid to the greater tuberosity. Its primary biomechanical role is to prevent superior migration of the humeral head, thereby restoring a stable fulcrum for the deltoid.

Question 89

A 24-year-old football player complains of posterior knee pain and instability. Examination demonstrates a positive posterior drawer test and increased external rotation of the tibia at both 30 and 90 degrees of knee flexion compared to the uninjured side. What is the most likely diagnosis?

Explanation

Increased tibial external rotation at both 30 and 90 degrees of flexion indicates a combined PCL and posterolateral corner (PLC) injury. An isolated PLC injury typically demonstrates increased external rotation only at 30 degrees.

Question 90

A 20-year-old cross-country runner presents with bilateral, deep, aching anterior leg pain that occurs 15 minutes into a run and resolves with rest. According to the Pedowitz criteria, which of the following intracompartmental pressure measurements is diagnostic for chronic exertional compartment syndrome (CECS)?

Explanation

The Pedowitz criteria for diagnosing chronic exertional compartment syndrome include a pre-exercise pressure >15 mm Hg, a 1-minute post-exercise pressure >30 mm Hg, or a 5-minute post-exercise pressure >20 mm Hg.

Question 91

A 16-year-old female dancer has recurrent lateral patellar dislocations. Her tibial tubercle-trochlear groove (TT-TG) distance is measured at 22 mm on MRI. She has normal patellar height. Which surgical procedure addresses her specific anatomic risk factor?

Explanation

A TT-TG distance >20 mm is considered pathologic and mechanically lateralizes the extensor mechanism. A medializing tibial tubercle osteotomy (often combined with MPFL reconstruction) directly corrects this abnormal lateral force vector.

Question 92

A 25-year-old professional baseball pitcher presents with pain in the late cocking phase of throwing. MRI reveals a peel-back SLAP lesion. What biomechanical alteration in the thrower's shoulder is most closely associated with the pathogenesis of this specific lesion?

Explanation

GIRD involves posteroinferior capsular contracture, shifting the glenohumeral contact point posterosuperiorly during maximum external rotation. This shift dramatically increases the peel-back forces on the superior labrum and biceps anchor, causing SLAP tears.

Question 93

A 40-year-old weightlifter requires a distal biceps tendon repair. If the surgeon opts for a traditional two-incision (Boyd-Anderson) technique rather than a single anterior extensile approach, the patient is at a relatively higher risk for which of the following complications?

Explanation

The two-incision technique was historically designed to minimize injury to the lateral antebrachial cutaneous nerve commonly seen with the single-incision approach. However, the muscle-splitting dissection significantly increases the risk of heterotopic ossification and radioulnar synostosis.

Question 94

A 22-year-old soccer player has a symptomatic 3.5 cm^2 full-thickness chondral defect on the weight-bearing surface of the medial femoral condyle. He has failed conservative management. Which cartilage restoration technique is most appropriate?

Explanation

Autologous chondrocyte implantation (ACI) is indicated for large (>2 to 4 cm^2) full-thickness chondral defects in young, active patients. Microfracture and OATS are typically reserved for smaller defects (usually <2 cm^2).

Question 95

A 19-year-old collegiate football linebacker presents with recurrent anterior shoulder instability. A 3D computed tomography scan reveals 25% anterior glenoid bone loss and a Hill-Sachs lesion that engages the anterior glenoid rim in abduction and external rotation ("off-track"). Which of the following is the most appropriate surgical management?

Explanation

In collision athletes with recurrent anterior shoulder instability and critical anterior glenoid bone loss (>20-25%), an isolated Bankart repair has an unacceptably high failure rate. A coracoid process transfer (Latarjet procedure) is the preferred treatment to restore stability through its unique triple-blocking effect. A Bankart repair with remplissage is typically reserved for "off-track" lesions with subcritical (<15-20%) glenoid bone loss.

General Orthopedics 2026 Practice Questions: Set 13 (Solved)

Orthopedic Sports Medicine 2026 MCQs: Board Review Questions & Answers (Part 1)

Key Takeaway

Orthopedic Sports Medicine 2026 MCQs: Board Review Questions & Answers (Part 1)

Chapter Index