Orthopedic Sports Medicine 2026 Board MCQs (Part 2)

Question 1

Initial repair of the large U-shaped rotator cuff tear shown in Figure 12 consists of closing the tear side-to-side to take advantage of margin convergence. The most significant biomechanical consequence of this repair step results in

Explanation

Margin convergence refers to the phenomenon that occurs with side-to-side closure of large U- or L-shaped rotator cuff tears in which the free margin of the tear converges toward the greater tuberosity as the side-to-side tear progresses. The creation of the converged cuff margin creates decreased strain in the free margin of the repaired cuff, resulting in a decreased strain in the repair sutures. While the size of the humeral head defect is made smaller with side-to-side closure, biomechanically, this is less significant. The mild increase in thickness of the repair at the side-to-side margin is less important than a reduction in stress in the repaired tissue. Stress in the crescent cable region of the cuff actually increases and becomes more physiologic in transmitting force from the cuff to the greater tuberosity. Burkhart SS: A stepwise approach to arthroscopic rotator cuff repair based on biomechanical principles. Arthroscopy 2000;16:82-90.

Question 2

A 15-year-old athlete collapses suddenly during practice and dies. What is the most likely cause of death?

Explanation

The number one cause of sudden death in the young athlete is myocardial pathology, with hypertrophic cardiomyopathy being most common. Because of cardiac muscle hypertrophy, the ventricular capacity is diminished and can result in decreased cardiac output. During exertional activities, the increased demand may not be able to be met and leads to sudden death. While the other choices can be the cause of sudden death in an otherwise healthy young athlete, their incidence is even more rare. Van Camp SP, Bloor CM, Mueller FO, et al: Nontraumatic sports death in high school and college athletes. Med Sci Sports Exerc 1995;27:641-647. Maron BJ, Shirani J, Pollac LC, et al: Sudden death in young competitive athletes: Clinical, demographic, and pathological profiles. JAMA 1996;276:199-204.

Question 3

A 17-year-old football player continues to have discomfort after sustaining a blow to his midthigh during a game 8 weeks ago. A plain radiograph is shown in Figure 13. What is the most appropriate management?

Explanation

The patient has myositis ossificans. Rest of the involved area is important to help limit the continued irritation of the muscle, but range-of-motion exercises are important to limit stiffness. While immobilization for 1 or 2 days following a muscle contusion is appropriate, longer periods of immobilization result in muscle atrophy and fibrosis. Injections and irradiation have not been found to be of benefit for myositis ossificans. Excision is rarely required, and if performed, it should not be performed prior to maturation of the lesion, which is a minimum of 6 months. Lipscomb AB, Thomas ED, Johnston RK: Treatment of myositis ossificans traumatica in athletes. Am J Sports Med 1976;4:111-120. Beiner JM, Jokl P: Muscle contusion injuries: Current treatment options. J Am Acad Orthop Surg 2001;9:227-237.

Question 4

When standing, dorsiflexion of the great toe will accentuate

Explanation

Dorsiflexion of the great toe will accentuate rigidity of the transverse tarsal articulation. Through the windlass mechanism, dorsiflexion of the great toe tightens the plantar fascia, stabilizing the longitudinal arch and placing the foot in supination. Supination makes the talonavicular and calcaneocuboid joints nonparallel, accentuating the rigidity of the transverse tarsal articulation. The heel also tends to go into varus, resulting in obligatory external tibial rotation. Mann RA: Biomechanics of the foot and ankle, in Mann RA, Coughlin MJ (eds): Surgery of the Foot and Ankle, ed 6. St Louis, MO, Mosby, 1993, pp 1-44.

Question 5

A 26-year-old professional rodeo bull rider sustained a grade III midshaft femoral fracture after being thrown from his bull. He underwent closed interlocking intermedullary nailing with a titanium rod, and his recovery was uneventful. Prior to returning to competition, the patient must

Explanation

While it is recommended that a patient gain full range of motion, pain-free function, and symmetric strength prior to returning to vigorous activities, it is absolutely essential that radiographs of the fracture site reveal a circumferential external bridging callus to prevent refracture. This is particularly important for comminuted femoral fractures with various sized fragments. It is also recommended that a return to rodeo riding be postponed for at least 1 year. Brumback RJ, Ellison TS: Intermedullary nailing of femoral stress fractures. J Bone Joint Surg Am 1992;74:106-112. Bucholz RW, Jones A: Fractures of the shaft of the femur. J Bone Joint Surg Am 1991;73:1561-1566.

Question 6

A 19-year-old soccer player feels a pop in his knee while making a cut and notes the development of an effusion over several hours. Examination reveals medial joint line tenderness, but the knee is stable to manual stress testing of all ligaments. Examination under anesthesia confirms a stable knee. What is the most critical factor in determining healing after repair of the lesion shown in Figure 14?

Explanation

Numerous clinical and basic science investigations have evaluated meniscal tear characteristics to identify factors that either promote or mitigate against meniscal healing. Complex tears have been noted to heal poorly, while longitudinal tears heal more predictably. Tear length, time from injury to repair, medial versus lateral meniscal tears, and the use of a fibrin clot have not been shown to consistently affect meniscal healing. However, rim width, the distance of the tear site from the peripheral meniscocapsular junction (vascular supply), has been shown to have a significant role in the ability of a meniscus repair to heal. DeHaven KE, Arnoczky SP: Meniscus repair: Basic science, indications for repair, and open repair. Instr Course Lect 1994;43:65-76.

Question 7

Which of the following tissues has the highest maximum load to failure?

Explanation

All of the tissues noted above are stronger than native ACL. Although it is often thought that the bone-patellar tendon-bone graft is the strongest when selecting a graft source for ACL reconstruction, biomechanical studies show that the quadruple semitendinosus and gracilis tendons are the strongest of the tissues listed. Woo SL, Hollis JM, Adams DJ, et al: Tensile properties of the human femur-anterior cruciate ligament-tibia complex: The effects of specimen age and orientation. Am J Sports Med 1991;19:217-225. Staubli HU, Schatzmann L, Brunner P, et al: Quadriceps tendon and patellar ligament cryosectional anatomy and structural properties in young adults. Knee Surg Sports Traumatol Arthrosc 1996;4:100-110.

Question 8

A 20-year-old basketball player has tenderness and bruising after sustaining a blow to the knee. A radiograph is shown in Figure 15. What is the most likely diagnosis?

Explanation

The patient has a bipartite patella. The line between the fragment and the main patella is smooth and sclerotic, indicating a chronic, not acute, entity. The location is classic for a bipartite patella, not a tumor. Schmidt DR, Henry JH: Stress injuries of the adolescent extensor mechanism. Clin Sports Med 1989;8:343-355.

Question 9

Reconstruction of the posterior cruciate ligament (PCL) via the inlay technique involves exposure of the PCL tibial insertion site by a posterior

Explanation

The posterior medial approach through the semimembranosus/medial gastrocnemius interval is used in the inlay technique for PCL reconstruction. Exposure of the posterior capsule of the knee through this interval provides the greatest margin of safety to avoid injury to the tibial nerve, motor branch of the medial gastrocnemius, and the peroneal nerve. The direct posterior approach using the medial sural cutaneous nerve allows exposure of the popliteal neurovascular structures, but deep dissection through this interval places the motor branch of the medial gastrocnemius at risk. The interval between the semitendinosus and semimembranosus is used in accessory incisions with medial meniscus repairs but does not allow exposure of the PCL insertion. Berg EE: Posterior cruciate tibial inlay reconstruction. Arthroscopy 1995;11:69-76.

Question 10

A 36-year-old recreational tennis player sustains the injury shown in Figure 16. Management should consist of

Explanation

The MRI scan shows a rupture of the patellar tendon. This injury is most appropriately addressed with primary repair. For athletic individuals, the results of nonsurgical management are suboptimal. Reconstructive procedures are not necessary. Matava MJ: Patellar tendon ruptures. J Am Acad Orthop Surg 1996;4:287-296.

Question 11

Figure 17 shows the clinical photograph of a 45-year-old female tennis player who has right arm pain and weakness with elevation after undergoing a cervical biopsy several months ago. The cause of her shoulder weakness is damage to the

Explanation

The patient has primary scapulotrapezius winging caused by surgical damage to the spinal accessory nerve during a lymph node biopsy. Other causes include blunt trauma, traction, and penetrating injuries. With spinal accessory palsy, the shoulder appears depressed and laterally translated because of unopposed serratus anterior muscle function. With primary serratus anterior winging that is the result of long thoracic nerve palsy, the scapula assumes a position of elevation and medial translation with the inferior angle rotated medially. The thoracodorsal nerve innervates the latissimus dorsi and is not associated with scapular winging. Kuhn JE, Plancher KD, Hawkins RJ: Scapular winging. J Am Acad Orthop Surg 1995;3:319-325.

Question 12

A collegiate rower reports the sudden onset of right chest pain while rowing. The athlete states that the pain is worse with deep inspiration and coughing. Examination reveals localized tenderness over the posterolateral corner of the eighth rib. What is the most likely diagnosis?

Explanation

A rib stress fracture, the most common injury to the thorax in rowing athletes, generally occurs during periods of intense training with a low stroke rate and heavy loads. It is characterized by the sudden onset of sharp, localized chest pain while rowing. The fifth through the ninth rib is generally affected, and the diagnosis is best established with a bone scan. An intercostal muscle strain generally has an insidious onset and may be poorly localized. Costochondritis affects the anterior costochondral junction. A pneumothorax and an empyema can cause nonlocalized chest pain but are associated with respiratory distress and systemic physical findings. Karlson KA: Rib stress fractures in elite rowers. Am J Sports Med 1998;26:516-520.

Question 13

Figures 18a and 18b show the radiographs of a 13-year-old baseball player who sustained a patellar dislocation with an associated lateral femoral condyle fracture. What ligament is attached to this fragment?

Explanation

18b The anterior cruciate ligament is attached to a portion of the lateral femoral condyle. The posterior cruciate ligament attaches to the medial femoral condyle. The lateral collateral and oblique popliteal ligaments attach proximal to this fragment. The intermeniscal ligament attaches the anterior horns of the menisci. Jobe CM, Wright M: Anatomy of the knee, in Fu FH, Harner CD, Vince KG (eds): Knee Surgery. Baltimore, MD, Williams & Wilkins, 1994, pp 1-54.

Question 14

Which of the following substances does not have androgenic effects?

Explanation

Growth hormone is the most abundant substance produced by the pituitary gland. Growth hormone has a direct anabolic effect by accelerating the incorporation of amino acids into proteins. It is becoming an increasingly popular anabolic steroid substitute; however, it is expensive and difficult to obtain. Androstenedione is an androgen produced by the adrenal glands and gonads. It acts as a potent anabolic steroid and is converted in the liver directly to testosterone with a resultant increase in levels after administration. DHEA is a naturally occurring hormone made by the adrenal cortex. It is converted to androstenedione, which in turn is converted to testosterone. The beneficial and adverse effects of DHEA can be correlated directly with those of testosterone. Nandrolone is also a potent anabolic steroid. It is commonly taken as 19-norandrostenedione and may be more favored because of its potent anabolic effects with less androgenic effects (no conversion to estrogen compounds). Creatine sales have skyrocketed, and it is a popular nutritional supplement. There is an expectation that creatine can increase strength and power performance; however, direct anabolic effects have not been demonstrated. Creatine serves as a substrate for hydrogen ions and contributes to the resynthesis of ATP (adenosine triphosphate) during maximal exercise. By enhancing ATP production and buffering local pH in muscle, there may be improved tolerance of anaerobic activities. Increases in muscle mass may be related to increased perception of improved training ability or an increase in muscle water content. Silver M: Use of ergogenic aids by athletes. J Am Acad Orthop Surg 2001;9:61-70.

Question 15

A superior labrum anterior and posterior (SLAP) lesion doubles the strain in which of the following stabilizing structures?

Explanation

A superior labrum, when intact, stabilizes the shoulder by increasing its ability to withstand excessive external rotational forces by an additional 32%. The presence of a SLAP lesion decreases this restraint and increases the strain in the superior band of the inferior glenohumeral ligament by over 100%. Rodosky MW, Harner CD, Fu FH: The role of the long head of the biceps muscle and superior glenoid labrum in anterior stability of the shoulder. Am J Sports Med 1994;22:121-130.

Question 16

What is the principal advantage of surgical repair for the lesion shown in Figure 19?

Explanation

The MRI scan shows a rupture of the Achilles tendon. The substantiated advantages of repair are less risk of re-rupture and greater plantar flexion strength. Dorsiflexion strength is not influenced. Motion, pain, and period of recovery are not specifically improved as a consequence of surgery. Bhandari M, Guyatt GH, Siddiqui F, et al: Treatment of acute Achilles tendon ruptures: A systematic overview and meta-analysis. Clin Orthop 2002;400:190-200.

Question 17

An 18-year-old high school football player sustains a left posterior hip dislocation that is reduced in the emergency department under IV sedation. Postreduction radiographs reveal a concentric reduction with no evidence of fracture or loose bodies within the joint. What is the most common complication of hip dislocations?

Explanation

Traumatic dislocation of the hip in sports injuries is uncommon, and 85% to 92% occur in a posterior direction. In dislocations without fractures, osteonecrosis is the most common complication occurring in 10% to 20% of patients. MRI should be performed at 3 months postreduction to rule out osteonecrosis. Nerve injuries are rare in this setting, and recurrent dislocations are unusual without acetabular fractures. Chondrolysis has been reported as a rare occurrence. Anderson K, Strickland S, Warren R: Hip and groin injures in athletes. Am J Sports Med 2001;29:521-533.

Question 18

A high school athlete reports the sudden onset of low back pain while performing a dead lift. Examination reveals lumbar paraspinal spasm and a positive straight leg raising test. Deep tendon reflexes, motor strength, and sensation in the lower extremities are normal. Radiographic findings are normal. If symptoms persist for longer than a few weeks, what is the best course of action?

Explanation

In the adolescent population, a lumbar herniated disk is characterized by a paucity of clinical findings, with a positive straight leg raising test the only consistently positive finding. This may result in a prolonged 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. An adolescent who lifts weights and has a history of back pain that fails to respond to a short period of active rest should undergo MRI evaluation for the diagnosis of a lumber herniated disk. Epstein JA, Epstein NE, Marc J, et al: Lumbar intervertebral disk herniation in teenage children: Recognition and management of associated anomalies. Spine 1984;9:427-432.

Question 19

Examination of a 23-year-old female college basketball player who has had anterior knee pain for the past 3 weeks reveals tenderness and fullness over the inferior patella and proximal patellar tendon. There is no patellofemoral crepitus, patella apprehension sign, or anterior or posterior instability. Initial management should include

Explanation

The patient has patellar tendinitis (jumper's knee). It is a common overuse condition seen in runners, volleyball players, soccer players, and jumpers but can be seen in any activity in which repeated extension of the knee is required. In the acute setting, the pain is well localized and there is tenderness and sometimes swelling of the tendon. MRI is recommended for evaluating chronic cases and for surgical planning. In the acute phases, ice, rest, and avoidance of the offending activity are recommended. Weakness of the quadriceps and hamstring muscle are thought to contribute to this problem; therefore, stretching and isometric exercise in a limited range of motion are important. Complete rest and intratendinous injections of steroids are detrimental to tendon physiology. Stanish WD, Rubinovich RM, Curwin S: Eccentric exercise in chronic tendinitis. Clin Orthop 1986;208:65-68.

Question 20

Which of the following findings is likely to be pathologic in a thin, well-conditioned endurance athlete?

Explanation

Left ventricular hypertrophy by voltage is a nonspecific diagnosis, especially in athletes with an asthenic body habitus. High vagal tone in endurance athletes may result in first degree or even type I second degree (ie, Wenckebach) AV block in endurance athletes. High vagal tone results in resting sinus bradycardia in many trained athletes. A I-II/IV systolic ejection murmur is occasionally found in healthy athletes; however, when the murmur increases in intensity with maneuvers that decrease ventricular filling, such as standing or the Valsalva maneuver, dynamic obstruction that is the result of hypertrophic obstructive cardiomyopathy should be suspected. Nonspecific STT wave changes in the lateral leads on ECG are not uncommon in highly trained athletes; thus, they are nonspecific for ischemic heart disease. Pelliccia A, Maron BJ, Culasso F, DiPaolo FM, et al: Clinical significance of abnormal electrocardiographic patterns in trained athletes. Circulation 2000;102:278-284.

Question 21

Figure 20 shows the radiograph of a 21-year-old college basketball player who jammed his left index finger on the rim. He reports pain and tenderness over the dorsum of the distal interphalangeal (DIP) joint. Examination reveals that he is unable to actively extend the DIP joint; however, the skin is intact. Management should consist of

Explanation

Mallet fingers without DIP joint subluxation can be treated with extension splinting. Surgical fixation may be necessary in bony mallet injuries when the joint is subluxated. Size of the bony fragment, while often correlating with stability, is not always an indication for fixation. Buddy taping allows motion; therefore, the fragment will not heal in the appropriate position. Intermittent splinting with range-of-motion exercises also will not allow the fragment to heal in the appropriate position. Crawford GP: The molded polyethylene splint for mallet finger deformities. J Hand Surg Am 1984;9:231-237.

Question 22

With a full-thickness articular cartilage injury, the body's healing response produces cartilage mainly composed of what type of collagen?

Explanation

With a full-thickness articular cartilage injury, a healing response is initiated with hematoma, stem cell migration, and vascular ingrowth. This response produces type I collagen and resultant fibrous cartilage rather than desired hyaline cartilage as produced by chondrocytes. This repair cartilage has diminished resiliency, stiffness, poor wear characteristics, and the predilection for arthritis. Type I collagen is also found in the annulus of intervertebral disks, tendon, bone, meniscus, and skin. Type II is found in articular cartilage and nucleus pulposus of intervertebral disks. Type III is found in skin and blood vessels, type IV is found in basement membranes, and type X is found in the calcified layer of cartilage. Arendt EA (ed): Orthopaedic Knowledge Update: Sports Medicine 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 19-28.

Question 23

A relative contraindication for anteromedial tibial tubercle transfer for patellar instability is arthrosis in what portion of the patella?

Explanation

Anteromedial displacement of the tibial tubercle unloads the distal and lateral facets of the patella and shifts the forces to the proximal and medial facets. Therefore, if findings indicate arthrosis predominately in the medial and proximal areas of the patella, this is considered a relative contraindication because it may accentuate arthritic symptoms. Fulkerson JP: Anteromedialization of the tibial tuberosity for patellofemoral malalignment. Clin Orthop 1983;177:176-181. Bellemans J, Cauwenberghs F, Witvrouw E, et al: Anteromedial tibial tubercle transfer in patients with chronic anterior knee pain and a subluxation-type patellar malalignment. Am J Sports Med 1997;25:375-381.

Question 24

An 18-year-old lacrosse player sustained a hamstring pull during a game. Examination the next day reveals ecchymosis through the posterior thigh and a palpable defect in the hamstring musculature in the middle third of the thigh. What is the most likely site of anatomic injury?

Explanation

Hamstring strains are common in athletes. Basic science research and clinical data indicate that the majority of these injuries occur at the myotendinous junction, not within the muscle belly. Avulsion of hamstring origin from the ischial tuberosity does occur but is less common. Complete tearing of all hamstring muscles is unlikely to occur. Griffin LY (ed): Orthopaedic Knowledge Update: Sports Medicine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 17-33.

Question 25

Figures 21a through 21c show the MRI scans of a 21-year-old football player who sustained a valgus knee injury while changing direction. Examination reveals swelling and tenderness along the medial aspect of the knee. There is a positive Lachman test, 3+ valgus laxity at 30 degrees, and 1+ valgus laxity at 0 degrees extension. The anterior drawer test is increased with the tibia in external rotation. The increase in the anterior drawer test with the tibia in external rotation is most likely the result of

Explanation

21b 21c The injury mechanism involves a valgus load applied to the knee with the foot in external rotation. The primary stabilizer to valgus laxity is the medial collateral ligament. The secondary restraints to valgus rotation are the cruciate ligaments. Examination indicates disruption of the medial collateral and anterior cruciate ligaments. Valgus opening in extension should also arouse suspicion for an injury to the posterior cruciate ligament; however, in this patient, the valgus opening in extension is mild. The slight opening in extension and the increased anterior drawer, especially with external rotation, indicates disruption of the posteromedial capsule and posterior oblique ligament. Figure 21a shows complete disruption of the superficial and deep medial collateral ligaments involving the meniscofemoral ligament. Figure 21b shows a more posterior coronal section with a torn posterior oblique ligament. Figure 21c shows disruption of the anterior cruciate ligament, while the posterior cruciate ligament at the tibial insertion appears with a homogenous normal signal. Warren LA, Marshall JL, Girgis F: The prime static stabilizer of the medial side of the knee. J Bone Joint Surg Am 1974;56:665-674.

Question 26

What is the primary advantage of utilizing a quadriceps tendon autograft over a bone-patellar tendon-bone (BTB) autograft in primary anterior cruciate ligament (ACL) reconstruction?

Explanation

Quadriceps tendon autografts have less harvest site morbidity, specifically demonstrating significantly lower rates of anterior knee pain and localized numbness compared to BTB autografts.

Question 27

A 24-year-old overhead throwing athlete presents with shoulder pain during the late cocking phase of throwing. What is the primary biomechanical mechanism contributing to a type II SLAP tear in this specific patient population?

Explanation

The peel-back mechanism occurs when the shoulder is placed in maximal abduction and external rotation, increasing torsional forces at the biceps anchor and causing posterosuperior labral detachment.

Question 28

A 45-year-old patient undergoes an MRI for acute posterior knee pain after a deep squat. The MRI reveals a medial meniscus posterior root tear. Biomechanically, leaving this injury untreated is most equivalent to which of the following?

Explanation

A medial meniscus posterior root tear causes a complete loss of circumferential hoop stresses, leading to peak medial compartment contact pressures equivalent to a total meniscectomy.

Question 29

During reconstruction of the medial patellofemoral ligament (MPFL), the femoral tunnel is positioned using strict radiographic landmarks to locate Schöttle's point. Where is this point anatomically located on a true lateral radiograph?

Explanation

Schöttle's point is radiographically located 1 mm anterior to the posterior cortex line, 2.5 mm distal to the posterior contour of the medial femoral condyle, and proximal to the posterior point of Blumensaat's line.

Question 30

A 30-year-old sustains an acute knee injury. On physical examination, the dial test is positive with 15 degrees of increased external rotation at 30 degrees of knee flexion, but symmetric to the contralateral side at 90 degrees of flexion. Which structural injury does this exam finding indicate?

Explanation

Increased external rotation isolated to 30 degrees of knee flexion indicates an isolated posterolateral corner (PLC) injury. Combined PCL and PLC injuries demonstrate increased rotation at both 30 and 90 degrees.

Question 31

A 21-year-old collegiate baseball pitcher reports medial elbow pain and decreased velocity. Valgus stress testing is positive. Which specific bundle of the ulnar collateral ligament (UCL) acts as the primary restraint to valgus stress during the late cocking phase of throwing?

Explanation

The anterior band of the anterior bundle of the UCL is the primary restraint to valgus stress from 30 to 120 degrees of elbow flexion, which is critical during the throwing motion.

Question 32

A 35-year-old recreational athlete sustains an acute Achilles tendon rupture. In discussing nonoperative versus operative management using modern functional rehabilitation protocols, which of the following statements is true?

Explanation

When modern early functional weight-bearing and rehabilitation protocols are utilized, there is no statistically significant difference in rerupture rates between operative and nonoperative management of acute Achilles tendon ruptures.

Question 33

A 25-year-old hockey player presents with groin pain exacerbated by hip flexion and internal rotation. Imaging shows a high alpha angle on the lateral radiograph. This specific hip morphology is most strongly associated with initial damage to which structure?

Explanation

Cam impingement, characterized by a high alpha angle, causes sheer forces that typically result in the delamination of the anterosuperior acetabular articular cartilage prior to frank labral detachment.

Question 34

A 14-year-old female gymnast complains of chronic lateral elbow pain. Radiographs and MRI reveal an osteochondritis dissecans (OCD) lesion of the capitellum. Which of the following is an absolute indication for operative management?

Explanation

Surgical indications for capitellar OCD lesions include detached or unstable lesions, the presence of intra-articular loose bodies, failed conservative treatment in a compliant patient, or skeletal maturity.

Question 35

A 19-year-old competitive swimmer presents with bilateral shoulder pain and a positive sulcus sign. She is diagnosed with multidirectional instability (MDI). What is the mainstay of initial treatment for her condition?

Explanation

The first line of treatment for multidirectional instability (MDI) is an extensive and prolonged physical therapy program focusing on strengthening the rotator cuff and periscapular stabilizers to improve dynamic joint control.

Question 36

A 22-year-old cross-country runner presents with bilateral anterior leg pain occurring consistently at mile 2 and resolving 30 minutes after rest. Which intracompartmental pressure measurement is most diagnostic for chronic exertional compartment syndrome (CECS)?

Explanation

According to the Pedowitz criteria, diagnostic thresholds for CECS 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 37

A 40-year-old water skier sustained a hyperflexion injury of the hip with an extended knee, resulting in an acute 3-tendon proximal hamstring avulsion. Retraction is measured at 4 cm. What is the most significant clinical risk of nonoperative management in this specific scenario?

Explanation

Complete 3-tendon proximal hamstring avulsions with significant retraction (>2 cm) are highly prone to chronic weakness, painful cramping, and sciatic nerve tethering if managed nonoperatively.

Question 38

A 55-year-old manual laborer undergoes an arthroscopic rotator cuff repair with an open subpectoral biceps tenodesis. What nerve is at greatest risk of iatrogenic injury if medial retractors are placed too aggressively during the subpectoral exposure?

Explanation

The musculocutaneous nerve is at significant risk if medial retraction is too deep or aggressive during a subpectoral biceps tenodesis, as it pierces the coracobrachialis medial to the surgical field.

Question 39

A 25-year-old basketball player sustains a noncontact twisting knee injury. Radiographs reveal an avulsion fracture of the anterolateral proximal tibia (Segond fracture). This radiographic finding is considered pathognomonic for an injury to which primary structure?

Explanation

A Segond fracture represents an avulsion of the anterolateral ligament/capsule complex from the tibia and is considered virtually pathognomonic for an anterior cruciate ligament (ACL) tear.

Question 40

During shoulder arthroscopy for a suspected massive rotator cuff tear, a distinct "comma sign" is observed. This visual landmark represents the torn edge of the subscapularis intimately attached to which of the following ligamentous structures?

Explanation

The arthroscopic "comma sign" is formed by the avulsed superior glenohumeral ligament (SGHL) and coracohumeral ligament (CHL) complex that remains firmly attached to the superolateral corner of a retracted subscapularis tendon.

Question 41

A 23-year-old professional soccer player sustains an acute Zone 2 fracture of the proximal fifth metatarsal during a match. To minimize the risk of nonunion and expedite his return to elite play, what is the most appropriate recommended treatment?

Explanation

Intramedullary screw fixation is the standard treatment of choice for elite athletes with acute Zone 2 (Jones) fractures, as it significantly decreases the risk of nonunion and allows for an earlier, reliable return to sport.

Question 42

A 28-year-old cyclist falls directly onto his shoulder. Radiographs demonstrate a type V acromioclavicular (AC) joint separation, indicating that the coracoclavicular (CC) ligaments are ruptured. Which specific ligaments comprise the CC complex?

Explanation

The coracoclavicular (CC) ligaments consist of the conoid (medial) and trapezoid (lateral) ligaments, which act as the primary vertical stabilizers of the acromioclavicular joint.

Question 43

A 17-year-old female soccer player undergoes an uncomplicated primary anterior cruciate ligament (ACL) reconstruction with a bone-patellar tendon-bone autograft. She successfully completes an accelerated rehabilitation program. What is her greatest risk factor for a future ACL injury upon returning to sport?

Explanation

Young, female athletes returning to high-risk sports after primary ACL reconstruction have a statistically higher rate of tearing the contralateral native ACL compared to rupturing the ipsilateral graft.

Question 44

A 55-year-old man presents with chronic shoulder weakness. MRI demonstrates a massive, retracted tear of the supraspinatus and infraspinatus tendons. Fatty infiltration is Goutallier grade 3. Electromyography reveals denervation of the infraspinatus. What is the most likely anatomic cause of this neurologic finding?

Explanation

Retraction of massive posterosuperior rotator cuff tears alters the course of the suprascapular nerve, often tethering or applying traction to it at the suprascapular notch, leading to neuropathy.

Question 45

A 22-year-old male hockey player presents with chronic groin pain exacerbated by hip flexion and internal rotation. An AP pelvis radiograph demonstrates an abnormal pistol-grip deformity of the proximal femur.

Which of the following is the most likely initial intra-articular pathologic consequence of this specific deformity?

Explanation

A cam deformity creates shear forces at the anterosuperior acetabulum during hip flexion and internal rotation. This classically leads to outside-in delamination of the acetabular cartilage at the chondrolabral junction.

Question 46

A 28-year-old man sustains a direct blow to the anteromedial aspect of his proximal tibia while his knee is flexed. Physical examination demonstrates a positive posterior drawer test. The dial test shows 15 degrees of increased external rotation at 30 degrees of knee flexion compared to the contralateral side, but symmetric external rotation at 90 degrees. What is the most likely diagnosis?

Explanation

Increased external rotation on the dial test at 30 degrees of flexion, which normalizes at 90 degrees, indicates an isolated posterolateral corner (PLC) injury. Combined PCL and PLC injuries show increased external rotation at both angles.

Question 47

A 22-year-old collegiate soccer player undergoes anterior cruciate ligament reconstruction using a bone-patellar tendon-bone autograft. Compared to a quadrupled hamstring autograft, which of the following is a recognized biomechanical advantage or characteristic of this graft choice?

Explanation

Bone-patellar tendon-bone (BTB) autograft allows for bone-to-bone healing in the osseous tunnels, typically at 6 weeks, which is faster than soft tissue healing. Quadrupled hamstring grafts generally possess a higher ultimate failure load and cross-sectional area compared to 10-mm BTB grafts.

Question 48

A 24-year-old professional baseball pitcher complains of vague posterior shoulder pain and a decrease in pitching velocity. On physical examination, he has 15 degrees of internal rotation and 125 degrees of external rotation at 90 degrees of abduction. Which of the following is the most appropriate initial management?

Explanation

This patient presents with glenohumeral internal rotation deficit (GIRD) caused by posterior capsular contracture, commonly seen in overhead throwing athletes. The initial treatment of choice is a targeted physical therapy program emphasizing sleeper stretches to stretch the posterior capsule.

Question 49

A 16-year-old female experiences recurrent patellar dislocations. Imaging reveals a tibial tubercle-trochlear groove (TT-TG) distance of 14 mm, a normal Caton-Deschamps index, and a shallow trochlea. What is the primary soft-tissue restraint to lateral patellar translation at 20 degrees of knee flexion that should be reconstructed in this patient?

Explanation

The medial patellofemoral ligament (MPFL) provides approximately 50% to 60% of the restraining force against lateral patellar translation from 0 to 30 degrees of knee flexion. Because her TT-TG distance is normal (<20 mm) and patellar height is normal, an isolated MPFL reconstruction is indicated.

Question 50

A 55-year-old man feels a "pop" in his posterior knee while descending stairs, followed by acute pain. MRI reveals a medial meniscus posterior root tear with 3 mm of extrusion. Biomechanically, this injury is most equivalent to which of the following?

Explanation

Poster root tears disrupt the circumferential hoop stresses of the meniscus, causing extrusion under axial load. Biomechanically, a complete root avulsion transmits contact pressures across the joint identical to a total meniscectomy, predisposing the knee to rapid articular cartilage degeneration.

Question 51

A 21-year-old collegiate baseball pitcher presents with medial elbow pain during the late cocking and early acceleration phases of throwing. Valgus stress testing reveals pain and increased laxity compared to the contralateral elbow. MRI shows a high-grade partial tear of the anterior bundle of the ulnar collateral ligament (UCL). The primary restraint to valgus stress at 90 degrees of elbow flexion is the:

Explanation

The anterior bundle of the ulnar collateral ligament is the primary restraint to valgus stress at the elbow from 30 to 120 degrees of flexion. It is most commonly injured in throwing athletes during the late cocking and early acceleration phases.

Question 52

A 23-year-old rugby player presents with recurrent anterior shoulder instability. CT scan with 3D reconstruction reveals 28% glenoid bone loss. He is planned for a Latarjet procedure. Which of the following best describes the "sling effect" contributing to anterior stability in this procedure?

Explanation

The Latarjet procedure provides stability via the bone block, capsular repair to the coracoacromial ligament stump, and the dynamic sling effect. The sling effect is produced by the conjoint tendon compressing the inferior capsule and subscapularis when the arm is abducted and externally rotated.

Question 53

A 19-year-old collegiate distance runner complains of bilateral anterolateral leg pain that reliably begins after running 2 miles and resolves 30 minutes after stopping. Radiographs and MRI are unremarkable. Intracompartmental pressure testing is performed. Which of the following Pedowitz criteria confirms the diagnosis of chronic exertional compartment syndrome?

Explanation

The Pedowitz criteria for chronic exertional compartment syndrome include a pre-exercise pressure >15 mm Hg, 1-minute post-exercise pressure >30 mm Hg, or a 5-minute post-exercise pressure >20 mm Hg. The patient's history and elevated compartment pressures warrant a fasciotomy if nonoperative management fails.

Question 54

A 35-year-old recreational athlete sustains an acute closed midsubstance Achilles tendon rupture. He opts for nonoperative management. Which of the following rehabilitation protocols has been shown to result in re-rupture rates comparable to operative management?

Explanation

High-quality randomized controlled trials and meta-analyses have shown that nonoperative management with early functional rehabilitation yields re-rupture rates similar to operative repair. It also avoids the surgical risks of infection and wound breakdown.

Question 55

A 14-year-old boy presents with vague anterior knee pain. Radiographs reveal a 1.5 cm osteochondritis dissecans (OCD) lesion on the lateral aspect of the medial femoral condyle. His physes are open. MRI shows no fluid behind the lesion. What is the most appropriate initial management?

Explanation

Juvenile OCD lesions (open physes) that are stable (no fluid behind the lesion on MRI) have a high rate of spontaneous healing with nonoperative management. Activity modification, including cessation of sports and protected weight-bearing, is the most appropriate initial treatment.

Question 56

A 28-year-old man sustains a knee dislocation (KD-III) following a motorcycle collision. The joint is reduced in the emergency department. He has weakness in ankle dorsiflexion and decreased sensation over the dorsal aspect of his foot. Which of the following structures was most likely injured, and what is its expected recovery rate without surgical repair?

Explanation

The common peroneal nerve is injured in 10-40% of multiligament knee injuries, often due to a stretch injury during a varus/hyperextension mechanism. The prognosis for functional recovery of a complete common peroneal nerve palsy associated with a knee dislocation is generally poor (<50%).

Question 57

A 21-year-old collegiate baseball pitcher has persistent deep shoulder pain during the late cocking phase of throwing despite 3 months of conservative management. MR arthrogram reveals a Type II SLAP tear. During arthroscopy, a Type II SLAP lesion is confirmed. What is the most appropriate surgical management for this overhead athlete?

Explanation

In young, high-demand overhead throwing athletes with a Type II SLAP tear, primary repair with suture anchors remains the standard of care to restore the native anatomy and tension of the biceps anchor. Biceps tenodesis is typically reserved for older patients or those who fail primary repair.

Question 58

A 25-year-old hockey player presents with chronic anterior groin pain exacerbated by hip flexion and internal rotation. Radiographs demonstrate an alpha angle of 65 degrees on the Dunn lateral view and normal acetabular version. This condition is most strongly associated with the development of which intra-articular pathology?

Explanation

Cam impingement, characterized by an increased alpha angle (>50-55 degrees) and loss of femoral head-neck offset, results in shear forces on the anterosuperior acetabular rim during flexion. This classically leads to anterosuperior labral tears and outside-in chondral delamination.

Question 59

On an AP pelvis radiograph of a 30-year-old woman with hip pain, the anterior wall of the acetabulum is seen crossing over the posterior wall before reaching the lateral edge of the sourcil. This radiographic finding is indicative of:

Explanation

The "crossover sign" occurs when the anterior wall line crosses lateral to the posterior wall line on a true AP pelvis radiograph. This indicates acetabular retroversion, a common cause of focal anterior pincer-type femoroacetabular impingement.

Question 60

A 42-year-old tennis player undergoes shoulder arthroscopy for impingement symptoms. Diagnostic arthroscopy reveals a partial articular-sided supraspinatus tendon avulsion (PASTA) involving 60% of the tendon thickness. What is the most widely accepted surgical management for this lesion?

Explanation

High-grade partial articular-sided rotator cuff tears (>50% tendon thickness) generally warrant surgical repair in active patients. This can be accomplished via a transtendon repair or by completing the tear to a full-thickness defect and performing a standard repair.

Question 61

A 21-year-old collegiate soccer player undergoes anterior cruciate ligament (ACL) reconstruction using a bone-patellar tendon-bone autograft. Which of the following is a recognized biomechanical or biological advantage of this graft choice compared to a quadrupled hamstring autograft at the time of initial healing?

Explanation

Bone-patellar tendon-bone (BPTB) autografts undergo bone-to-bone healing, providing faster biologic incorporation (typically 6 weeks) at the tunnel apertures compared to soft tissue grafts. Hamstring grafts generally have a higher initial ultimate tensile load.

Question 62

A 35-year-old recreational baseball pitcher has a symptomatic Type II SLAP tear that has failed conservative management. He opts for an arthroscopic SLAP repair. What is the most common post-operative complication of this procedure?

Explanation

Postoperative stiffness, particularly a loss of external rotation, is the most common complication following arthroscopic SLAP repair. Due to this risk, many surgeons now prefer primary biceps tenodesis for older or non-overhead athletes.

Question 63

A 24-year-old professional football player suffers a posterior knee dislocation. After reduction, his ankle-brachial index (ABI) is 0.7. CT angiography shows an intimal tear of the popliteal artery. Following vascular repair, what is the most appropriate management of his multiligament knee injury?

Explanation

In the setting of an acute popliteal artery repair, spanning external fixation is recommended to protect the vascular anastomosis. Ligamentous reconstruction is appropriately delayed until vascular stability and soft tissue conditions optimize.

Question 64

A 16-year-old female presents with recurrent lateral patellar instability. Imaging shows a tibial tubercle-trochlear groove (TT-TG) distance of 22 mm, a normal TT-PCL distance, and normal trochlear depth. Which of the following is the most appropriate surgical intervention?

Explanation

A TT-TG distance > 20 mm is a recognized risk factor for patellar instability and a primary indication for a medializing tibial tubercle osteotomy. This is typically combined with an MPFL reconstruction to restore the primary soft-tissue restraint.

Question 65

During medial patellofemoral ligament (MPFL) reconstruction, placing the femoral tunnel too proximal will most likely result in which of the following kinematic abnormalities?

Explanation

Placing the MPFL femoral tunnel too proximal relative to Schöttle's point causes the graft to tighten excessively as the knee flexes. This leads to a loss of flexion and abnormally high medial patellofemoral cartilage contact pressures.

Question 66

A 45-year-old male undergoes arthroscopic rotator cuff repair for a massive, retracted, U-shaped tear. Margin convergence is performed prior to securing the tendon to the greater tuberosity. What is the primary biomechanical advantage of margin convergence?

Explanation

Margin convergence closes the posterior and anterior leaves of a U-shaped tear, converting it to a crescent shape. This significantly decreases tension and strain at the free margin of the tendon where it is repaired to the bone footprint.

Question 67

A 20-year-old collegiate runner presents with severe, bilateral leg pain that occurs 15 minutes into his run and forces him to stop. Resting compartment pressures are 10 mmHg. Using the Pedowitz criteria, which of the following post-exercise compartment pressure measurements confirms the diagnosis of chronic exertional compartment syndrome (CECS)?

Explanation

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

Question 68

A 22-year-old female collegiate soccer player undergoes anterior cruciate ligament (ACL) reconstruction with a bone-patellar tendon-bone autograft. What is the most common technical error leading to late graft failure?

Explanation

The most common technical error in ACL reconstruction is non-anatomic tunnel placement, specifically placing the femoral tunnel too anteriorly. This creates a graft that is tight in flexion and loose in extension, leading to loss of motion and early graft rupture.

Question 69

During a single-bundle posterior cruciate ligament (PCL) reconstruction using an Achilles tendon allograft, what is the optimal knee position and applied force during graft tensioning to best restore native knee kinematics?

Explanation

In a single-bundle PCL reconstruction, the graft is classically tensioned at 90 degrees of flexion with an anterior drawer force applied to reduce the anatomic step-off of the medial tibial plateau. This optimally restores the function of the anterolateral bundle.

Question 70

A 24-year-old rugby player presents with recurrent anterior shoulder instability. 3D CT and MRI indicate 22% anterior glenoid bone loss and an engaging, off-track Hill-Sachs lesion. Which of the following surgical interventions is most appropriate to prevent recurrent instability?

Explanation

The Latarjet procedure (coracoid transfer) is the standard of care for contact athletes with significant anterior glenoid bone loss (typically >15-20%). An arthroscopic Bankart repair alone or with remplissage is inadequate for critical glenoid bone loss.

Question 71

A 45-year-old female presents with sudden onset medial knee pain after deep knee flexion. An MRI reveals the pathology shown in Figure 55.

Assuming this represents a posterior root tear of the medial meniscus, which of the following biomechanical consequences most closely mirrors this injury?

Explanation

A posterior root tear of the medial meniscus completely disrupts the circumferential hoop stresses of the meniscus. Biomechanical studies have demonstrated that this leads to altered contact areas and peak pressures equivalent to a total meniscectomy.

Question 72

A 28-year-old hockey player undergoes hip arthroscopy with osteochondroplasty for a Cam-type femoroacetabular impingement (FAI). Which of the following complications is most highly associated with over-resection (resection of >30% of the diameter) of the femoral head-neck junction?

Explanation

Resection of more than 30% of the femoral neck diameter during osteochondroplasty significantly alters the biomechanics of the proximal femur, drastically increasing the risk of an iatrogenic femoral neck fracture.

Question 73

In the setting of a multiligamentous knee injury (KD-III-M), reconstruction of the posteromedial corner is planned. The posterior oblique ligament (POL) acts as the primary restraint to which of the following forces?

Explanation

The posterior oblique ligament (POL) is the primary restraint to internal rotation of the tibia at early angles of knee flexion (0 to 30 degrees). The superficial MCL is the primary restraint to valgus at 30 degrees of flexion.

Question 74

A 42-year-old manual laborer has a symptomatic type II superior labrum anterior-posterior (SLAP) tear that has failed 6 months of nonoperative management. Compared to an arthroscopic SLAP repair, proceeding with a primary biceps tenodesis in this patient demographic is associated with:

Explanation

In older patients (typically >35-40 years) or manual laborers, SLAP repairs have higher rates of failure and postoperative stiffness. Biceps tenodesis yields more reliable pain relief and higher rates of return to work in this demographic.

Question 75

A 22-year-old basketball player undergoes matrix-induced autologous chondrocyte implantation (MACI) for a 3.5 square-centimeter full-thickness osteochondral defect on the medial femoral condyle. What is the primary histological composition of the optimally generated repair tissue?

Explanation

MACI is designed to generate hyaline-like cartilage, which is primarily composed of Type II collagen. In contrast, marrow stimulation techniques like microfracture produce fibrocartilage, primarily composed of Type I collagen.

Question 76

A 19-year-old collegiate baseball pitcher presents with anterior shoulder pain. Examination of the throwing arm reveals 20 degrees of internal rotation (IR) and 130 degrees of external rotation (ER). The contralateral arm has 60 degrees of IR and 90 degrees of ER. What is the initial treatment of choice for this condition?

Explanation

This patient has Glenohumeral Internal Rotation Deficit (GIRD) secondary to posterior capsular contracture. The first-line treatment is a targeted physical therapy program utilizing cross-body and sleeper stretches to stretch the posterior capsule.

Question 77

During an ulnar collateral ligament (UCL) reconstruction using the docking technique, a muscle-splitting approach through the flexor pronator mass is utilized. Which nerve is most at risk of iatrogenic injury during this specific surgical approach?

Explanation

The medial antebrachial cutaneous nerve (MABC) and its branches run superficially over the medial epicondyle and are highly vulnerable during the surgical approach to the ulnar collateral ligament.

Question 78

A 21-year-old cross-country runner complains of bilateral lower leg pain that occurs 15 minutes into a run and strictly resolves with rest. Compartment pressure testing is performed. Which of the following measurements is diagnostic for chronic exertional compartment syndrome (CECS) according to the Pedowitz criteria?

Explanation

The Pedowitz criteria for diagnosing chronic exertional compartment syndrome require one or more of the following: resting pressure >15 mm Hg, 1-minute post-exercise pressure >30 mm Hg, or 5-minute post-exercise pressure >20 mm Hg.

Question 79

A 26-year-old cyclist sustains a type III acromioclavicular (AC) joint separation. Biomechanical studies indicate that the primary restraint to superior translation of the distal clavicle is the:

Explanation

The coracoclavicular (CC) ligaments consist of the conoid and trapezoid. The conoid ligament is the primary restraint to superior translation of the clavicle, while the trapezoid is the primary restraint to axial compression.

Question 80

An 18-year-old football player sustains a bucket-handle meniscal tear in the red-white zone. Which of the following surgical factors most significantly enhances the biological healing potential of this meniscal repair?

Explanation

Concomitant ACL reconstruction significantly enhances meniscal healing. The drilling of osseous tunnels releases bone marrow elements, stem cells, and growth factors into the joint, creating a robust biological environment for repair.

Question 81

Following an arthroscopic rotator cuff repair, tendon-to-bone healing progresses through inflammatory, proliferative, and remodeling phases. During the remodeling phase, which type of collagen is primarily synthesized to replace the provisional matrix?

Explanation

During the initial proliferative healing phase of a rotator cuff repair, primarily Type III collagen is deposited as scar tissue. In the remodeling phase, this is gradually replaced by stronger, highly organized Type I collagen.

Question 82

A 16-year-old female suffers a lateral patellar dislocation resulting in an incompetent medial patellofemoral ligament (MPFL). Where is the correct anatomic femoral footprint of the MPFL located radiographically?

Explanation

The femoral attachment of the MPFL (often radiographically defined by Schöttle's point) sits in the saddle between the adductor tubercle (which is proximal) and the medial epicondyle (which is distal).

Question 83

A 35-year-old recreational athlete sustains an acute Achilles tendon rupture. He elects for nonoperative management utilizing a functional rehabilitation protocol with early weight-bearing. Compared to acute surgical repair, this modern nonoperative approach is associated with:

Explanation

Recent high-quality literature demonstrates that modern nonoperative management utilizing early functional rehabilitation protocols yields equivalent functional outcomes and similar re-rupture rates compared to surgical repair, while avoiding surgical complications.

Question 84

In evaluating articular cartilage lesions in the knee of a high-performance athlete, which MRI sequence is most specifically sensitive for detecting early proteoglycan loss before structural morphological changes occur?

Explanation

Advanced compositional MRI sequences, such as T2 mapping, T1rho, and dGEMRIC, are specifically utilized to assess the biochemical composition of cartilage. They can detect early loss of proteoglycans and collagen network disruption prior to macroscopic cartilage loss.

Question 85

A 23-year-old collegiate baseball pitcher presents with medial elbow pain that occurs during the late cocking and early acceleration phases of throwing. Magnetic resonance imaging (MRI) reveals a high-grade partial tear of the proximal ulnar collateral ligament (UCL). He has not attempted any nonoperative treatment. What is the most appropriate initial management?

Explanation

First-line management for a partial UCL tear in a throwing athlete involves an initial period of rest, structured physical therapy, and often a PRP injection. Surgery is generally reserved for complete tears or partial tears that fail a comprehensive trial of nonoperative management.

Question 86

A 25-year-old rugby player undergoes a Latarjet procedure for recurrent anterior shoulder instability with 22% anterior glenoid bone loss and an "off-track" Hill-Sachs lesion. Which of the following best describes the primary biomechanical advantage of this specific surgical technique?

Explanation

The Latarjet procedure primarily provides stability through the "sling effect" of the conjoint tendon on the anteroinferior capsule during arm abduction and external rotation. This dynamic stabilization accounts for the majority of the procedure's success, supplemented by the bone block increasing the glenoid arc.

Question 87

During a medial patellofemoral ligament (MPFL) reconstruction in a 16-year-old female with recurrent patellar dislocations, the surgeon identifies the anatomic femoral attachment site using fluoroscopy. Where is this anatomic attachment located relative to the medial femoral epicondyle and adductor tubercle?

Explanation

The anatomic femoral attachment of the MPFL is located in a saddle-shaped sulcus just distal to the adductor tubercle and proximal to the medial epicondyle. Precise anatomic graft placement is critical to avoid overtightening the graft in flexion and altering patellofemoral kinematics.

Question 88

A 24-year-old male is brought to the emergency department after a high-velocity knee dislocation (KD-III). The knee is urgently reduced. His foot is warm, but palpable pulses are asymmetric. An ankle-brachial index (ABI) is measured at 0.85. What is the most appropriate next step in management?

Explanation

An Ankle-Brachial Index (ABI) of less than 0.9 in the setting of a multiligamentous knee injury is a "hard-soft" sign of potential popliteal artery compromise. The standard of care mandates immediate advanced vascular imaging, most commonly CTA, to evaluate for an intimal tear or occlusion prior to definitive orthopedic intervention.

Question 89

A 55-year-old patient experiences a sudden pop in the posterior knee while descending stairs. MRI confirms a complete posterior root tear of the medial meniscus. What is the most significant biomechanical consequence of this specific injury if left untreated?

Explanation

A posterior root tear of the medial meniscus disrupts the continuity of the meniscal ring, abolishing its ability to convert axial loads into hoop stresses. Biomechanically, this failure leads to immediate meniscal extrusion and profoundly increased peak contact pressures equivalent to a total meniscectomy.

Question 90

A 28-year-old weightlifter presents with acute right axillary pain and weakness after performing a heavy bench press.

Physical examination reveals significant ecchymosis and a loss of the anterior axillary fold contour. Which of the following is the most appropriate surgical management for a complete rupture in this demographic?

Explanation

Pectoralis major ruptures most commonly occur at the humeral insertion (sternocostal head) in weightlifters performing bench presses. Anatomic repair is recommended for active individuals, which involves reattaching the tendon at its native footprint on the proximal humerus, located lateral to the bicipital groove.

Question 91

An 8-year-old male (Tanner stage 1) sustains a complete midsubstance anterior cruciate ligament (ACL) tear while skiing. He has significant subjective instability and giving way with daily activities. What is the most appropriate surgical treatment option to minimize the risk of growth arrest?

Explanation

In prepubescent children (Tanner stage 1) with significant remaining growth potential, physeal-sparing ACL reconstruction techniques are indicated to prevent physeal injury and limb deformity. An iliotibial band extra-articular over-the-top reconstruction (e.g., Micheli/Kocher technique) safely addresses instability without crossing the open physes.

Question 92

A 22-year-old elite baseball pitcher complains of posterior shoulder pain exclusively during the late cocking phase of throwing. Physical examination reveals a 25-degree deficit in internal rotation compared to the contralateral side. A superior labrum anterior to posterior (SLAP) tear is identified on MR arthrography. Which mechanism best explains the development of this specific labral pathology?

Explanation

In overhead throwers, Glenohumeral Internal Rotation Deficit (GIRD) caused by a contracted posteroinferior capsule shifts the glenohumeral contact point posterosuperiorly. During the late cocking phase (abduction and maximal external rotation), this shift causes the biceps root to twist and transmit torsional forces, known as the peel-back mechanism, tearing the superior labrum.

Question 93

During hip arthroscopy for a patient with symptomatic femoroacetabular impingement (FAI), the surgeon addresses a large Cam lesion. Which intra-articular pathologic pattern is most classically associated with this specific femoral morphology?

Explanation

Cam morphology, defined by a loss of spherical head-neck offset, engages the anterosuperior acetabular rim during hip flexion and internal rotation. This repetitive shear stress leads to an "inside-out" pattern of acetabular articular cartilage delamination from the subchondral bone, often accompanied by an adjacent labral detachment.

Question 94

A 35-year-old bodybuilder undergoes a single-incision anterior approach for the repair of an acute distal biceps tendon rupture. Postoperatively, he notes lateral forearm numbness but retains normal motor function of his fingers and wrist. Which neural structure was most likely injured during the exposure?

Explanation

The lateral antebrachial cutaneous nerve (LABC) is the most commonly injured nerve during a single-incision anterior distal biceps repair, usually due to traction neuropraxia from lateral retractors. The posterior interosseous nerve (PIN) is at risk during the two-incision technique or with overly deep dissection, but its injury would cause motor deficits in finger and thumb extension.

Question 95

A 24-year-old active male presents with persistent medial knee pain. MRI demonstrates a 4.5 cm squared full-thickness uncontained chondral defect on the weight-bearing surface of the medial femoral condyle, with an underlying 12 mm deep subchondral bone cyst. What is the most appropriate surgical intervention?

Explanation

Osteochondral allograft transplantation (OCA) is the treatment of choice for large (>2-3 cm squared) full-thickness cartilage defects associated with significant underlying subchondral bone loss or cyst formation. Procedures like MACI address the cartilage surface but do not adequately replace structurally compromised subchondral bone.

Question 96

When evaluating graft options for primary anterior cruciate ligament (ACL) reconstruction, which of the following grafts possesses the highest initial ultimate tensile load to failure in a controlled biomechanical testing environment?

Explanation

A quadrupled hamstring tendon autograft has the highest initial ultimate tensile load to failure (exceeding 4000 N), which is significantly higher than the native ACL (~2160 N) and BPTB autograft (~2977 N). However, clinical success depends heavily on biological healing, initial graft fixation, and precise tunnel placement.

Question 97

A 21-year-old collegiate distance runner presents with bilateral anterolateral leg pain that reliably begins 15 minutes into her run and subsides within 30 minutes of resting. To confirm the diagnosis of chronic exertional compartment syndrome, which of the following dynamic intra-compartmental pressure measurements is highly specific and considered diagnostic?

Explanation

According to the modified Pedowitz criteria for chronic exertional compartment syndrome, diagnostic thresholds include a resting pressure >15 mm Hg, a 1-minute post-exercise pressure >30 mm Hg, or a 5-minute post-exercise pressure >20 mm Hg. The 1-minute post-exercise pressure >30 mm Hg provides high diagnostic specificity.

General Orthopedics 2026 Practice Questions: Set 13 (Solved)

Orthopedic Sports Medicine 2026 MCQs: Board Review Questions & Answers (Part 2)

Key Takeaway

Orthopedic Sports Medicine 2026 MCQs: Board Review Questions & Answers (Part 2)

Chapter Index