AAOS & ABOS Sports Medicine MCQs: Knee & Shoulder

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?

Sports Medicine 2004 Practice Questions: Set 1 (Solved) - Figure 1

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

Sports Medicine 2004 Practice Questions: Set 1 (Solved) - Figure 2

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

Sports Medicine 2004 Practice Questions: Set 1 (Solved) - Figure 3

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

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?

Sports Medicine 2004 Practice Questions: Set 1 (Solved) - Figure 6

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

Sports Medicine 2004 Practice Questions: Set 1 (Solved) - Figure 7

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

Sports Medicine 2004 Practice Questions: Set 1 (Solved) - Figure 8

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?

Sports Medicine 2004 Practice Questions: Set 1 (Solved) - Figure 9

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

Sports Medicine 2004 Practice Questions: Set 1 (Solved) - Figure 10

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

Sports Medicine 2004 Practice Questions: Set 1 (Solved) - Figure 11

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

Sports Medicine 2004 Practice Questions: Set 1 (Solved) - Figure 12

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?

Sports Medicine 2004 Practice Questions: Set 1 (Solved) - Figure 13

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?

Sports Medicine 2004 Practice Questions: Set 1 (Solved) - Figure 14

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?

Sports Medicine 2004 Practice Questions: Set 1 (Solved) - Figure 15

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?

Sports Medicine 2004 Practice Questions: Set 1 (Solved) - Figure 16

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?

Sports Medicine 2004 Practice Questions: Set 1 (Solved) - Figure 17

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?

Sports Medicine 2004 Practice Questions: Set 1 (Solved) - Figure 18

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

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

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

Sports Medicine 2004 Practice Questions: Set 1 (Solved) - Figure 23

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?

Sports Medicine 2004 Practice Questions: Set 1 (Solved) - Figure 24

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

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?

Sports Medicine 2004 Practice Questions: Set 1 (Solved) - Figure 27

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?

Sports Medicine 2004 Practice Questions: Set 1 (Solved) - Figure 28

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

Sports Medicine 2004 Practice Questions: Set 1 (Solved) - Figure 29

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 13-year-old female soccer player with widely open physes sustains a complete anterior cruciate ligament (ACL) tear. Which of the following surgical techniques minimizes the risk of physeal arrest?

Explanation

In skeletally immature patients with widely open physes, physeal-sparing techniques like the all-epiphyseal hamstring autograft or extra-articular iliotibial band procedures are recommended. Transphyseal drilling, especially with bone blocks across the physis, significantly increases the risk of growth arrest and angular deformity.

Question 27

A 21-year-old collegiate rugby player with a history of recurrent anterior shoulder dislocations presents for surgical evaluation. CT imaging demonstrates 26% anterior glenoid bone loss. What is the most appropriate surgical intervention?

Explanation

The Latarjet procedure (coracoid transfer) is indicated for anterior shoulder instability with critical glenoid bone loss, generally defined as greater than 20-25%. Arthroscopic or open Bankart repairs alone have an unacceptably high failure rate in the setting of critical bone loss.

Question 28

A high school football player is diagnosed with a concussion. He rests for 3 days and is now completely asymptomatic at rest and at school. According to the standard graduated return-to-play protocol, what is the minimum time before he can return to full-contact game play?

Explanation

The standard graduated return-to-play protocol involves a 6-step progression (each step taking a minimum of 24 hours). An athlete must remain asymptomatic at each stage to progress, meaning the fastest return to full-contact games is 5 days from the initiation of the protocol.

Question 29

A 24-year-old male falls onto a hyperflexed knee during a basketball game. MRI confirms an isolated, complete Grade III tear of the posterior cruciate ligament (PCL). Which of the following is the most appropriate initial management?

Explanation

Isolated PCL tears, even Grade III, have high healing potential and are typically treated nonoperatively initially. A hinged knee brace locked in full extension (or a dynamic PCL brace) is utilized to counteract the posterior tibial sag caused by gravity and hamstring pull.

Question 30

Which of the following pathophysiological mechanisms defines Second Impact Syndrome in a concussed athlete?

Explanation

Second Impact Syndrome occurs when an athlete sustains a second head injury before symptoms from a prior concussion have resolved. This triggers a catastrophic loss of cerebral vascular autoregulation, leading to rapid, fatal brain swelling and herniation.

Question 31

A 23-year-old baseball pitcher complains of posterior shoulder pain during the late cocking phase of throwing. Arthroscopy reveals undersurface fraying of the posterior supraspinatus and posterosuperior labrum. What is the most likely diagnosis?

Explanation

Internal impingement is a condition commonly seen in overhead athletes characterized by posterior shoulder pain in the late cocking phase (abduction and maximal external rotation). It involves pathologic contact between the articular surface of the rotator cuff and the posterosuperior glenoid labrum.

Question 32

A 55-year-old avid runner sustains an acute posterior root tear of the medial meniscus. If left untreated, this injury is biomechanically equivalent to which of the following?

Explanation

A complete tear of the medial meniscus posterior root leads to a complete loss of meniscal hoop stresses. Biomechanically, this results in increased contact pressures and cartilage overload equivalent to a total medial meniscectomy, predisposing to rapid osteoarthritis.

Question 33

A 28-year-old hockey player takes a severe hit into the boards, landing directly on his lateral shoulder. Examination reveals a prominent distal clavicle. Radiographs show a Type III acromioclavicular (AC) joint separation. What is the standard initial treatment?

Explanation

Type III AC joint separations (complete rupture of AC and CC ligaments) are generally treated nonoperatively with a brief period of sling immobilization, early range of motion, and physical therapy. Surgery is reserved for patients who fail conservative management or specific high-level overhead laborers.

Question 34

A 25-year-old rugby player receives a direct blow to the anteromedial aspect of the tibia. On examination, the dial test shows 15 degrees of increased external rotation at 30 degrees of knee flexion compared to the uninjured side, but symmetric rotation at 90 degrees of flexion. Which structure is injured?

Explanation

A positive dial test (increased external rotation of >10 degrees) at 30 degrees of flexion with a negative test at 90 degrees of flexion indicates an isolated posterolateral corner (PLC) injury. If the dial test is positive at both 30 and 90 degrees, it suggests a combined PCL and PLC injury.

Question 35

A 19-year-old female collegiate soccer player is being evaluated in the clinic 4 weeks after sustaining a concussion. She complains of persistent headaches and "fogginess." Which of the following is the strongest predictor of a prolonged recovery (>14 days) in concussed athletes?

Explanation

Numerous studies indicate that the initial symptom severity reported by the athlete in the first few days post-injury is the strongest and most consistent predictor of a prolonged recovery from concussion. Loss of consciousness and amnesia are poor predictive factors.

Question 36

A 16-year-old female experiences a primary lateral patellar dislocation while dancing. Radiographs reveal a large osteochondral loose body in the lateral gutter. What is the most appropriate management?

Explanation

While first-time patellar dislocations are typically treated nonoperatively, the presence of an osteochondral loose body is a classic indication for early surgical intervention. Arthroscopy allows for removal or fixation of the fragment and evaluation of the articular surface.

Question 37

A 32-year-old male weightlifter feels a sharp pop in his anterior chest/axilla while performing a heavy bench press. Examination reveals a cosmetic defect, loss of the anterior axillary fold, and weakness with adduction and internal rotation. The rupture most likely involves which anatomical location?

Explanation

Pectoralis major ruptures classicially occur in weightlifters doing the bench press during the eccentric phase. The sternal head at or near its insertion on the humerus is the most frequently injured portion due to the maximal tension it experiences at the bottom of the lift.

Question 38

Which of the following anatomical variants is considered an independent risk factor for sustaining a non-contact anterior cruciate ligament (ACL) tear?

Explanation

An increased posterior tibial slope is a well-established bony risk factor for ACL tears. A steeper slope increases the anterior translational force on the tibia during axial loading, thereby placing greater strain on the ACL.

Question 39

A 45-year-old manual laborer presents with anterior shoulder pain. He has a positive O'Brien test and MRI confirms an isolated Type II SLAP tear. After failing 6 months of physical therapy, what surgical intervention provides the most reliable clinical outcome?

Explanation

In patients older than 35-40 years with a Type II SLAP tear, biceps tenodesis provides more reliable pain relief and a lower complication/revision rate compared to SLAP repair. SLAP repairs in older patients are associated with high rates of postoperative stiffness.

Question 40

A 30-year-old male sustains a severe hyperextension injury to his knee, resulting in a KD-III multiligament knee dislocation. On examination, he is unable to dorsiflex his ankle or extend his great toe. This neurologic deficit is due to an injury of a nerve structurally tethered at which of the following locations?

Explanation

The patient has a foot drop, indicating an injury to the common peroneal nerve, which is common in severe knee dislocations (especially posterolateral). The common peroneal nerve is susceptible to traction injury due to its rigid tethering at the fibular neck.

Question 41

A 55-year-old male fell onto his outstretched right arm. He now complains of significant shoulder weakness. Physical examination demonstrates increased passive external rotation compared to the contralateral shoulder and a positive Bear Hug test. Which tendon is ruptured?

Explanation

The Bear Hug test is highly sensitive and specific for subscapularis pathology. Furthermore, an acute subscapularis tear results in increased passive external rotation due to the loss of the anterior restricting structure.

Question 42

Chronic traumatic encephalopathy (CTE) is increasingly recognized in athletes with a history of repetitive concussive and subconcussive impacts. Which of the following is the hallmark neuropathological finding in CTE?

Explanation

The definitive diagnosis of CTE requires post-mortem neuropathological examination. The hallmark finding is the perivascular accumulation of hyperphosphorylated tau protein, uniquely distributed at the depths of the cortical sulci.

Question 43

A 14-year-old boy presents with insidious onset of anterior knee pain and catching. Radiographs demonstrate an osteochondritis dissecans (OCD) lesion. What is the most common anatomic location for this lesion?

Explanation

Osteochondritis dissecans (OCD) of the knee most commonly affects the lateral aspect of the medial femoral condyle. This location accounts for approximately 70-80% of all knee OCD lesions.

Question 44

A 21-year-old gymnast presents with medial scapular winging. The inferior medial border of the scapula becomes extremely prominent when she pushes against a wall. Which muscle and nerve combination are primarily affected?

Explanation

Classic medial winging of the scapula, especially pronounced with forward elevation or wall push-ups, is caused by weakness or paralysis of the serratus anterior muscle. This muscle is innervated by the long thoracic nerve.

Question 45

During a routine pre-participation physical, a 16-year-old football player uses the SCAT6 tool to establish a baseline. What is the primary purpose of obtaining a baseline SCAT6 score in a healthy athlete?

Explanation

The primary utility of baseline testing (such as the SCAT6) is to provide individualized normative data for the athlete. If a concussion occurs, comparing post-injury scores to the baseline helps clinicians accurately assess cognitive deficits and track recovery.

Question 46

A 17-year-old high school football player sustains a concussion. He is asymptomatic at rest after 4 days. He completes a light aerobic exercise phase without symptoms. What is the next step in his return-to-play protocol?

Explanation

The standard graduated return-to-play protocol progresses through: symptom-limited activity, light aerobic exercise, sport-specific exercise, non-contact training drills, full-contact practice, and return to sport. After completing light aerobic exercise, the next phase is sport-specific exercise.

Question 47

During an anterior cruciate ligament (ACL) reconstruction, placing the femoral tunnel too anteriorly (high in the notch) will result in which of the following biomechanical consequences?

Explanation

A femoral tunnel placed anterior to the isometric point increases the distance between the tibial and femoral attachment sites as the knee flexes. This results in a graft that is excessively tight in flexion and loose in extension, limiting terminal knee flexion.

Question 48

A 20-year-old collegiate baseball pitcher undergoes a Type II SLAP repair with suture anchors after failing nonoperative management. What is the most common postoperative complication that prevents return to his previous level of play?

Explanation

In throwing athletes, SLAP repairs are notorious for causing postoperative stiffness, specifically a loss of external rotation. This restriction limits their late cocking phase, significantly decreasing pitching velocity and preventing return to pre-injury performance levels.

Question 49

A 25-year-old soccer player sustains an isolated Grade II posterior cruciate ligament (PCL) sprain. What is the most appropriate initial management?

Explanation

Isolated Grade I and II PCL injuries are treated nonoperatively with a brief period of immobilization in extension or use of a dynamic PCL brace to prevent posterior tibial sag. Rehabilitation focuses heavily on quadriceps strengthening to counteract posterior tibial translation.

Question 50

A 19-year-old rugby player has recurrent anterior shoulder dislocations. CT imaging

reveals 25% anterior glenoid bone loss. What is the most appropriate definitive surgical management?

Explanation

Glenoid bone loss exceeding 20-25% is a contraindication to an isolated soft-tissue Bankart repair due to unacceptably high recurrence rates. A bony augmentation procedure, such as the Latarjet procedure, is the gold standard for definitive stabilization.

Question 51

Which of the following best describes the pathophysiology of Second Impact Syndrome in a concussed athlete who returns to play prematurely?

Explanation

Second Impact Syndrome occurs when a brain sustains a second concussive injury before symptoms from an earlier concussion have resolved. It leads to a failure of cerebral vascular autoregulation, resulting in massive, rapid brain swelling and potential herniation.

Question 52

A 45-year-old recreational runner feels a 'pop' in the back of his knee while squatting. MRI shows a medial meniscus posterior root tear with meniscal extrusion. Biomechanically, this injury is most equivalent to which of the following?

Explanation

A posterior root tear disrupts the hoop stresses of the meniscus, causing it to extrude under load. Biomechanically, this failure to convert axial loads into hoop stresses renders the knee functionally equivalent to one that has undergone a total meniscectomy.

Question 53

A 24-year-old volleyball attacker presents with posterior shoulder pain during the cocking phase of serving. Exam shows a positive posterior impingement sign. Pathophysiologically, this condition is characterized by contact between the posterosuperior glenoid labrum and which structure?

Explanation

Internal impingement occurs in overhead athletes during maximum abduction and external rotation. It is characterized by the undersurface of the posterior supraspinatus and anterior infraspinatus tendons impinging against the posterosuperior glenoid labrum.

Question 54

During reconstruction of the medial patellofemoral ligament (MPFL) for recurrent patellar instability, the anatomical femoral attachment site (Schöttle's point) is best identified radiographically in relation to which landmarks?

Explanation

Schöttle's point marks the isometric femoral origin of the MPFL. On a strict lateral radiograph, it is located 1 mm anterior to the posterior cortical extension line, 2.5 mm proximal to the posterior border of Blumensaat's line, and proximal to the posterior origin of the medial femoral condyle.

Question 55

According to the Canadian CT Head Rule, which of the following is a high-risk indication for a head CT scan in a 20-year-old athlete presenting with a Glasgow Coma Scale (GCS) score of 15 after a minor head trauma?

Explanation

The Canadian CT Head Rule mandates a CT scan for minor head trauma if high-risk criteria are met, such as GCS < 15 at 2 hours post-injury, suspected open/depressed skull fracture, any sign of basal skull fracture, >/= 2 episodes of vomiting, or age >/= 65 years.

Question 56

A 28-year-old skier sustains a knee dislocation and undergoes immediate field reduction. In the emergency department, pulses are symmetric and normal. What is the most appropriate next step in vascular assessment?

Explanation

Following a knee dislocation, normal palpable pulses do not exclude an intimal tear of the popliteal artery. An Ankle-Brachial Index (ABI) should be measured; an ABI < 0.9 mandates further imaging, such as a CT angiogram, while an ABI > 0.9 allows for serial clinical observation.

Question 57

A 25-year-old hockey player sustains a direct blow to the point of his shoulder. Radiographs reveal an acromioclavicular (AC) joint separation with the distal clavicle displaced posteriorly into the trapezius fascia. What is the Rockwood classification type of this injury?

Explanation

In the Rockwood classification of AC joint injuries, a Type IV injury is characterized by posterior displacement of the distal clavicle into or through the trapezius muscle/fascia. This injury generally requires surgical stabilization.

Question 58

The most devastating neurovascular complication during tibial tunnel drilling for a posterior cruciate ligament (PCL) reconstruction is injury to which of the following structures?

Explanation

The popliteal artery lies directly posterior to the PCL tibial attachment site on the posterior capsule. Over-penetration of the guide pin or drill during tibial tunnel creation is a well-known risk for catastrophic popliteal artery injury.

Question 59

A 30-year-old weightlifter feels a 'tear' in his anterior chest while performing a heavy bench press. Examination reveals an asymmetric chest wall and a palpable defect in the anterior axillary fold. The vast majority of these pectoralis major injuries occur at which anatomic location?

Explanation

Pectoralis major ruptures most commonly occur in weightlifters performing bench presses. The most frequent site of rupture is an avulsion of the tendon directly from its insertion on the proximal humerus lateral to the bicipital groove.

Question 60

A 14-year-old gymnast presents with vague anterior knee pain. Radiographs

reveal an osteochondritis dissecans (OCD) lesion. In the knee, what is the most common anatomic location for an OCD lesion?

Explanation

The classic and most frequent location for an osteochondritis dissecans (OCD) lesion in the knee is the lateral aspect of the medial femoral condyle. It accounts for roughly 70-80% of all knee OCD lesions.

Question 61

During a soccer match, a player clashes heads with an opponent. He is conscious but confused. Which of the following components of the SCAT5 (Sport Concussion Assessment Tool 5) is specifically designed to evaluate his immediate memory?

Explanation

In the SCAT5, immediate memory is tested by reading a list of 5 or 10 words and having the athlete repeat them back across multiple trials. Questions about the venue test orientation (Maddocks score), while months in reverse or digits backward assess concentration.

Question 62

Which of the following is a recognized biomechanical or anatomic risk factor for non-contact anterior cruciate ligament (ACL) tears in female athletes?

Explanation

Risk factors for ACL tears in females include an increased posterior tibial slope, decreased intercondylar notch width, increased dynamic knee valgus during landing, and quadriceps dominance (poor hamstring activation). Increased posterior slope shifts the tibia anteriorly under axial load, stressing the ACL.

Question 63

A 45-year-old recreational tennis player presents with shoulder pain and weakness after a fall on an outstretched arm. Physical exam reveals increased passive external rotation compared to the contralateral side and a positive lift-off test. Which of the following physical examination tests would also most likely be positive?

Explanation

The clinical presentation (increased passive external rotation, positive lift-off test) indicates a subscapularis tendon tear. The bear hug test and belly-press test are also highly specific and sensitive physical examination maneuvers for diagnosing subscapularis pathology.

Question 64

A 24-year-old professional baseball pitcher experiences deep shoulder pain during the late cocking phase of throwing. MRI confirms a Type II SLAP lesion. Which of the following biomechanical mechanisms is most responsible for this specific injury in overhead throwing athletes?

Explanation

In overhead throwers, Type II SLAP tears are primarily caused by a 'peel-back' mechanism. During maximal abduction and external rotation (late cocking phase), the biceps vector shifts posteriorly, transmitting torsional forces that peel the labrum from the glenoid.

Question 65

A 16-year-old high school soccer player sustains a concussion and is progressing through a stepwise return-to-play protocol. During step 3 (sport-specific exercise), she develops a mild headache. What is the most appropriate next step in her management?

Explanation

If symptoms occur during any stage of a graded return-to-play concussion protocol, the athlete should drop back to the previous asymptomatic level. This is done only after resting for at least 24 hours until symptoms fully resolve.

Question 66

A 22-year-old female presents with recurrent instability 18 months after an anterior cruciate ligament (ACL) reconstruction. Physical examination reveals a positive Lachman and pivot-shift test. Radiographs and MRI suggest graft failure. What is the most common technical error leading to ACL graft failure?

Explanation

The most common technical error leading to recurrent instability and ACL graft failure is placing the femoral tunnel too anteriorly or vertically. This results in poor control of rotational instability and increased stress on the graft during knee flexion.

Question 67

A 21-year-old collegiate rugby player with a history of recurrent anterior shoulder dislocations presents for surgical evaluation. A 3D CT scan demonstrates a 27% anterior glenoid bone loss and an engaging Hill-Sachs lesion. Which of the following is the most appropriate surgical management?

Explanation

Anterior glenoid bone loss greater than 20-25% is a critical defect that is associated with unacceptably high failure rates for isolated arthroscopic soft-tissue stabilization. The Latarjet procedure (coracoid transfer) is the standard of care for restoring stability in this scenario.

Question 68

A 55-year-old man feels a sudden 'pop' in the posterior aspect of his knee while squatting. MRI reveals a complete radial tear at the posterior root of the medial meniscus. If left untreated, this injury most closely mimics the biomechanical consequences of which of the following?

Explanation

A complete tear of the meniscal root eliminates the meniscus's ability to convert axial loads into hoop stresses. Biomechanically, this functions identically to a total meniscectomy, leading to rapid compartmental cartilage degradation.

Question 69

A high school football player sustains a concussion but conceals his symptoms to stay in the game. He subsequently takes another hit to the head and collapses, rapidly deteriorating into a coma. What is the primary pathophysiologic mechanism of Second Impact Syndrome?

Explanation

Second Impact Syndrome occurs when a second head injury is sustained before the symptoms of the first have resolved. This disrupts cerebral autoregulation, causing massive engorgement of the cerebral vasculature and fatal brain herniation.

Question 70

A 45-year-old recreational tennis player has symptomatic failure of nonoperative management for an isolated Type II SLAP tear. In this specific demographic, which surgical intervention has been shown to yield the highest patient satisfaction and return to sport rates?

Explanation

In patients older than 40 years, biceps tenodesis demonstrates superior clinical outcomes, better pain relief, and higher return-to-sport rates compared to SLAP repair, which carries a higher risk of postoperative stiffness in this age group.

Question 71

A 28-year-old skier presents with acute knee pain after a twisting injury. On physical examination, the dial test shows 15 degrees of increased external rotation on the injured side at 30 degrees of knee flexion, but symmetric external rotation at 90 degrees of flexion. This examination finding is most consistent with an isolated injury to which of the following structures?

Explanation

A positive dial test (increased external rotation of >10 degrees compared to the contralateral side) at 30 degrees of flexion, but not at 90 degrees, indicates an isolated posterolateral corner (PLC) injury. If it is positive at both 30 and 90 degrees, it indicates a combined PLC and PCL injury.

Question 72

Internal impingement of the shoulder in an elite overhead thrower typically involves the compression of which of the following structures during the late cocking/early acceleration phase?

Explanation

Internal impingement occurs during maximal abduction and external rotation when the greater tuberosity pinches the articular-sided fibers of the supraspinatus and infraspinatus tendons against the posterosuperior glenoid labrum.

Question 73

A 16-year-old female presents with recurrent lateral patellar dislocations. Imaging demonstrates a normal TT-TG distance (12 mm) but an elevated Caton-Deschamps index of 1.5. Which of the following surgical procedures is most appropriate to address her specific pathoanatomy in addition to medial patellofemoral ligament (MPFL) reconstruction?

Explanation

A Caton-Deschamps index > 1.2 indicates patella alta, a major risk factor for patellar instability. When performing an MPFL reconstruction in a patient with significant patella alta, distalization of the tibial tubercle should be performed to engage the patella into the trochlea earlier in flexion.

Question 74

Following a sport-related concussion, an athlete is evaluated by the team physician. Which of the following factors at the time of initial injury is the strongest and most consistent predictor of a prolonged recovery (lasting greater than 14 days)?

Explanation

Extensive literature, including the Concussion in Sport Group consensus statements, identifies that the severity of initial symptoms in the first few days following a concussion is the strongest predictor of a prolonged recovery.

Question 75

A 35-year-old man presents with anterior shoulder pain and internal rotation weakness following a fall onto an outstretched hand. The examiner notes a positive belly-press test. Which of the following nerves innervates the primary muscle evaluated by this specific test?

Explanation

The belly-press test evaluates the subscapularis muscle. The subscapularis is innervated by both the upper and lower subscapular nerves, which originate from the posterior cord of the brachial plexus.

Question 76

A 25-year-old running back sustains a direct blow to the proximal tibia with his knee flexed. MRI confirms an isolated, Grade II injury of the posterior cruciate ligament (PCL). What is the most appropriate initial management?

Explanation

Isolated Grade I and II PCL tears are successfully managed non-operatively. Rehabilitation should focus heavily on quadriceps strengthening, as the quadriceps act as a dynamic antagonist to the PCL by resisting posterior tibial translation.

Question 77

A 20-year-old collegiate swimmer presents with insidious onset of anterior shoulder pain. Examination reveals a prominent inferior medial scapular border and scapular dyskinesis at rest and during dynamic motion (SICK scapula syndrome). Initial physical therapy should focus on strengthening which of the following muscle groups?

Explanation

SICK scapula syndrome represents Scapular malposition, Inferior medial border prominence, Coracoid pain, and dysKinesis. Rehabilitation must emphasize strengthening the periscapular stabilizers, specifically the serratus anterior and lower trapezius, while stretching the pectoralis minor.

Question 78

An 11-year-old male presents with vague anterior knee pain and catching. Radiographs reveal an osteochondritis dissecans (OCD) lesion. In the knee, what is the most common anatomic location for an OCD lesion?

Explanation

The classic and most common location for osteochondritis dissecans (OCD) of the knee is the lateral aspect of the medial femoral condyle (LAME: Lateral Aspect Medial Epicondyle/Condyle).

Question 79

A 28-year-old patient presents to the emergency department after sustaining a severe hyperextension injury to the knee. Examination reveals gross multi-planar instability consistent with a knee dislocation (KD-III). The dorsalis pedis pulse is palpable but diminished compared to the contralateral side. The Ankle-Brachial Index (ABI) is calculated to be 0.7. What is the most appropriate next step in management?

Explanation

An ABI < 0.9 in the setting of a knee dislocation is highly suspicious for a popliteal artery injury. The most appropriate next step to accurately define the lesion prior to intervention is a CT angiogram (or standard arteriogram).

Question 80

A 19-year-old collegiate hockey player suffers a first-time anterior shoulder dislocation. It is successfully reduced in the emergency department. If this athlete is treated non-operatively with a sling and physical therapy, what is his approximate risk of recurrent instability?

Explanation

Young, contact-sport athletes (particularly males under the age of 20) have extremely high recurrence rates for anterior shoulder instability when treated non-operatively, frequently cited as greater than 80-90%.

Question 81

During the acute neurometabolic cascade of a sport-related concussion, indiscriminate release of excitatory neurotransmitters (such as glutamate) leads to a rapid ionic shift across the neuronal membrane. Which of the following best describes this immediate ionic and metabolic state?

Explanation

The acute neurometabolic cascade of concussion is characterized by glutamate release causing massive potassium efflux and calcium influx. This leads to a local energy crisis as Na+/K+ pumps work in overdrive, exacerbated by a paradoxical decrease in cerebral blood flow.

Question 82

When counseling a high school athlete on graft choices for an anterior cruciate ligament (ACL) reconstruction, the surgeon discusses bone-patellar tendon-bone (BPTB) autograft versus hamstring autograft. Which of the following postoperative complications is significantly more common with a BPTB autograft?

Explanation

The most frequent specific complication associated with BPTB autograft, compared to hamstring autograft, is anterior knee pain and pain with kneeling. Saphenous nerve neuritis is more common with hamstring harvest.

Question 83

A 30-year-old recreational cyclist falls directly onto his right shoulder. Clinical examination and radiographs demonstrate 100% superior displacement of the clavicle relative to the acromion, with an increased coracoclavicular distance compared to the normal side. The deltotrapezial fascia appears clinically intact based on the reducible nature of the joint. What is the most widely recommended initial treatment for this Grade III acromioclavicular (AC) joint separation?

Explanation

For standard, non-laboring or non-overhead athletic patients, acute Grade III AC joint separations are best managed non-operatively. Initial treatment consists of a brief period in a sling for comfort followed by early range of motion and physical therapy.

Question 84

A 19-year-old college football player sustains a concussion during a game. Under current guidelines, when is it appropriate for him to begin a graduated return-to-play protocol?

Explanation

A graduated return-to-play protocol should only be initiated once a concussed athlete is completely asymptomatic at rest off all medications, and neurocognitive testing has returned to baseline. Each stage of the return-to-play protocol typically requires 24 hours without symptom recurrence.

Question 85

A 20-year-old collegiate gymnast is undergoing anterior cruciate ligament (ACL) reconstruction. Which of the following graft choices is associated with the highest rate of postoperative anterior knee pain and difficulty kneeling?

Explanation

Bone-patellar tendon-bone (BTB) autograft is historically associated with the highest incidence of anterior knee pain and kneeling morbidity compared to hamstring or quadriceps autografts. Despite this, it remains a popular choice for high-demand athletes due to excellent stability and bone-to-bone healing.

Question 86

A 21-year-old baseball pitcher presents with deep shoulder pain during the late cocking phase of throwing. MRI arthrogram reveals a Type II SLAP tear. After 3 months of physical therapy focusing on periscapular stabilization and posterior capsular stretching, his symptoms persist. What is the most appropriate surgical intervention?

Explanation

A Type II SLAP tear involves detachment of the superior labrum and biceps anchor from the glenoid. In a young, high-demand overhead athlete who has failed conservative management, arthroscopic SLAP repair is the traditional preferred surgical treatment.

Question 87

A 28-year-old male presents to the emergency department with a multiligamentous knee injury following a high-speed motor vehicle collision. Which of the following physical exam findings mandates immediate surgical exploration by vascular surgery?

Explanation

An expanding popliteal hematoma with absent pedal pulses is a "hard sign" of arterial injury, mandating immediate surgical exploration. An ABI < 0.9 is a "soft sign" that requires further vascular imaging (like a CT angiogram) but not necessarily immediate exploration.

Question 88

A 30-year-old male sustains a grade III posterior cruciate ligament (PCL) tear in a dashboard injury. When planning an isolated single-bundle PCL reconstruction, which native bundle is typically reconstructed to restore maximal restraint to posterior tibial translation at 90 degrees of flexion?

Explanation

The anterolateral bundle of the PCL is the larger, stronger bundle and is tightest in deeper knee flexion (90 degrees). Single-bundle PCL reconstructions primarily target the anterolateral bundle to restore the primary restraint against posterior tibial translation.

Question 89

A 16-year-old high school football player sustains a mild concussion. He returns to play the following week while still experiencing mild headaches. During the game, he receives a minor blow to the chest, collapses, and falls into a coma. What is the primary pathophysiologic mechanism of this rapid decline?

Explanation

Second Impact Syndrome occurs when an athlete sustains a second head injury before symptoms of a prior concussion have completely resolved. It triggers a catastrophic loss of cerebral blood flow autoregulation, resulting in massive brain swelling, herniation, and potentially death.

Question 90

A 22-year-old baseball pitcher presents with posterior shoulder pain during the late cocking phase of throwing. On examination, he has pain with abduction and external rotation, which is relieved by a relocation maneuver. What is the most likely underlying arthroscopic finding?

Explanation

This presentation is classic for internal impingement, which occurs in overhead athletes during late cocking when the greater tuberosity abuts the posterosuperior glenoid. This repetitive contact leads to articular-sided rotator cuff fraying and posterosuperior labral lesions.

Question 91

A 12-year-old elite baseball pitcher presents with a gradual onset of proximal arm pain when throwing. Radiographs demonstrate widening and irregularity of the proximal humeral physis. What is the most appropriate initial management?

Explanation

Little League Shoulder is a stress fracture of the proximal humeral physis caused by repetitive rotational stresses during throwing. The mainstay of treatment is absolute rest and cessation of throwing for typically 3 months to allow physeal healing.

Question 92

A 22-year-old soccer player undergoes an acute ACL reconstruction along with a meniscal repair for a vertical longitudinal tear in the red-red zone of the medial meniscus. Which of the following factors is most strongly associated with successful healing of this meniscal tear?

Explanation

Concomitant ACL reconstruction creates a post-operative hemarthrosis rich in growth factors and bone marrow elements (from notch preparation and tunnel drilling). This biological environment significantly improves the healing rates of concurrent meniscal repairs.

Question 93

A 28-year-old bodybuilder feels a pop in his anterior axilla while performing a heavy bench press. Examination reveals an asymmetric axillary fold and weakness in internal rotation and adduction. Which aspect of the pectoralis major is most commonly ruptured in this specific scenario?

Explanation

Pectoralis major ruptures most commonly occur at the humeral insertion in weightlifters performing the bench press. The sternal head is preferentially loaded and ruptures first because it is placed under maximal stretch when the arm is extended, abducted, and externally rotated.

Question 94

A 17-year-old female experiences recurrent lateral patellar dislocations. Evaluation reveals a tibial tubercle-trochlear groove (TT-TG) distance of 22 mm and a normal Patellar Height (Caton-Deschamps index 1.0). Which surgical intervention is most appropriate to address her instability?

Explanation

A TT-TG distance greater than 20 mm is considered pathologic and predisposes the patella to lateral instability. A medializing tibial tubercle osteotomy (e.g., Fulkerson osteotomy) combined with MPFL reconstruction is indicated to correct both the bony malalignment and soft tissue deficiency.

Question 95

A 14-year-old male presents with knee pain. Radiographs show an osteochondritis dissecans (OCD) lesion on the lateral aspect of the medial femoral condyle. His physes are open, and MRI shows no high T2 signal behind the lesion. What is the most appropriate initial management?

Explanation

Juvenile OCD lesions (occurring in patients with open physes) that are stable on MRI (indicated by the lack of high T2 signal fluid behind the fragment) have a high rate of spontaneous healing. Protected weight-bearing and activity modification for 3 to 6 months is the standard initial treatment.

Question 96

A 20-year-old collegiate tennis player is found to have a 25-degree deficit in glenohumeral internal rotation compared to his non-dominant arm, though his total arc of motion is equivalent bilaterally. He complains of vague posterior shoulder pain. What is the most appropriate first-line treatment?

Explanation

Glenohumeral internal rotation deficit (GIRD) is characterized by a loss of internal rotation with a corresponding gain in external rotation. The definitive first-line treatment is a dedicated physical therapy program utilizing sleeper stretches and cross-body adduction to stretch the contracted posterior capsule.

Question 97

A 25-year-old sustains a direct blow to the anteromedial tibia with the knee in extension. Examination reveals a grade 3 varus stress test at 30 degrees of flexion and a positive dial test at 30 degrees. However, at 90 degrees of flexion, the dial test is symmetric to the contralateral side. Which structures are most likely injured?

Explanation

An isolated posterolateral corner (PLC) injury results in increased external rotation on the dial test at 30 degrees of knee flexion but not at 90 degrees. If the PCL is concomitantly injured, the dial test will be positive (increased external rotation >10 degrees) at both 30 and 90 degrees.

Question 98

A 17-year-old soccer player collides head-to-head with an opponent and falls. He reports transient dizziness and a headache but denies any loss of consciousness. On sideline evaluation using the SCAT5, he has difficulty with delayed recall. What is the most appropriate next step in management?

Explanation

Any athlete suspected of sustaining a concussion must be immediately removed from play and cannot return on the same day under any circumstances. Subsequent medical evaluation is required, and the athlete must complete a strict graduated return-to-play protocol.

AAOS & ABOS Sports Medicine MCQs (Set 1): Knee, Shoulder & Concussion | Board Review

Quick Medical Answer

AAOS & ABOS Sports Medicine MCQs (Set 1): Knee, Shoulder & Concussion | Board Review

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Guide Overview