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Updated Orthopedic Review | Dr Hutaif General Orthopedi -...

Ortho Sport Sports Medicine Board Review | Dr Hutaif Sp -...

23 Apr 2026 135 min read 118 Views
Illustration of knowledge update sports - Dr. Mohammed Hutaif

Key Takeaway

For anyone wondering about ORTHO MCQS SPORT 10, A "knowledge update sports" resource provides critical insights into common athletic injuries. For instance, noncomplicated crown fractures are the most frequent maxillofacial/dental injury in ice hockey, while articular surface partial-thickness rotator cuff tears are common shoulder pathologies. These updates enhance understanding of injury prevalence, diagnosis, and contributing factors in sports medicine.

Ortho Sport Sports Medicine Board Review | Dr Hutaif Sp -...

Comprehensive 100-Question Exam


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Question 1

A 20-year-old female presents with recurrent lateral patellar instability. MRI reveals an intact MPFL but a Tibial Tubercle-Trochlear Groove (TT-TG) distance of 24 mm. Which of the following is the most appropriate surgical management?





Explanation

The TT-TG distance is a crucial measurement in patellar instability. A distance > 20 mm is considered abnormal and generally an indication for tibial tubercle medialization (e.g., Fulkerson osteotomy). MPFL reconstruction alone in the setting of a TT-TG > 20 mm is associated with a significantly higher failure rate due to uncorrected excessive lateral pull.

Question 2

In calculating the Instability Severity Index Score (ISIS) for an 18-year-old competitive rugby player with recurrent anterior shoulder instability, which of the following factors would contribute points indicating a higher risk of recurrence after an arthroscopic Bankart repair?





Explanation

The ISIS score evaluates the risk of recurrence after arthroscopic anterior shoulder stabilization. Points are awarded for: age < 20 years (2 pts), participation in competitive sports (2 pts), contact sports (1 pt), loss of inferior glenoid contour on AP radiograph (2 pts), and visible Hill-Sachs lesion on AP radiograph (2 pts). A score > 6 suggests a high risk of failure with arthroscopic repair, and Latarjet should be considered.

Question 3

During Ulnar Collateral Ligament (UCL) reconstruction using the docking technique, which structure is at greatest risk of iatrogenic injury during the splitting of the flexor pronator mass and exposure of the sublime tubercle?





Explanation

The medial antebrachial cutaneous (MABC) nerve branches extensively over the medial elbow. Its posterior branch often crosses directly over the area where the flexor-pronator split is performed to expose the sublime tubercle during UCL reconstruction. Careful blunt dissection and nerve retraction are essential to prevent painful neuromas or numbness.

Question 4

A 25-year-old male sustains a knee dislocation. Exam reveals a grade III Lachman, grade III posterior drawer, and increased opening to varus stress at 0 and 30 degrees. Valgus stress is stable. According to the Schenck classification, what type of knee dislocation is this?





Explanation

The Schenck classification describes knee dislocations based on the ligaments torn. KD-I: one cruciate. KD-II: both cruciates. KD-III: both cruciates and one collateral (M for MCL, L for LCL). KD-IV: all four ligaments. This patient has ACL, PCL, and LCL tears (varus instability) with an intact MCL (stable valgus), classifying it as KD-III L.

Question 5

A 50-year-old male feels a "pop" in the back of his knee while squatting. MRI shows a medial meniscus posterior root tear. Which of the following radiographic findings is most strongly associated with chronic untreated medial meniscus posterior root tears?





Explanation

Medial meniscus root tears result in a loss of hoop stresses, effectively acting like a total meniscectomy. This drastically increases peak contact pressures in the medial compartment, predisposing the patient to subchondral insufficiency fractures, spontaneous osteonecrosis of the knee (SONK), and rapidly progressive osteoarthritis.

Question 6

A 45-year-old male sustains a traumatic subscapularis tear. Physical exam reveals increased passive external rotation compared to the contralateral side. Which special test is most specific for an isolated tear of the upper portion of the subscapularis tendon?





Explanation

The Bear-hug test is highly sensitive and specific for identifying tears involving the upper portion of the subscapularis. The Lift-off test is generally more effective at evaluating the inferior portion of the subscapularis. The Belly-press test evaluates the overall subscapularis but can be compensatory.

Question 7

A 16-year-old high school female soccer player is undergoing ACL reconstruction. Which of the following graft choices is associated with the highest risk of re-rupture in this specific demographic?





Explanation

Multiple studies and registries (e.g., MOON cohort) have demonstrated that the use of allografts in young, highly active patients (especially under age 20) is associated with a significantly higher failure/re-rupture rate compared to autografts.

Question 8

A 22-year-old hockey player presents with anterior groin pain with flexion and internal rotation. Radiographs demonstrate an alpha angle of 65 degrees on the Dunn lateral view. Which of the following pathomechanical processes is most likely occurring in this patient?





Explanation

An alpha angle > 55 degrees indicates a Cam deformity. Cam impingement typically causes outside-in shear forces as the non-spherical femoral head enters the acetabulum during flexion and internal rotation. This leads to delamination of the anterosuperior acetabular cartilage from the subchondral bone, often leaving the labrum relatively intact in the early stages.

Question 9

A 30-year-old male weightlifter feels a tear in his anterior chest while performing a heavy bench press. Which segment of the pectoralis major muscle is most commonly torn in this mechanism, and where does it insert on the humerus?





Explanation

The pectoralis major tendon undergoes a 180-degree twist before inserting onto the lateral lip of the bicipital groove. This twist causes the lower sternocostal head to insert proximal (superior) and deep to the clavicular head. The sternal head undergoes peak tension during eccentric contraction (like the bottom of a bench press) and is the most commonly torn segment.

Question 10

A 24-year-old marathon runner presents with bilateral exercise-induced anterior leg pain. Which of the following intracompartmental pressure measurements (using the Pedowitz criteria) is diagnostic for Chronic Exertional Compartment Syndrome (CECS)?





Explanation

The modified Pedowitz criteria for diagnosing Chronic Exertional Compartment Syndrome (CECS) require one or more of the following: pre-exercise resting pressure > 15 mmHg, 1 minute post-exercise pressure > 30 mmHg, or 5 minutes post-exercise pressure > 20 mmHg.

Question 11

A 28-year-old male has a symptomatic 3.5 cm² full-thickness chondral defect on the medial femoral condyle. He has failed conservative management. Which of the following surgical interventions is most appropriate for a defect of this size in an active patient, assuming intact menisci and normal alignment?





Explanation

For large chondral defects (> 2 cm²) in young, active patients, cell-based therapies like MACI or osteochondral allografts are indicated. Microfracture and OATS are generally reserved for smaller lesions (< 2 cm²) due to the limited quantity of autograft available and inferior fibrocartilage properties associated with microfracture over large areas.

Question 12

In the management of a type IV SLAP lesion extending into the biceps root in a 40-year-old laborer, what is the most appropriate surgical treatment?





Explanation

A Type IV SLAP lesion involves a tear of the superior labrum that extends into the biceps tendon. In older active patients or manual laborers, or when > 30% of the biceps tendon is involved, a biceps tenodesis provides reliable pain relief and functional restoration, avoiding the stiffness and failure rates associated with SLAP repairs in this demographic.

Question 13

A 21-year-old football player sustains a syndesmotic ankle injury. Which of the following radiographic measurements is the most reliable indicator of a syndesmotic injury on a standard AP and mortise radiograph?





Explanation

The tibiofibular clear space is measured 1 cm proximal to the plafond. A distance > 5 mm on BOTH the AP and Mortise views is the most reliable indicator of syndesmotic widening, as it is relatively unaffected by rotational variations during image acquisition, unlike tibiofibular overlap.

Question 14

A 9-year-old male (Tanner Stage I) sustains a complete ACL rupture. He has significant subjective instability. To minimize the risk of growth arrest, which of the following ACL reconstruction techniques is most appropriate?





Explanation

In very young children with significant growth remaining (Tanner stage I or II), physeal-sparing techniques are recommended to avoid growth arrest. An all-epiphyseal technique tunnels through the epiphysis entirely, completely avoiding both the femoral and tibial physes.

Question 15

A 23-year-old professional baseball pitcher presents with posterior shoulder pain during the late cocking phase of throwing. MRI arthrogram is likely to reveal which of the following classic findings associated with internal impingement?





Explanation

Internal impingement occurs during hyper-abduction and external rotation (late cocking phase). The greater tuberosity impinges against the posterosuperior glenoid margin, compressing the posterosuperior rotator cuff (supraspinatus/infraspinatus junction) and the posterosuperior labrum. This leads to articular-sided partial "kissing" lesions of the cuff and labrum.

Question 16

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





Explanation

In a skeletally immature patient with an intact, stable OCD lesion (indicated by intact articular cartilage and lack of fluid behind the lesion on T2 MRI), a trial of conservative management consisting of activity restriction and weight-bearing modification is indicated, as these have a high rate of spontaneous healing.

Question 17

A 19-year-old cyclist falls directly onto his shoulder and sustains a midshaft clavicle fracture. Which of the following is an absolute indication for open reduction and internal fixation?





Explanation

Absolute indications for operative fixation of a clavicle fracture include open fractures, associated neurovascular injury, and "floating shoulder" (scapular neck fracture with clavicle fracture). Skin tenting, 100% displacement, and shortening > 2 cm are generally considered relative indications depending on the patient's activity level and expectations.

Question 18

A 26-year-old male sustains a dashboard injury resulting in an isolated PCL tear. He undergoes conservative treatment but continues to have posterior instability. If PCL reconstruction is performed, which bundle of the PCL is the primary restraint to posterior tibial translation at 90 degrees of knee flexion, and should be the primary focus of an anatomic single-bundle reconstruction?





Explanation

The PCL consists of the anterolateral (AL) and posteromedial (PM) bundles. The AL bundle is larger, is tight in flexion, and provides the primary restraint to posterior translation at 90 degrees of flexion. It is the bundle targeted in single-bundle PCL reconstructions. The PM bundle is tight in extension.

Question 19

A 55-year-old female recreational runner presents with refractory lateral hip pain. MRI reveals a full-thickness tear of the gluteus medius tendon at its insertion. Which aspect of the greater trochanter does the main tendon of the gluteus medius insert onto?





Explanation

The gluteus medius inserts primarily onto the lateral and superoposterior facets of the greater trochanter. The gluteus minimus inserts more anteriorly onto the anterior facet. The posterolateral aspect is covered by the trochanteric bursa.

Question 20

A 19-year-old collegiate cross-country runner presents with a stress fracture of the femoral neck. She has a history of oligomenorrhea. As part of the female athlete triad, which underlying physiologic derangement is the primary driver of her amenorrhea and subsequent bone density loss?





Explanation

The Female Athlete Triad is fundamentally driven by low energy availability (LEA), meaning dietary energy intake is insufficient to support the energy expended during exercise. This LEA leads to hypothalamic suppression, reducing GnRH pulsatility, which causes functional hypothalamic amenorrhea and a hypoestrogenic state, ultimately culminating in reduced bone mineral density and stress fractures.

Question 21

A 25-year-old athlete sustains a dashboard injury resulting in an isolated Grade III PCL tear. He has persistent posterior instability and knee pain despite 6 months of physical therapy. You plan a single-bundle PCL reconstruction. Which of the following accurately describes the correct tunnel placement for the femoral tunnel in an anatomic single-bundle reconstruction?





Explanation

The anterolateral (AL) bundle is the larger and stronger bundle of the PCL. In a single-bundle PCL reconstruction, the femoral tunnel should be centered in the AL bundle footprint, which is located relatively shallow in the notch (closer to the articular cartilage margin of the medial femoral condyle) compared to the PM bundle footprint.

Question 22

A 30-year-old male presents with a high-velocity knee dislocation. Upon assessment, he has absent pulses in the foot. An ABI is 0.7. An emergency arteriogram confirms a popliteal artery occlusion. What is the most appropriate sequence of operative treatment?





Explanation

In the setting of a knee dislocation with vascular injury (Schenck KD IV/V with vascular compromise), the accepted protocol is to quickly stabilize the knee with a spanning external fixator to prevent disruption of the vascular repair. This is followed by immediate vascular repair (or a temporary shunt depending on ischemia time), and fasciotomies if indicated. Definitive ligamentous reconstruction is typically staged.

Question 23

A 50-year-old female presents with acute onset posteromedial knee pain after squatting. MRI reveals a complete radial tear of the posterior root of the medial meniscus.

Biomechanically, how does a medial meniscus posterior root tear alter the knee joint?





Explanation

A posterior root tear of the medial meniscus disrupts the hoop stresses of the meniscus. Biomechanically, this functions similarly to a total medial meniscectomy, leading to a significant increase in peak contact pressures and a decrease in contact area in the medial compartment, predisposing the knee to rapid osteoarthritis.

Question 24

A 22-year-old collegiate baseball pitcher complains of vague anterior shoulder pain and a 'dead arm' sensation. MRI arthrogram shows a Type II SLAP tear. Nonoperative management has failed. During arthroscopy, a peel-back of the superior labrum is observed. What is the most appropriate surgical management for this patient?





Explanation

In a young overhead athlete (like a baseball pitcher) with a Type II SLAP tear who fails conservative treatment, arthroscopic SLAP repair is traditionally recommended to restore the labral anchor and maintain throwing mechanics. Biceps tenodesis is typically reserved for older patients (>35-40 years), revision settings, or non-overhead athletes, as tenodesis in elite overhead throwers may alter the pitching mechanics and decrease velocity.

Question 25

A 28-year-old cyclist falls directly onto his shoulder. Radiographs demonstrate a 150% superior displacement of the clavicle relative to the acromion with no posterior displacement on the axillary view. Which ligaments/structures are disrupted in this injury?





Explanation

A Type V AC joint injury involves >100% (often up to 300%) superior displacement of the clavicle. This degree of displacement requires disruption of the AC ligaments, CC ligaments, and the stabilizing deltotrapezial fascia. Type III involves up to 100% displacement, where AC and CC are torn, but the deltotrapezial fascia is largely intact.

Question 26

A 24-year-old rugby player has recurrent anterior shoulder instability. CT scan with 3D reconstruction reveals 25% anterior glenoid bone loss. A Latarjet procedure is planned. Which of the following accurately describes the 'sling effect' provided by the Latarjet procedure?





Explanation

The Latarjet procedure stabilizes the shoulder via three mechanisms: 1) the bone block increases the anteroposterior diameter of the glenoid (bony effect); 2) the conjoint tendon acts as a dynamic sling over the lower subscapularis and anteroinferior capsule in the abduction/external rotation position (sling effect); 3) capsular repair to the stump of the coracoacromial ligament (capsular effect).

Question 27

A 21-year-old hockey player presents with groin pain exacerbated by hip flexion and internal rotation. Radiographs demonstrate a pistol grip deformity and an alpha angle of 65 degrees.

In an isolated Cam impingement, where does cartilage delamination typically first occur?





Explanation

Cam morphology involves an aspherical femoral head (reduced head-neck offset) that creates shear forces on the anterosuperior acetabular cartilage during hip flexion and internal rotation. This leads to chondral delamination from the underlying subchondral bone and subsequent labral tears in the anterosuperior quadrant. Pincer impingement typically causes direct labral compression and 'contrecoup' cartilage lesions in the posteroinferior acetabulum.

Question 28

A 19-year-old female dancer complains of a painless snapping sensation over her lateral hip when she walks. Examination reveals a palpable snap over the greater trochanter when the hip is moved from flexion to extension. Which structure is most commonly implicated in this condition?





Explanation

External snapping hip syndrome (coxa saltans) is caused by the snapping of the iliotibial (IT) band or the anterior border of the gluteus maximus over the greater trochanter during hip flexion and extension. Internal snapping hip is caused by the iliopsoas tendon snapping over the iliopectineal eminence or femoral head.

Question 29

A 22-year-old cross-country runner presents with bilateral exercise-induced leg pain that forces him to stop running after 2 miles. Symptoms resolve 30 minutes after rest. Compartment pressure testing of the anterior compartment yields a pre-exercise pressure of 20 mmHg, 1-minute post-exercise pressure of 40 mmHg, and 5-minute post-exercise pressure of 30 mmHg. What is the most appropriate management?





Explanation

The patient has Chronic Exertional Compartment Syndrome (CECS). Pedowitz criteria for diagnosis include one or more of the following: resting pressure >= 15 mmHg, 1-minute post-exercise pressure >= 30 mmHg, or 5-minute post-exercise pressure >= 20 mmHg. Given his pressures meet the criteria and he seeks definitive management for athletic limiting pain, an elective fasciotomy (typically anterior and lateral compartments) is the most effective surgical treatment.

Question 30

A 35-year-old weekend warrior sustains an acute Achilles tendon rupture while playing basketball. He opts for percutaneous surgical repair to minimize wound complications. Which nerve is at greatest risk of iatrogenic injury during a percutaneous Achilles tendon repair?





Explanation

The sural nerve courses posterolaterally in the distal third of the leg, crossing the lateral border of the Achilles tendon roughly 10 cm proximal to the calcaneal insertion. It is at the greatest risk of injury (entrapment or laceration) during percutaneous or minimally invasive Achilles tendon repairs.

Question 31

A 26-year-old soccer player has chronic lateral ankle instability despite aggressive physical therapy. You plan a modified Brostrom-Gould procedure. Which structures are repaired and advanced in this procedure?





Explanation

The Brostrom procedure involves direct repair of the torn ATFL and CFL. The Gould modification incorporates the mobilization and advancement of the extensor retinaculum (specifically the inferior extensor retinaculum) to reinforce the repair, limit inversion, and help address subtle subtalar instability.

Question 32

A 14-year-old male presents with vague knee pain and intermittent catching. Radiographs show a well-circumscribed radiolucency in the typical location for an OCD lesion of the knee. What is the most common anatomical location for an Osteochondritis Dissecans (OCD) lesion in the knee?





Explanation

The most common location for an OCD lesion in the knee is the lateral aspect of the medial femoral condyle (often remembered by the acronym LAME - Lateral Aspect Medial Epicondyle/condyle), accounting for approximately 70-80% of all cases in the knee.

Question 33

A 20-year-old collegiate pitcher undergoes a Ulnar Collateral Ligament (UCL) reconstruction utilizing a palmaris longus autograft (Tommy John surgery). Which bundle of the UCL is the primary restraint to valgus stress at the elbow during the late cocking and early acceleration phases of throwing, and must be reconstructed?





Explanation

The anterior bundle of the medial ulnar collateral ligament (UCL) is the primary static restraint to valgus stress at the elbow from 20 to 120 degrees of flexion. It is the specific bundle that is reconstructed during Tommy John surgery. The posterior bundle is a secondary restraint, and the transverse bundle (Cooper's ligament) provides no significant stability.

Question 34

A 25-year-old professional baseball pitcher complains of posterior shoulder pain during the late cocking phase of throwing. Physical exam shows a Glenohumeral Internal Rotation Deficit (GIRD) of 25 degrees compared to the contralateral side, and a positive posterior impingement sign.

What are the hallmark arthroscopic findings of internal impingement in the thrower's shoulder?





Explanation

Internal impingement occurs when the arm is in extreme abduction and external rotation (late cocking phase). The greater tuberosity impinges against the posterosuperior glenoid rim. This pinches the posterior cuff and posterosuperior labrum, leading to 'kissing lesions': partial articular-sided tears of the posterior supraspinatus/anterior infraspinatus (PASTA) and posterosuperior labral fraying.

Question 35

A 19-year-old female gymnast presents with a femoral neck stress fracture. She has a BMI of 17, secondary amenorrhea, and a history of dietary restriction. In the context of the Female Athlete Triad (now part of Relative Energy Deficiency in Sport - RED-S), which underlying pathophysiological mechanism primarily drives the decrease in bone mineral density?





Explanation

The Female Athlete Triad consists of low energy availability (with or without an eating disorder), menstrual dysfunction (commonly amenorrhea), and low bone mineral density. Low energy availability suppresses the hypothalamic-pituitary-ovarian axis, leading to hypoestrogenism. Estrogen deficiency increases osteoclastic resorption and decreases osteoblastic bone formation, leading to premature osteoporosis and an increased risk of stress fractures.

Question 36

A 45-year-old male felt a pop in his knee while descending stairs and now cannot actively extend his knee. Radiographs reveal patella baja (infera).

Which of the following is the most likely diagnosis?





Explanation

Patella baja (abnormally low-riding patella) combined with a loss of active knee extension points to a quadriceps tendon rupture, as the intact patellar tendon tethers the patella down while the superior pull of the quadriceps is lost. Conversely, a patellar tendon rupture results in patella alta (high-riding patella) due to the unopposed pull of the quadriceps.

Question 37

A 28-year-old football player sustains a contact injury to the anteromedial aspect of his knee, forcing it into hyperextension and varus. He has a positive dial test at 30 degrees of flexion, but it is equal to the contralateral side at 90 degrees. Which structure is primarily injured?





Explanation

The dial test measures external rotation of the tibia relative to the femur. Increased external rotation (>10 degrees compared to the normal side) at 30 degrees of flexion but normal rotation at 90 degrees indicates an isolated posterolateral corner (PLC) injury. If it is positive at both 30 and 90 degrees, it indicates a combined PCL and PLC injury.

Question 38

A 40-year-old male bodybuilder feels a tearing sensation in his anterior elbow while lifting a heavy object. He has an abnormal Hook test. Operative repair is planned via a two-incision technique. Which complication is most uniquely associated with the two-incision technique compared to a single-incision anterior approach?





Explanation

While the two-incision technique (anterior incision to retrieve the tendon, posterior incision to attach it to the radial tuberosity) decreases the risk of radial nerve/PIN injury compared to the single-incision approach, it historically carries a higher risk of heterotopic ossification and proximal radioulnar synostosis because it involves dissection through the interosseous membrane or exposing the ulna during the posterior approach.

Question 39

A 55-year-old tennis player sustains a fall onto an outstretched hand. He complains of anterior shoulder pain and weakness. Physical exam reveals a positive 'bear-hug' test and increased external rotation compared to the normal side. Which tendon is primarily affected, and what structure is at risk for medial subluxation as a consequence?





Explanation

The bear-hug test and belly-press test are specific for subscapularis tendon tears. An isolated subscapularis tear also leads to increased passive external rotation. The upper border of the subscapularis forms the medial wall of the bicipital groove. When the upper subscapularis tears, the long head of the biceps tendon can subluxate or dislocate medially out of the groove.

Question 40

A 25-year-old patient has a symptomatic 3 cm^2 focal full-thickness chondral defect on the medial femoral condyle. You are considering Matrix-induced Autologous Chondrocyte Implantation (MACI). Which of the following is an absolute contraindication for MACI?





Explanation

Uncorrected mechanical malalignment (e.g., varus alignment with a medial compartment defect) is an absolute contraindication for any advanced cartilage restoration procedure, including MACI. The uncorrected abnormal contact forces will lead to early failure of the graft. The malalignment must be corrected concurrently (e.g., High Tibial Osteotomy) or prior to the cartilage procedure.

Question 41

During a medial patellofemoral ligament (MPFL) reconstruction for recurrent patellar instability, the femoral attachment is identified. Which of the following best describes the anatomic location of the MPFL origin on the femur?





Explanation

The anatomic femoral origin of the MPFL is located in a saddle-like depression between the adductor tubercle (proximal) and the medial epicondyle (distal and anterior). Schöttle's point radiographically defines this attachment, situated just anterior to the posterior cortical line and proximal to the posterior border of Blumensaat's line.

Question 42

A 22-year-old elite baseball pitcher complains of vague deep shoulder pain and decreased throwing velocity. MR arthrogram demonstrates a Type II SLAP tear. If nonoperative management fails, which of the following is the most appropriate surgical intervention?





Explanation

In a young overhead athlete (e.g., <25 years) with a Type II SLAP tear who fails conservative management, arthroscopic SLAP repair is the preferred treatment, though return to previous level of play can be challenging. Older patients or non-overhead athletes typically do better with biceps tenodesis.

Question 43

When performing an ACL reconstruction, a femoral tunnel placed too anteriorly (shallow in the notch) will result in which of the following graft tension patterns?





Explanation

A femoral tunnel placed too anteriorly (in the intercondylar notch, which is high/shallow in arthroscopic position) will cause the ACL graft to be loose in extension and excessively tight in flexion, potentially limiting range of motion. Conversely, a tunnel placed too posterior (deep) results in a graft tight in extension and loose in flexion.

Question 44

The primary static stabilizers of the posterolateral corner (PLC) of the knee include all of the following EXCEPT:





Explanation

The primary static stabilizers of the PLC are the LCL, popliteus tendon, and popliteofibular ligament. The biceps femoris is an important dynamic stabilizer of the lateral knee, but not considered one of the primary static restraints.

Question 45

A 45-year-old weightlifter undergoes a single-incision anterior approach for a distal biceps tendon repair. Postoperatively, he presents with inability to extend his fingers and thumb, but normal wrist extension with radial deviation. Which nerve was most likely injured during the procedure?





Explanation

The posterior interosseous nerve (PIN) is at risk during a single-incision anterior approach for distal biceps repair if retractors are placed improperly on the radial neck. Injury to the PIN results in loss of digit extension (ECDC) and thumb extension (EPL), but wrist extension is preserved albeit with radial deviation because ECRL (innervated by the radial nerve proper) is intact, whereas ECU (innervated by PIN) is paralyzed.

Question 46

A 20-year-old collegiate runner presents with bilateral leg pain that occurs consistently after 15 minutes of running and resolves within 30 minutes of rest. Which of the following intracompartmental pressure measurements confirms the diagnosis of chronic exertional compartment syndrome (CECS)?





Explanation

Pedowitz criteria for chronic exertional compartment syndrome (CECS) include 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 47

A 14-year-old male presents with vague knee pain. Radiographs reveal an osteochondritis dissecans (OCD) lesion. What is the most common anatomic location for an OCD lesion in the knee?





Explanation

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

Question 48

During an open coracoclavicular (CC) ligament reconstruction for a type V acromioclavicular joint separation, the surgeon must be aware of the anatomic orientations of the CC ligaments. Which of the following statements is true regarding the conoid and trapezoid ligaments?





Explanation

The conoid ligament is medial to the trapezoid ligament. It originates on the base of the coracoid (posterior to pec minor) and inserts on the conoid tubercle (posterior-inferior clavicle). The conoid primarily resists superior/inferior translation, while the trapezoid primarily resists horizontal (AP) compression/translation.

Question 49

A 35-year-old tennis player presents with anterior shoulder pain exacerbated by forward flexion and internal rotation. Examination demonstrates increased translation on the load-and-shift test and a positive bear-hug test. An MRI is obtained showing narrowing of the coracohumeral interval. Which structure is most likely to be injured in this condition?





Explanation

Coracoid impingement syndrome typically occurs when the coracohumeral interval is narrowed (<6-7 mm), leading to impingement of the subscapularis tendon and the long head of the biceps. The bear-hug test is highly specific for evaluating a subscapularis tendon tear.

Question 50

A 45-year-old female presents with acute knee pain after squatting. MRI reveals a medial meniscus posterior root tear. Biomechanically, what is the consequence of this tear if left untreated?





Explanation

A meniscal root tear leads to extrusion of the meniscus and a complete loss of circumferential hoop stresses. This functionally unloads the compartment, resulting in altered joint kinematics and increased peak contact pressures that are biomechanically equivalent to those seen after a total meniscectomy. Early osteoarthritis is a known sequela.

Question 51

In an overhead throwing athlete, the anterior bundle of the ulnar collateral ligament (UCL) of the elbow is the primary restraint to valgus stress. Which band of the anterior bundle is the primary restraint to valgus force in early flexion (30-60 degrees) and which is tightest in deeper flexion (90-120 degrees)?





Explanation

The anterior bundle of the UCL consists of the anterior and posterior bands. The anterior band is the primary restraint to valgus stress from 30 to 90 degrees of flexion (early/mid flexion). The posterior band becomes taut in deeper flexion (90-120 degrees).

Question 52

A 28-year-old professional volleyball player presents with insidious onset of posterior shoulder pain and weakness. Physical examination reveals isolated atrophy of the infraspinatus muscle with normal supraspinatus bulk and strength. Where is the most likely site of nerve compression?





Explanation

Entrapment of the suprascapular nerve at the spinoglenoid notch affects only the infraspinatus muscle, leading to isolated atrophy and external rotation weakness. Entrapment at the suprascapular notch (more proximal) would affect both the supraspinatus and infraspinatus muscles. Paralabral cysts associated with posterior SLAP tears are a common cause of spinoglenoid notch compression in overhead athletes.

Question 53

A 24-year-old hockey player presents with groin pain with hip flexion and internal rotation. Radiographs are ordered to evaluate for femoroacetabular impingement (FAI). An elevated alpha angle is indicative of which morphology, and on what view is it best measured?





Explanation

An elevated alpha angle (typically > 50-55 degrees) is indicative of Cam morphology (asphericity of the femoral head-neck junction). It is best measured on a Dunn lateral, cross-table lateral, or Meyer lateral radiograph. Pincer morphology is associated with acetabular overcoverage and evaluated with the lateral center-edge angle or crossover sign on an AP pelvis radiograph.

Question 54

A 30-year-old male is involved in a high-speed motor vehicle collision and sustains a knee dislocation (Schenck KD-III). Following closed reduction, distal pulses are symmetric but the ankle-brachial index (ABI) is 0.85. What is the most appropriate next step in management?





Explanation

Following a knee dislocation, vascular assessment is critical to rule out popliteal artery injury. An ABI < 0.9, even with symmetric palpable pulses, necessitates further imaging, typically CT angiography (or arterial duplex ultrasound), to definitively rule out a vascular intimal tear or occlusion. Immediate exploration is indicated for hard signs of vascular injury (e.g., absent pulses after reduction, expanding hematoma).

Question 55

A 21-year-old collegiate football player sustains a syndesmotic ankle injury after a teammate falls on his lower leg. What is the classic mechanism of injury for a syndesmotic (high) ankle sprain?





Explanation

The classic mechanism of injury for a syndesmotic (high) ankle sprain is forced dorsiflexion and external rotation of the foot relative to the tibia. This forces the wider anterior aspect of the talar dome into the mortise, spreading the tibia and fibula and injuring the anterior inferior tibiofibular ligament (AITFL) and interosseous membrane.

Question 56

A 19-year-old female dancer complains of a visible, audible 'snap' over the lateral aspect of her hip when moving from flexion to extension. She has tenderness over the greater trochanter. Which structures are most commonly involved in this condition?





Explanation

External snapping hip syndrome (coxa saltans) is most commonly caused by the iliotibial (IT) band or anterior border of the gluteus maximus snapping over the greater trochanter of the femur during hip flexion/extension. Internal snapping hip is caused by the iliopsoas tendon snapping over the iliopectineal eminence or femoral head.

Question 57

During a rotator cuff repair, an understanding of the vascular supply is essential. The 'critical zone' of the supraspinatus tendon, where tears most commonly initiate, is primarily located at what distance proximal to its insertion on the greater tuberosity?





Explanation

The 'critical zone' of the supraspinatus tendon is an area of relative hypovascularity located approximately 10 to 15 mm proximal to its insertion on the greater tuberosity. This is the most common site for degenerative rotator cuff tears.

Question 58

Articular cartilage has a highly organized structure that responds to mechanical loading. In which zone are the collagen fibers oriented perpendicular to the articular surface to provide resistance against compressive forces?





Explanation

In the deep (radial) zone of articular cartilage, the collagen fibers are arranged perpendicular to the joint surface. This arrangement provides maximal resistance to compressive forces. In the superficial tangential zone, collagen fibers are oriented parallel to the joint surface to resist shear forces.

Question 59

A 26-year-old professional baseball pitcher presents with posterior shoulder pain during the late cocking phase of throwing. He exhibits a GIRD (glenohumeral internal rotation deficit) of 25 degrees. Which of the following best describes the pathophysiology of internal impingement in this patient?





Explanation

Internal impingement (posterior superior glenohumeral impingement) occurs in overhead throwing athletes during the late cocking phase (abduction and maximal external rotation). It involves the impingement of the undersurface of the posterior supraspinatus and anterior infraspinatus along with the posterosuperior labrum between the greater tuberosity and the posterosuperior glenoid rim.

Question 60

When performing a transtibial posterior cruciate ligament (PCL) reconstruction, the graft is subjected to high stress at the acute angle where it exits the posterior tibial tunnel and heads anteriorly to the femoral footprint. This phenomenon is known as the 'killer turn'. Which surgical technique was developed specifically to avoid this issue?





Explanation

The tibial inlay technique involves a posterior approach to the knee and fixing the bone block of a bone-patellar tendon-bone graft directly into a trough at the posterior tibial anatomic footprint of the PCL. This avoids the acute angle ('killer turn') at the posterior aperture of a transtibial tunnel, which can cause graft abrasion and attenuation.

Question 61

A 25-year-old professional football player sustains a contact injury to his knee. On physical examination, the Dial test demonstrates 15 degrees of increased external rotation on the injured side compared to the contralateral side at 30 degrees of knee flexion. However, at 90 degrees of knee flexion, the external rotation is symmetric bilaterally. Based on these findings, which of the following structures is most likely INTACT?





Explanation

The Dial test is used to evaluate posterolateral corner (PLC) and posterior cruciate ligament (PCL) injuries. An increase of >10 degrees of external rotation at 30 degrees of flexion compared to the uninjured side indicates an isolated PLC injury. If the asymmetry is present at both 30 degrees and 90 degrees of flexion, it indicates a combined PLC and PCL injury. Since the test is symmetric at 90 degrees, the PCL is intact.

Question 62

A 50-year-old female presents with acute medial knee pain after feeling a 'pop' while squatting. An MRI is obtained.

Imaging confirms a medial meniscus posterior root tear. What is the primary biomechanical consequence of this specific injury if left untreated?





Explanation

Meniscal root tears disrupt the circumferential continuity of the meniscus, leading to a loss of hoop stresses. This results in meniscal extrusion and alters the knee's biomechanics, effectively increasing tibiofemoral contact pressures to levels equivalent to a total meniscectomy, predisposing the patient to rapid osteoarthritis.

Question 63

A 22-year-old rugby player presents with recurrent anterior shoulder instability despite a prior arthroscopic Bankart repair. A revision MRI arthrogram demonstrates a 'J-sign' in the axillary pouch rather than the normal U-shape.

Which of the following describes the pathology?





Explanation

A HAGL (Humeral Avulsion of the Glenohumeral Ligament) lesion occurs when the inferior glenohumeral ligament (IGHL) is avulsed from its humeral attachment. On a coronal MRI arthrogram, the normal U-shaped axillary recess is converted to a J-shape due to extravasation of contrast through the humeral-sided defect. Failure to recognize a HAGL lesion is a known cause of recurrent instability following an isolated Bankart repair.

Question 64

A 21-year-old collegiate pitcher undergoes ulnar collateral ligament (UCL) reconstruction using the docking technique with a palmaris longus autograft.

What is the most common postoperative complication associated with this procedure?





Explanation

Ulnar neuropathy is the most common complication following UCL reconstruction, reported in 5% to 20% of cases, though it is usually transient. Meticulous care to protect or properly transpose the ulnar nerve is critical during the approach and tunnel drilling.

Question 65

A 45-year-old manual laborer presents with a massive, irreparable posterosuperior rotator cuff tear involving the supraspinatus and infraspinatus. The subscapularis is completely intact. He demonstrates a lag sign and pseudoparalysis of external rotation, but maintains forward elevation to 130 degrees. Which of the following tendon transfers is biomechanically optimal to restore external rotation in this patient?





Explanation

In the setting of a massive irreparable posterosuperior rotator cuff tear with an intact subscapularis and preserved forward elevation, the primary functional deficit is loss of external rotation. The lower trapezius transfer, often augmented with an Achilles tendon allograft, has a superior line of pull matching the native infraspinatus compared to the latissimus dorsi, making it biomechanically optimal for restoring external rotation.

Question 66

A 28-year-old patient is scheduled for an osteochondral allograft (OCA) reconstruction for a 4x4 cm focal symptomatic chondral defect on the medial femoral condyle. To maximize chondrocyte viability at the time of implantation, what is the optimal storage protocol for the allograft?





Explanation

Osteochondral allografts depend on viable chondrocytes to maintain the extracellular matrix. Fresh storage at 4°C is the standard. While immediate use ensures the highest viability, a mandatory 14-day disease testing period (for HIV, Hep B/C, etc.) is required. The optimal window for implantation balancing safety and chondrocyte viability is typically 14 to 28 days.

Question 67

A 24-year-old marathon runner presents with chronic, bilateral anterolateral leg pain that reliably begins 15 minutes into a run and resolves shortly after resting. Suspecting chronic exertional compartment syndrome (CECS), intracompartmental pressures are measured. According to the Pedowitz criteria, which of the following measurements confirms the diagnosis?





Explanation

The modified Pedowitz criteria for chronic exertional compartment syndrome (CECS) are: (1) Resting pre-exercise pressure >= 15 mmHg; (2) 1-minute post-exercise pressure >= 30 mmHg; or (3) 5-minute post-exercise pressure >= 20 mmHg. A resting pressure of 16 mmHg and 1-minute post-exercise pressure of 35 mmHg meets two of these criteria.

Question 68

A 32-year-old female runner complains of deep gluteal pain that radiates down the posterior thigh. Symptoms are exacerbated by long strides. MRI of the pelvis demonstrates narrowing of the space between the ischial tuberosity and the lesser trochanter. Edema and signal change are most likely to be seen in which of the following muscles?





Explanation

Ischiofemoral impingement is characterized by narrowing of the space between the ischial tuberosity and the lesser trochanter. This compression typically results in edema, inflammation, or tearing of the quadratus femoris muscle, which runs through this anatomic space.

Question 69

A 18-year-old female with recurrent patellar instability is undergoing medial patellofemoral ligament (MPFL) reconstruction. When identifying the femoral attachment radiographically using the Schottle point, where should the origin be placed on a true lateral radiograph?





Explanation

Schottle's point describes the radiographic anatomy of the femoral insertion of the MPFL on a true lateral radiograph. It is located 1 mm anterior to a line extending from the posterior femoral cortex, 2.5 mm distal to a perpendicular line intersecting the posterior origin of the medial femoral condyle, and proximal to the level of the posterior medial epicondyle.

Question 70

A 25-year-old male presents with symptomatic instability 3 years after primary ACL reconstruction. Radiographs and CT scan demonstrate a well-placed femoral tunnel but substantial widening of the tibial tunnel, measuring 16 mm in diameter. What is the most appropriate management strategy?





Explanation

In revision ACL reconstruction, tunnel widening greater than 14 mm is generally an indication for a two-stage procedure. The first stage involves removing the old hardware and bone grafting the enlarged tunnels. The second stage, performed 4-6 months later after graft incorporation, involves the new ACL reconstruction. Single-stage revision with a 16 mm tunnel poses a high risk of poor graft fixation and failure.

Question 71

A 30-year-old competitive weightlifter feels a sudden tearing sensation in his anterior shoulder/chest while performing the eccentric (downward) phase of a heavy bench press. On examination, he has weakness in internal rotation and an asymmetric axillary fold.

Which portion of the pectoralis major tendon is most susceptible to injury in this scenario?





Explanation

Pectoralis major ruptures most commonly occur in young, active males during the eccentric phase of a bench press. The sternal head at the humeral insertion is the most frequently torn segment. The sternal head tendon twists 180 degrees before inserting on the humerus, placing it under maximal tension when the arm is extended and externally rotated.

Question 72

A 22-year-old collegiate hockey player complains of insidious onset anterior groin pain, worse with deep hip flexion. Physical exam reveals a positive FADIR test. Plain radiographs, including a Dunn lateral view, demonstrate an abnormal head-neck junction. An alpha angle greater than what threshold is highly indicative of symptomatic Cam-type femoroacetabular impingement (FAI)?





Explanation

The alpha angle is used to quantify the severity of a Cam deformity in femoroacetabular impingement (FAI). It is measured on a lateral radiograph (like the Dunn view) or axial MRI/CT. An alpha angle > 50-55 degrees indicates a loss of normal sphericity at the femoral head-neck junction, characteristic of Cam impingement.

Question 73

A 40-year-old male sustains an acute distal biceps tendon rupture while lifting a heavy object. He undergoes surgical repair utilizing a single-incision anterior approach. Which nerve is most at risk of injury during this specific surgical approach?





Explanation

The lateral antebrachial cutaneous nerve (LABCN), a continuation of the musculocutaneous nerve, is the most commonly injured nerve during a single-incision anterior approach for distal biceps repair. Injury to the Posterior Interosseous Nerve (PIN) is classically associated with the two-incision approach if the forearm is not kept in full supination during the posterior dissection.

Question 74

A 25-year-old professional athlete sustains a severe syndesmotic sprain (high ankle sprain) with radiographic widening of the ankle mortise. The surgeon discusses fixation utilizing a dynamic suture-button construct versus rigid syndesmotic screw fixation. Based on current literature, what is a primary advantage of dynamic fixation?





Explanation

Dynamic suture-button constructs (e.g., TightRope) allow for physiological micromotion at the syndesmosis and do not require routine removal, unlike syndesmotic screws which often break or are removed prior to full weight-bearing. Studies show similar or improved functional outcomes and a lower reoperation rate for hardware removal with dynamic fixation.

Question 75

A 26-year-old baseball pitcher presents with posterior shoulder pain that is most severe during the late cocking phase of throwing. He has a 20-degree glenohumeral internal rotation deficit (GIRD). Arthroscopic evaluation reveals 'internal impingement.' Which structures are pathologically abutting each other in this condition?





Explanation

Internal impingement typically affects overhead-throwing athletes during the late cocking phase (maximum abduction and external rotation). It involves the pathologic abutment of the articular (undersurface) side of the posterior supraspinatus and anterior infraspinatus tendons against the posterosuperior glenoid labrum, leading to 'kissing lesions' (partial-thickness cuff tears and labral fraying).

Question 76

A 45-year-old male trips and falls on his flexed knee while playing basketball. He is unable to actively perform a straight leg raise. Lateral radiographs of the knee demonstrate significant patella baja (infera). What is the most likely diagnosis?





Explanation

In a quadriceps tendon rupture, the patella is pulled distally by the intact patellar tendon, resulting in patella baja on lateral radiographs. Conversely, a patellar tendon rupture would result in patella alta due to the unopposed proximal pull of the quadriceps muscle. Quadriceps tendon ruptures are also more common in patients > 40 years old.

Question 77

A 35-year-old recreational basketball player sustains an acute Achilles tendon rupture. He is evaluating operative versus non-operative treatment. Based on recent high-level randomized controlled trials (RCTs), what is true regarding early functional rehabilitation protocols (non-operative) compared to surgical repair?





Explanation

Recent high-level evidence (such as the Willits RCT) demonstrates that when an early, dynamic functional rehabilitation protocol is strictly followed, the re-rupture rate of non-operatively treated Achilles tendon ruptures is equivalent to surgically treated ones. Non-operative management avoids surgical complications such as infection, wound breakdown, and sural nerve injury.

Question 78

A 21-year-old ballerina presents with an audible and palpable 'clunk' deep in her anterior groin. This consistently occurs when she extends her hip from a flexed, abducted, and externally rotated position. She denies any history of trauma. What is the most likely anatomic cause of this specific snapping?





Explanation

This is the classic presentation of Internal Snapping Hip syndrome (Coxa Saltans Interna). It is caused by the iliopsoas tendon snapping over the iliopectineal eminence or the anterior femoral head as the hip is moved from a flexed, abducted, and externally rotated position into extension and internal rotation. External snapping hip involves the IT band over the greater trochanter.

Question 79

A 20-year-old collegiate rugby player sustains a closed, midshaft clavicle fracture. He is treated non-operatively in a sling. At his 6-week follow-up, he is pain-free with full shoulder range of motion. Radiographs demonstrate bridging callus on 2 of 4 cortices. What is the standard recommendation for return to contact/collision sports?





Explanation

Return to contact or collision sports following a non-operatively treated clavicle fracture requires clinical healing (no pain, full ROM, symmetric strength) AND solid radiographic union, which is strictly defined as bridging callus on all 4 cortices on orthogonal views. This typically takes 10 to 12 weeks. Premature return risks refracture.

Question 80

A 40-year-old recreational tennis player has recalcitrant lateral epicondylitis (tennis elbow) that has failed 6 months of physical therapy, bracing, and NSAIDs. He elects to undergo a Platelet-Rich Plasma (PRP) injection. Based on current basic science and clinical evidence, which PRP formulation is most effective for tendinopathy such as lateral epicondylitis?





Explanation

Current evidence suggests that Leukocyte-Rich PRP (LR-PRP) is more effective for tendinopathies (such as lateral epicondylitis and patellar tendinopathy) due to the robust inflammatory response it induces, which helps restart the healing cascade in chronic tendinosis. Conversely, Leukocyte-Poor PRP (LP-PRP) is generally preferred for intra-articular injections (like knee osteoarthritis) to minimize an excessive inflammatory response and synoviocyte apoptosis.

Question 81

A 48-year-old female presents with acute medial knee pain after squatting to pick up a heavy box. She felt a "pop" in the back of her knee. MRI reveals a complete radial tear of the posterior horn of the medial meniscus within 5 mm of its bony attachment.

Biomechanically, what is the consequence of nonoperative management of this specific injury pattern?





Explanation

A posterior root tear of the medial meniscus disrupts the circumferential fibers, leading to a complete loss of hoop stresses. Biomechanical studies demonstrate that this results in contact pressures and kinematics equivalent to a total meniscectomy, rapidly accelerating the progression of osteoarthritis. Early surgical repair is recommended to restore joint mechanics.

Question 82

A 42-year-old recreational tennis player presents with vague, deep shoulder pain. He has a positive O'Brien's active compression test. MRI arthrogram reveals a Type II Superior Labrum Anterior Posterior (SLAP) tear. What is the most evidence-based surgical management for this patient if conservative therapy fails?





Explanation

In patients over 35-40 years of age, arthroscopic or open biceps tenodesis has been shown to have lower reoperation rates, less postoperative stiffness, and superior return to sport outcomes compared to arthroscopic SLAP repair for isolated Type II SLAP tears.

Question 83

A 24-year-old football player sustains a high-energy knee injury. Evaluation reveals global instability of the knee. According to the Schenck classification of knee dislocations, a KD-III-M injury specifically involves tears of which of the following ligamentous structures?





Explanation

The Schenck classification describes knee dislocations based on the pattern of ligamentous injury. KD-I is a single cruciate (usually ACL or PCL) with collateral injury. KD-II involves both ACL and PCL with intact collaterals. KD-III involves both cruciates and one collateral (KD-III-M involves the MCL; KD-III-L involves the LCL/PLC). KD-IV involves all four major ligaments. KD-V includes a periarticular fracture.

Question 84

A 12-year-old male soccer player presents with vague, intermittent medial knee pain. Radiographs demonstrate a radiolucent lesion with a sclerotic margin on the lateral aspect of the medial femoral condyle. An MRI shows a 14 mm Osteochondritis Dissecans (OCD) lesion with no subchondral fluid or cysts. His distal femoral physis is wide open. What is the most appropriate initial management?





Explanation

Juvenile OCD lesions (open physes) that are stable on MRI (absence of high T2 signal behind the fragment, no cysts, intact cartilage) have a high potential for spontaneous healing. Initial management is nonoperative, consisting of rest, activity modification (cessation of sports), and protective weight-bearing until symptoms resolve and radiographic healing is evident.

Question 85

During a Tommy John procedure (Ulnar Collateral Ligament reconstruction) using a modified Jobe technique with submuscular ulnar nerve transposition in a 20-year-old collegiate pitcher, what fascial structure must be released distally to prevent postoperative ulnar nerve compression?





Explanation

When performing a submuscular transposition of the ulnar nerve, it is critical to release potential sites of compression. Proximally, the medial intermuscular septum and the Arcade of Struthers must be resected. Distally, the deep flexor-pronator aponeurosis (fascia of the FCU) must be released as the nerve enters the two heads of the FCU to prevent distal kinking or compression.

Question 86

A 34-year-old male sustains an acute, mid-substance Achilles tendon rupture playing basketball. He elects for percutaneous surgical repair to minimize wound complications. Which nerve is at the highest risk of iatrogenic injury during this specific procedure, and what is its anatomic relationship to the Achilles tendon?





Explanation

The sural nerve is at the highest risk of injury during percutaneous or minimally invasive Achilles tendon repairs. It courses proximal to distal, moving from the midline of the posterior calf to the lateral aspect, crossing the lateral border of the Achilles tendon approximately 9.8 cm proximal to the calcaneal insertion.

Question 87

A 21-year-old hockey player presents with chronic groin pain exacerbated by deep flexion. Examination reveals a positive anterior impingement (FADIR) test. AP pelvis and Dunn lateral radiographs are obtained.

The radiograph shows an alpha angle of 68 degrees. This finding is most characteristic of which pathomorphology?





Explanation

An alpha angle greater than 50-55 degrees on a lateral or Dunn view of the hip indicates Cam morphology, characterized by asphericity (a "bump") at the anterolateral femoral head-neck junction. This bony prominence impacts the anterosuperior acetabular rim during flexion and internal rotation, causing labral and chondral damage.

Question 88

A 28-year-old professional soccer player is diagnosed with a core muscle injury (athletic pubalgia) after complaining of chronic, insidious-onset lower abdominal and proximal adductor pain. The underlying pathophysiology most commonly involves a biomechanical imbalance between which two opposing muscular attachments on the pubis?





Explanation

Athletic pubalgia, or core muscle injury, is fundamentally an injury to the pubic joint complex. It is most commonly caused by a functional imbalance and antagonistic pull between the rectus abdominis (pulling superiorly) and the adductor longus (pulling inferiorly) at their common aponeurotic attachment on the pubis.

Question 89

A 29-year-old competitive weightlifter feels a sharp 'tearing' sensation in his anterior axilla while performing a heavy bench press. Examination reveals extensive ecchymosis, a loss of the anterior axillary fold contour, and weakness in internal rotation and adduction. MRI confirms a complete avulsion of the sternoclavicular head from the humerus. Which of the following is true regarding surgical repair of this injury?





Explanation

In active individuals and athletes, surgical repair of a complete pectoralis major rupture (especially the sternoclavicular head, which ruptures most commonly during the eccentric phase of a bench press) yields significantly superior subjective outcomes, return to sport, and peak torque strength compared to nonoperative management. The sternoclavicular head actually inserts distal to the clavicular head on the humerus, forming a twisted "U" shaped tendon.

Question 90

A 19-year-old female collegiate distance runner presents with bilateral anterior leg pain and paresthesias on the dorsum of her foot that reliably occur 15 minutes into a run and resolve 30 minutes after stopping. She undergoes intracompartmental pressure testing. According to the Pedowitz criteria, which of the following pressure measurements is diagnostic for Chronic Exertional Compartment Syndrome (CECS)?





Explanation

The modified Pedowitz criteria for diagnosing Chronic Exertional Compartment Syndrome (CECS) require one or more of the following intracompartmental pressure values: a pre-exercise (resting) pressure >15 mmHg, a 1-minute post-exercise pressure >30 mmHg, or a 5-minute post-exercise pressure >20 mmHg.

Question 91

A 13-year-old elite baseball pitcher presents with insidious onset of shoulder pain in his throwing arm. Radiographs reveal widening and lateral fragmentation of the proximal humeral physis. What is the fundamental pathophysiology of this condition (Little League Shoulder)?





Explanation

Little League Shoulder is an overuse injury seen in skeletally immature overhead throwing athletes. The repetitive rotational torque stresses the open physis, causing a fatigue failure that manifests as a Salter-Harris type I stress fracture (epiphysiolysis) of the proximal humeral physis.

Question 92

A 26-year-old male presents with persistent medial knee pain following a localized trauma 2 years ago. He has failed nonoperative management. MRI reveals an isolated, well-contained 4.0 cm^2 full-thickness chondral defect on the weight-bearing surface of the medial femoral condyle. The subchondral bone is intact. What is the most appropriate cartilage restoration procedure for a defect of this size?





Explanation

For large, full-thickness chondral defects (>2.0 to 3.0 cm^2) in young, active patients, cell-based therapies like MACI (or osteochondral allograft) are indicated. Microfracture and OATS (autograft) are generally reserved for smaller defects (<2.0 cm^2) due to the poor wear characteristics of fibrocartilage (microfracture) and donor site morbidity (OATS). Debridement alone is insufficient for a symptomatic 4cm^2 defect.

Question 93

A 52-year-old man trips on a stair and experiences a sudden inability to actively extend his right knee. Examination reveals a palpable defect proximal to the patella. Radiographs demonstrate patella baja. He undergoes a primary quadriceps tendon repair using transosseous tunnels. To optimize patellofemoral tracking and minimize abnormal tilt, where should the transosseous tunnels be positioned within the patella?





Explanation

When repairing a quadriceps tendon rupture via transosseous tunnels, the drill holes should be placed in the anterior half (or anterior third) of the patella. If the sutures are tied too posteriorly (near the articular surface), it causes an anterior tilt of the superior pole of the patella, leading to abnormal patellofemoral contact pressures and tracking.

Question 94

A 22-year-old soccer player sustains a twisting injury to his left knee. Physical examination reveals a positive Dial test, demonstrating 15 degrees of increased external rotation compared to the contralateral knee at 30 degrees of flexion, but symmetric external rotation at 90 degrees of flexion. Which structure is unequivocally injured?





Explanation

The Dial test evaluates external rotation of the tibia relative to the femur. Increased external rotation (>10 degrees compared to the normal side) at 30 degrees of flexion, with normal rotation at 90 degrees, indicates an isolated injury to the posterolateral corner (PLC). If external rotation is increased at both 30 and 90 degrees, it indicates a combined PLC and PCL injury.

Question 95

A 27-year-old professional volleyball attacker complains of insidious posterior shoulder aching and weakness when attempting to spike the ball. Physical exam reveals notable atrophy of the infraspinatus fossa, but the supraspinatus fossa appears normal. External rotation strength is 3/5, while abduction strength in the scapular plane is 5/5. Where is the most likely anatomic location of nerve compression?





Explanation

The suprascapular nerve innervates the supraspinatus and then passes through the spinoglenoid notch to innervate the infraspinatus. Entrapment at the suprascapular notch affects both muscles (supraspinatus and infraspinatus weakness/atrophy). Entrapment at the spinoglenoid notch (often due to a paralabral cyst from a posterior labral tear in overhead athletes) affects only the infraspinatus.

Question 96

A 24-year-old American football running back sustains a hyper-dorsiflexion injury to his first metatarsophalangeal (MTP) joint on an artificial turf field. He is diagnosed with a severe 'turf toe' injury. Which anatomic structure is the primary plantar restraint to dorsal subluxation of the proximal phalanx at the first MTP joint?





Explanation

Turf toe is a sprain of the first MTP joint, typically caused by forced hyper-dorsiflexion. The plantar plate complex (which includes the plantar plate proper, the sesamoids, and the flexor hallucis brevis tendons) is the primary static and dynamic restraint preventing dorsal subluxation of the proximal phalanx.

Question 97

A 19-year-old female gymnast is diagnosed with a second metatarsal stress fracture. She reports amenorrhea for the last 9 months and a highly restrictive diet. Dual-energy X-ray absorptiometry (DEXA) reveals a Z-score of -1.8. According to the current consensus on the Female Athlete Triad and Relative Energy Deficiency in Sport (RED-S), what is the driving pathophysiologic factor for her compromised bone mineral density?





Explanation

The Female Athlete Triad (low energy availability, menstrual dysfunction, and low bone mineral density) is driven by low energy availability (with or without a disordered eating component). This energetic deficit suppresses the hypothalamic-pituitary-ovarian axis, leading to hypoestrogenism, which disrupts normal bone metabolism and results in decreased bone mineral density.

Question 98

A 22-year-old lacrosse player sustains a rotational ankle injury. Radiographs show no fracture, but the external rotation stress view reveals a medial clear space of 6 mm. MRI confirms a syndesmotic injury.

Which ligament is the first to tear in this sequence and provides the primary resistance to anterior translation of the distal fibula?





Explanation

In a syndesmotic 'high ankle' sprain, the anterior inferior tibiofibular ligament (AITFL) is typically the first structure to tear during an external rotation mechanism. It provides approximately 35% of the resistance to lateral displacement of the fibula and is the primary restraint to anterior translation of the distal fibula.

Question 99

A 17-year-old female presents with recurrent lateral patellar dislocations. Nonoperative management has failed. MRI evaluation of her knee demonstrates a normal trochlear depth but reveals a tibial tubercle-trochlear groove (TT-TG) distance of 22 mm. What is the most appropriate surgical intervention to correct this specific anatomic risk factor?





Explanation

A TT-TG distance >20 mm is considered an absolute indication for a medializing tibial tubercle osteotomy (such as a Fulkerson anteromedialization osteotomy) to correct the severe lateral vector force on the patella. While MPFL reconstruction is often performed concurrently, isolated MPFL reconstruction in the setting of a TT-TG >20 mm has a high failure rate.

Question 100

A 25-year-old professional baseball pitcher presents with chronic, posterior shoulder pain during the late cocking and early acceleration phases of throwing. Physical examination reveals a glenohumeral internal rotation deficit (GIRD) of 25 degrees. What is the classic pathophysiologic mechanism of "internal impingement" in this athlete?





Explanation

Internal impingement in overhead throwing athletes occurs in the late cocking phase (maximum external rotation and abduction). It involves the abnormal abutment or "pinching" of the articular surface of the posterior rotator cuff (infraspinatus/supraspinatus) and the posterosuperior labrum between the greater tuberosity and the posterior-superior glenoid rim. It is highly associated with GIRD and anterior capsular laxity.

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