Orthopedic Sports Medicine 2026 MCQs: Board Review

Question 1

An 18-year-old high school football player sustains a thigh injury that results in the findings shown in Figure 1. Initial management should consist of

Explanation

The radiograph shows myositis ossificans within the quadriceps muscle. This condition occurs as a complication of muscle injury. Initial treatment should include rest, ice, compression, and elevation. While gentle active range of motion is encouraged in the functional recovery from this injury, passive stretching is contraindicated as it can enhance hemorrhage and accentuate the development of myositis ossificans. Ultrasound is similarly contraindicated because it can enhance the development of myositis ossificans and has no proven efficacy in this patient; electrical stimulation also has no proven benefits. Massage is contraindicated in the initial management of this injury because of its influence on increasing local blood flow. Anderson JE (ed): Grant's Atlas of Anatomy. Baltimore, MD, Williams & Wilkins, 1978, pp 4.39-4.49. Brumet ME, Hontas RB: The thigh, in DeLee JC, Drez D Jr (eds): Orthopaedic Sports Medicine. Philadelphia, PA, WB Saunders, 1994, pp 1086-1112. Antao NA: Myositis of the hip in a professional soccer player: A case report. Am J Sports Med 1988;16:82-83.

Question 2

What is the function of the rotator cuff during throwing?

Explanation

The coupled action of the rotator cuff prevents superior migration and controls anterior and posterior translation by depressing the humeral head. Poppen NK, Walker PS: Normal and abnormal motion of the shoulder. J Bone Joint Surg Am 1976;58:195-201.

Question 3

A 24-year-old female soccer player has had lateral joint line pain and a recurrent effusion in the left knee after sustaining a twisting injury 6 weeks ago. She reports that symptoms worsen with athletic activities. MRI scans are shown in Figures 2a through 2c. What is the most likely diagnosis?

Explanation

2b 2c The MRI scans show the typical findings of a torn discoid lateral meniscus. The average transverse diameter of the lateral meniscus is 11 or 12 mm. A discoid lateral meniscus is suggested when three or more contiguous 5-mm sagittal sections on the MRI scan show continuity of the menicus between the anterior and posterior horns, or when two adjacent peripheral sagittal 5-mm sections show equal meniscal height. Normally the black "bow tie" would be seen on two contiguous sagittal sections. The presence of a discoid meniscus can be further confirmed if coronal views reveal increased width. Jordan MR: Lateral meniscal variants: Evaluation and treatment. J Am Acad Orthop Surg 1996;4:191-200.

Question 4

A 29-year-old woman who underwent an anterior cruciate ligament (ACL) reconstruction 6 months ago now reports difficulty achieving full knee extension, and physical therapy fails to provide relief. The knee is stable on ligament testing. Figure 3 shows the findings at a repeat arthroscopy. Treatment should now include

Explanation

The patient has a cyclops lesion. This is a nodule of fibroproliferative tissue that originates from either drilling debris from the tibial tunnel or remnants of the ACL stump; more rarely it is the result of broken graft fibers. The treatment of choice is excision of the nodule and, if needed, additional notchplasty. Marked improvements in function and symptoms have been noted after removal of the extension block and resumption of a rehabilitation program. Delince P, Krallis P, Descamps PY, et al: Different aspects of the cyclops lesion following anterior cruciate ligament reconstruction: A multifactorial etiopathogenesis. Arthroscopy 1998;14:869-876.

Question 5

The major blood supply to the cruciate ligaments arises from which of the following structures?

Explanation

The major blood supply to the cruciate ligaments arises from the ligamentous branches of the middle genicular artery. Few terminal branches of the inferior genicular artery contribute to the blood supply. The synovial plexus and sheath covering the cruciate ligaments are also supplied by branches of the middle genicular artery. The blood supply to the cruciate ligaments is predominately of soft-tissue origin. There is no significant osseous vascular contribution to the ligaments. Arnoczky SP: Anatomy of the anterior cruciate ligament. Clin Orthop 1983;172:19-25.

Question 6

In the anterior cruciate ligament (ACL)-deficient knee, which of the following variables has the highest correlation with the development of arthritis?

Explanation

Ample evidence supports an increased rate of degenerative arthritis in the ACL-deficient knee. Several variables play a role in the development of the arthritis, but the integrity of the meniscus has been shown to be the single most important factor. O'Brien WR: Degenerative arthritis of the knee following anterior cruciate ligament injury: Role of the meniscus. Sports Med Arthroscopy Rev 1993;1:114-118. Fetto JF, Marshall JL: The natural history and diagnosis of anterior cruciate ligament insufficiency. Clin Orthop 1980;147:29-38.

Question 7

A 20-year-old football player has immediate pain in the midfoot and is unable to bear weight after an opposing player lands on the back of his plantar flexed foot. AP and lateral radiographs are shown in Figures 4a and 4b. Management should consist of

Explanation

4b The history and radiographs indicate a Lisfranc fracture-dislocation of the foot. The radiographs show the classic "fleck sign," which is an avulsion of the Lisfranc ligament from the base of the second metatarsal. Most authors recommend open reduction and internal fixation of this injury. Closed reduction can be attempted, but anatomic reduction is unlikely because of the interposed bone fragments and soft tissues. Standard radiographs are not reliable in identifying 1 to 2 mm of subluxation of the tarsometatarsal joint. The tarsometatarsal joint has a poor tolerance to even mild subluxation, and the resulting decrease in joint contact area increases the likelihood of posttraumatic arthritis. Open reduction with the joint visible allows more anatomic reduction and internal fixation of larger osteochondral fragments or excision of smaller interposed fragments. Bellabarba C, Sanders R: Dislocations of the foot, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, vol 2, pp 1539-1558.

Question 8

What effect does deep freezing have on allograft tissue?

Explanation

Deep freezing is the simplest and most widely used method of ligament allograft storage. All cells in the tissue are destroyed with the freezing. However, for this reason, it is not a preferred storage method for menisci or cartilage allografts. Although this method may enhance success because it removes potential antigens located on the cells, it cannot guarantee elimination of HIV transmission. The advantage of cryopreservation storage is that a significant number of cells will survive the process, a factor important in meniscal allograft survival after implantation. No deleterious effects are noted clinically because of the acellularity of the tissue. Shelton WR, Treacy SH, Dukes AD, Bomboy AL: Use of allografts in knee reconstruction: I. Basic science aspects and current status. J Am Acad Orthop Surg 1998;6:165-168.

Question 9

A 32-year-old man who works as a laborer has had left trapezius wasting and lateral scapular winging after injuring his shoulder when a cargo box fell onto his neck 8 months ago. He now reports posterior shoulder pain and fatigue, and he has difficulty shrugging his shoulder. Examination reveals marked scapular winging, impingement signs, and an asymmetrical appearance when the patient attempts a shoulder shrug. Primary scapular-trapezius winging is the result of damage to the

Explanation

The patient has primary scapular-trapezius winging. This condition can be caused by blunt trauma to the relatively superficial spinal accessory nerve that is located in the floor of the posterior cervical triangle in the subcutaneous tissue. Other causes of injury include penetrating trauma, traction, or surgical injury. With trapezius winging, the shoulder appears depressed and laterally translated because of an unopposed serratus anterior. This contrasts with primary serratus anterior winging, which is caused by injury to the long thoracic nerve. In this condition, the scapula assumes a position of superior elevation and medial translation, and the inferior angle is rotated medially. The thoracodorsal nerve supplies the latissimus dorsi and is not involved in primary scapular winging. Kuhn JE, Plancher KD, Hawkins RJ: Scapular winging. J Am Acad Orthop Surg 1995;3:319-325.

Question 10

A 32-year-old football coach has had a 4-month history of increasing right wrist pain, particularly during blocking exercises, and he reports significant pain with range of motion and gripping activities. He denies any history of trauma. Examination reveals dorsal wrist tenderness and boggy fullness over the dorsum of the wrist. No erythema is noted. Grip strength is 60% compared with the opposite side. Radiographs are shown in Figures 5a and 5b. What is the most likely diagnosis?

Explanation

5b The patient has Kienbock's disease (osteonecrosis of the lunate), which presents with boggy synovitis of the wrist, decreased range of motion, and often normal radiographs. The patient's radiographs reveal small fragments from the lunate, with increased density in the lunate body. While a traumatic event may precede the patient's pain, often an insidious increase in pain is found. Repetitive trauma has been suggested as a possible cause. This disease process is classically associated with an ulnar-negative variant. An MRI scan, revealing a low-intensity signal in the lunate, is the best diagnostic tool for early Kienbock's disease. Green DP, Hotchkiss RN, Pederson WC: Green's Operative Hand Surgery, ed 4. Philadelphia, PA, Churchill Livingstone, 1999, pp 837-848.

Question 11

Which of the following properties apply to the human meniscus when compared with articular cartilage?

Explanation

The meniscal cartilage, like articular cartilage, possesses viscoelastic properties. The extracellular matrix is a biphasic structure composed of a solid phase (collagen, proteoglycan) that acts as a fiber-reinforced porous-permeable composite, and a fluid phase that may be forced through the solid matrix by a hydraulic pressure gradient. Although these properties are shared with articular cartilage, the meniscus is more elastic and less permeable than articular cartilage. Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 3-23.

Question 12

An 18-year-old football player lands on a flexed knee and ankle after being tackled. Examination reveals increased external rotation and posterior translation and varus at 30 degrees of flexion, which decreases as the knee is flexed to 90 degrees. What is the most likely diagnosis?

Explanation

The flexed knee and ankle mechanism of injury can result in a PCL and/or posterolateral corner injury. The examination reveals an isolated injury to the posterolateral corner (arcuate, popliteus, posterolateral capsule). This results in increased posterior translation and external rotation, as well as varus that is most notable at 30 degrees of flexion and decreases as the knee is further flexed to 90 degrees. Combined PCL and posterolateral corner injuries are characterized by increasing instability as the knee is flexed to 90 degrees from 30 degrees, while isolated PCL tears show the greatest degree of instability at 90 degrees of flexion. A rupture of the quadriceps tendon would not affect anterior or posterior stability, whereas an isolated rupture of the lateral collateral ligament, which is a rare injury, is characterized by varus instability at 30 degrees of knee flexion without posterior translation. Harner CD, Hoher J: Evaluation and treatment of posterior cruciate ligament injuries. Am J Sports Med 1998;26:471-482.

Question 13

Figure 6 shows the radiograph of a 14-year-old baseball player who felt a pop and had an immediate onset of pain in his elbow after a hard throw from the outfield. The best course of action should be to

Explanation

The valgus stress at the elbow caused by throwing strains the medial collateral ligament. The medial epicondyle, on which the ligament inserts, is the last ossification center to fuse to the distal humerus, and acute avulsion of the medial epicondyle can occur in adolescents. If the elbow is allowed to heal in a displaced position, valgus instability and loss of elbow extension may result. Valgus instability is especially problematic for the throwing athlete. Surgical treatment with rigid internal fixation is the treatment of choice for displaced medial epicondyle avulsion fractures. Valgus instability is prevented, and the rigid fixation allows for early range of motion. Case SL, Hennrikus WL: Surgical treatment of displaced medial epicondyle fractures in adolescent athletes. Am J Sports Med 1997;25:682-686.

Question 14

Osteophyte formation at the posteromedial olecranon and olecranon articulation in high-caliber throwing athletes is most often the result of underlying

Explanation

During the late acceleration phase of throwing, the triceps forcibly contracts, extending the elbow as the ball is released. Normally, this force is absorbed by the anterior capsule and the brachialis and biceps muscles. However, if the ulnar collateral ligament is insufficient, the elbow will be in a subluxated position during extension and cause impaction of the olecranon and the olecranon fossa posteromedially. Over time, osteophyte formation is likely to occur. Conway JE, Jobe FW, Glousman RE, Pink M: Medial instability of the elbow in throwing athletes: Treatment by repair or reconstruction of the ulnar collateral ligament. J Bone Joint Surg Am 1992;74:67-83.

Question 15

Sudden cardiac death in the young athlete is most frequently caused by

Explanation

Hypertrophic cardiomyopathy is the leading cause of sudden cardiac death in athletes, accounting for 40% of reported cases. Most athletes have no previous symptoms, and sudden death may be the first clinical manifestation. The prevalence of hypertrophic cardiomyopathy in the general population is 1 in 500, with a mortality rate of 2% to 4% in young adults. Athletes with active myocarditis should not engage in sports for up to 6 months, and although they may be at risk for the development of chronic cardiomyopathy, it is rarely a cause of sudden cardiac death. Mitral valve prolapse with an accompanying systolic murmur is common in the general population, but infrequently a cause of sudden cardiac death. Weakening of the aortic wall associated with Marfan syndrome can result in abrupt rupture of the aorta. This accounts for 3% of sudden cardiac deaths in young athletes. Marfan syndrome usually can be detected on preparticipation screenings by its skeletal and ocular manifestations. Atherosclerotic coronary artery disease is the most common cause of sudden cardiac death in older athletes, accounting for 75% of reported cases. However, it is much less common in the young competitive athlete. Burke AP, Farb A, Virmani R, Goodin J, Smialek JE: Sports-related and non-sports-related sudden cardiac death in young adults. Am Heart J 1991;121:568-575.

Question 16

A 14-year-old football player has had right knee pain for the past 2 months; however, he denies any history of trauma. Examination shows an abductor lurch and increased external rotation of the right lower extremity. The best course of action should be to

Explanation

Slipped capital femoral epiphysis is the most common pathology involving the hip in adolescents. While patients with acute slips may report severe pain and are unable to ambulate, those with chronic slips often have pain during ambulation, a limp, and increased external rotation of the hip. While 60% of the patients specifically report hip pain, the remainder have pain in the thigh or knee. The initial diagnostic study of choice is AP and frog-lateral radiographs of the pelvis; bilateral involvement is frequently seen. Boyer DW, Mickelson MR, Ponseti IV: Slipped capital femoral epiphysis: Long-term follow-up study of one hundred and twenty-one patients. J Bone Joint Surg Am 1981;63:85-95.

Question 17

Which of the following is considered the appropriate initial management protocol for an unconscious football player without spontaneous respirations?

Explanation

The on-field evaluation and management of the seriously injured athlete requires advance preparation and planning. It is imperative that the health care team have a game plan in place and the proper equipment readily available. The initial step consists of stabilizing the head and neck by manually holding the head and neck in a neutral position. Then, in the following order, check for breathing, pulses, and level of consciousness. If the athlete is breathing, simply remove the mouth guard and maintain the airway. If the athlete is not breathing, the face mask must be removed and the chin strap left in place. An open airway must be established, followed by assisted breathing. CPR is only instituted when breathing and circulation are compromised. If the athlete is unconcious or has a suspected cervical spine injury, 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 Am Coll Surg 1997;82:42-44. Vegso JJ, Lehman RC: Field evaluation and management of head and neck injuries. Clin Sports Med 1987;6:1-15.

Question 18

Figure 7 shows the radiograph of an 18-year-old hockey player who sustained a shoulder injury during a fall into the side boards. Examination reveals a significant prominence at the acromioclavicular joint. Management should consist of

Explanation

The radiograph shows a type V acromioclavicular separation with greater than 100% superior elevation of the clavicle. This finding implies detachment of the deltoid and trapezius from the distal clavicle. Because of severe compromise of function and potential compromise to the overlying skin, surgery is the treatment of choice for type V acromioclavicular separations. During reduction and repair, meticulous repair of the deltotrapezial fascia will also aid in securing the repair. Nuber GW, Bowen MK: Acromioclavicular joint injuries and distal clavicle fractures. J Am Acad Orthop Surg 1997;5:11-18.

Question 19

A 22-year-old professional ballet dancer reports a 3-month history of posterior ankle pain that occurs when she changes from a flat foot to pointe (hyperplantar flexed position). Examination does not elicit the pain with forced passive plantar flexion. A radiograph is shown in Figure 8. What is the most likely cause of the pain?

Explanation

The most common causes of posterior ankle pain in ballet dancers are flexor hallucis longus tenosynovitis and os trigonum syndrome. Flexor hallucis longus tenosynovitis differs from a symptomatic os trigonum by the absence of pain with forced plantar flexion and the presence of pain with resisted plantar flexion of the great toe. The pain is often felt in the posterior ankle and can be associated with a snapping or triggering sensation. Os trigonum syndrome commonly occurs in ballet dancers who perform in a position of extreme plantar flexion. The pain occurs from entrapment of the os trigonum between the posterior portion of the talus and calcaneus. Hamilton WG, Geppert MJ, Thompson FM: Pain in the posterior aspect of the ankle in dancers: Differential diagnosis and operative treatment. J Bone Joint Surg Am 1996;78:1491-1500.

Question 20

An 18-year-old man recently underwent an uncomplicated arthroscopic partial medial meniscectomy that was complicated by reflex sympathetic dystrophy (RSD), also termed "sympathetically maintained pain" (SMP). What is the most common finding of this condition?

Explanation

The hallmark for RSD or SMP is the presence of pain that is out of proportion to that expected for the degree of the injury. SMP often extends well beyond the involved area and is present in a nonanatomic distribution. The pain is frequently described as a burning sensation, with extreme sensitivity to light touch. Joint stiffness can be present but is a nonspecific finding. There may be cold intolerance, but this is not a cardinal symptom. Sweating actually may be increased. Osteopenia, if present, is a late finding. Lindenfeld TN, Bach BR Jr, Wojtys EM: Reflex sympathetic dystrophy and pain dysfunction in the lower extremity. Instr Course Lect 1997;46:261-268.

Question 21

What is the main function of collagen found within articular cartilage?

Explanation

The main function of collagen in articular cartilage is to provide the tissue's tensile strength. It also immobilizes proteoglycans within the extracellular matrix. Compressive properties are maintained by proteoglycans. Cartilage metabolism is maintained by the indwelling chondrocytes. The flow of water through the tissue promotes transport of nutrients and provides a source of lubricant for the joint. Simon SR (ed): Orthopaedic Basic Science. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 3-44.

Question 22

A 15-year-old girl who competes in gymnastics has immediate pain and giving way of the left elbow after falling from the uneven parallel bars and landing on her outstretched arms. Examination reveals swelling and tenderness about the elbow, especially over the medial side. Measurement of elbow motion shows 0 degrees to 125 degrees of flexion, and valgus stress at the elbow is painful. AP, lateral, and stress radiographs are shown in Figures 9a through 9c. Management should consist of

Explanation

9b 9c While many low-demand patients with injuries to the ulnar collateral ligament can be treated nonsurgically, Jobe and associates described two situations in which ulnar collateral ligament reconstruction is indicated: (1) an acute complete rupture in a competitive athlete who uses the upper extremities extensively and who wishes to remain active; and (2) chronic pain or instability that does not improve after at least 3 months of nonsurgical management. Rarely is direct surgical repair of the ligament possible or able to withstand the valgus stresses applied to the elbow. Most authors recommend surgical reconstruction of the ulnar collateral ligament using a palmaris longus, plantaris, or fourth toe extensor tendon from the fourth autograft. Andrews JR, Jelsma RD, Joyce ME, et al: Open surgical procedures for injuries to the elbow in throwers. Oper Tech Sports Med 1994;4:109-133. Jobe FW, Kvitne RS: Elbow instability in the athlete. Instr Course Lect 1991;40:17-23.

Question 23

A 15-year-old boy who participates in track reports acute pain along the left iliac crest during a sprint. Examination reveals that the anterior superior iliac spine is nontender. The most likely diagnosis is an injury to the

Explanation

The patient has iliac apophysitis. The radiographic findings are easily overlooked but usually reveal slight asymmetric widening of the iliac crest apophysis. The apophysis is the most vulnerable structure, as it is three to five times weaker than the tendon. This is not an epiphyseal site, and injury to the muscle or the tendinous insertion to bone (enthesis) is unlikely. Clancy WG Jr, Foltz AS: Iliac apophysitis and stress fractures in adolescent runners. Am J Sports Med 1976;4:214-218. Waters PM, Millis MB: Hip and pelvic injuries in the young athlete, in Stanitski CL, DeLee JC, Drez D Jr (eds): Pediatric and Adolescent Sports Medicine. Philadelphia, PA, WB Saunders, 1994, pp 279-293. Lombardo SJ, Retting AC, Kerlan RK: Radiographic abnormalities of the iliac apophysis in adolescent athletes. J Bone Joint Surg Am 1983;65:444-446.

Question 24

A 40-year-old woman who is an avid tennis player reports the insidious onset of progressive left shoulder pain for the past 2 months. Examination reveals full range of motion with a positive impingement sign. Strength in the supraspinatus and infraspinatus muscles is normal, although stress testing is painful. An earlier subacromial cortisone injection provided good, but only temporary relief. An AP radiograph of the left shoulder is shown in Figure 10. Management should now consist of

Explanation

The radiograph shows calcific deposits within the substance of the supraspinatus tendon. Patients with this condition are prone to recurrent bouts of acute inflammation in the shoulder. While the response to cortisone injection is often dramatic, repeated injections are not recommended because of injury to the collagen fibers. Good results have been obtained with arthroscopic evacuation of the calcium deposits. In one study, the addition of a subacromial decompression did not improve the results. Jerosch J, Strauss JM, Schmiel S: Arthroscopic treatment of calcific tendinitis of the shoulder. J Shoulder Elbow Surg 1998;7:30-37.

Question 25

Which of the following nerves is susceptible to entrapment near the calcaneal attachment site of the plantar fascia and can mimic or co-exist with plantar fasciitis?

Explanation

The first branch of the lateral plantar nerve is susceptible to entrapment beneath the deep fascia of the adductor hallucis muscle adjacent to the calcaneal attachment of the plantar fascia. This can be a cause of chronic heel pain. Additionally, the nerve is vulnerable to injury by a blind dissection in releasing the plantar fascia. The dorsal cutaneous branch of the superficial peroneal nerve supplies sensation to the dorsum of the foot. The medial calcaneal branch of the posterior tibial nerve lies in the subcutaneous tissues and innervates the skin of the heel. It is vulnerable to injury from skin incisions on the medial side of the heel. The lateral branch of the medial plantar nerve forms the second and third common digital nerves. Entrapment of the proper medial plantar nerve can occur at the master knot of Henry. This is well distal to the calcaneal attachment of the plantar fascia, and the pain usually radiates more distally in the arch, separate from heel pain. The communicating branch of the fourth common digital nerve crosses to the third common digital nerve. Therefore, the third common digital nerve receives supply from both the lateral and medial plantar nerves. This dual supply has been implicated in the increased incidence of digital neuroma of the third common digital nerve. Bordelon RL: Heel pain, in Mann RA, Coughlin MJ (eds): Surgery of the Foot and Ankle, ed 6. St Louis, MO, CV Mosby, 1993, pp 837-857. Mann RA, Baxter DE: Diseases of the nerves, in Mann RA, Coughlin MJ (eds): Surgery of the Foot and Ankle, ed 6. St Louis, MO, CV Mosby, 1993, pp 543-574.

Question 26

In medial patellofemoral ligament (MPFL) reconstruction, placing the femoral attachment too proximal and anterior relative to Schöttle's point will result in which of the following kinematic abnormalities?

Explanation

A femoral tunnel placed too proximal to Schöttle's point leads to increased distance between the attachment sites during knee flexion. This causes excessive graft tension in deep flexion and a potential loss of motion.

Question 27

A 22-year-old collegiate baseball pitcher presents with vague posterior shoulder pain. Physical examination reveals an internal rotation deficit of 25 degrees compared to the contralateral side, but total arc of motion is symmetric. What is the primary pathoanatomic cause of this condition?

Explanation

Glenohumeral internal rotation deficit (GIRD) in overhead athletes is primarily caused by contracture and thickening of the posteroinferior capsule. A symmetric total arc of motion suggests a soft tissue adaptation rather than a bony retroversion abnormality.

Question 28

Which of the following biomechanical consequences most accurately describes an unhealed posterior medial meniscal root tear?

Explanation

A posterior medial meniscal root tear disrupts the hoop stresses of the meniscus, leading to extrusion and altered kinematics. Biomechanically, it is equivalent to a total medial meniscectomy, significantly increasing tibiofemoral peak contact pressures.

Question 29

During a transphyseal anterior cruciate ligament (ACL) reconstruction in an 11-year-old patient with wide-open physes, placing the tibial tunnel too vertically increases the risk of injuring which structure, potentially leading to which deformity?

Explanation

A steep, vertical tibial tunnel risks violating the anteriorly located tibial tubercle apophysis. Premature closure of the anterior aspect of the proximal tibial physis leads to a genu recurvatum deformity as the posterior physis continues to grow.

Question 30

A 9-year-old Tanner stage 1 male sustains a complete midsubstance anterior cruciate ligament (ACL) rupture. Which of the following surgical techniques minimizes the risk of growth arrest?

Explanation

In a Tanner stage 1 child with significant remaining growth, an all-epiphyseal (physeal-sparing) ACL reconstruction using a soft-tissue graft minimizes the risk of physeal injury and subsequent growth arrest. Bone-plug grafts across the physis are contraindicated due to a high risk of premature closure.

Question 31

Which of the following represents the primary static restraint to external rotation of the tibia at 30 degrees of knee flexion?

Explanation

The lateral collateral ligament (LCL) is the primary static restraint to varus stress and also serves as the primary restraint to external rotation at 30 degrees of knee flexion. The popliteus and popliteofibular ligament play secondary roles in resisting external rotation.

Question 32

A 22-year-old collegiate baseball pitcher complains of vague posterior shoulder pain and a decrease in pitching velocity. Physical examination reveals 20 degrees of internal rotation and 130 degrees of external rotation. Radiographs are normal. What is the most appropriate initial management?

Explanation

Glenohumeral internal rotation deficit (GIRD) in overhead throwing athletes is characterized by a loss of internal rotation with a concomitant gain in external rotation. Initial management consists of a targeted stretching program, focusing on the posterior capsule (e.g., sleeper stretches).

Question 33

A 50-year-old female experiences an acute pop in her posterior knee while squatting. MRI reveals a complete radial tear of the medial meniscus posterior root. Which of the following is the most likely biomechanical consequence of this untreated injury?

Explanation

A posterior medial meniscal root tear results in the complete loss of circumferential hoop stresses, rendering the meniscus biomechanically equivalent to a total meniscectomy. This leads to significantly increased contact pressures and rapid progression of osteoarthritis.

Question 34

During a medial patellofemoral ligament (MPFL) reconstruction, the femoral tunnel is being drilled. To reproduce native isometry, the ideal femoral attachment site should be located:

Explanation

Schottle's point defines the radiographic femoral footprint of the MPFL, which is located just proximal and posterior to the medial epicondyle, and distal to the adductor tubercle. Non-anatomic placement leads to graft tension mismatch and potential failure.

Question 35

A 23-year-old rugby player has recurrent anterior shoulder instability. CT scan shows an off-track Hill-Sachs lesion and 15% anterior glenoid bone loss. Which of the following procedures is most appropriate?

Explanation

For a patient with subcritical glenoid bone loss (<20%) but an engaging or "off-track" Hill-Sachs lesion, arthroscopic Bankart repair combined with a Remplissage procedure effectively prevents the Hill-Sachs lesion from engaging the anterior glenoid rim. Latarjet is typically reserved for critical glenoid bone loss (>20%).

Question 36

Cam impingement of the hip is primarily characterized by which of the following anatomic abnormalities?

Explanation

Cam impingement results from an aspherical femoral head and decreased anterior head-neck offset, leading to abnormal contact between the femoral neck and the anterosuperior acetabular rim during hip flexion and internal rotation. Acetabular retroversion and coxa profunda are associated with pincer impingement.

Question 37

A 35-year-old recreational basketball player sustains an acute, closed midsubstance Achilles tendon rupture. Compared to surgical repair, which of the following is a known outcome of modern functional bracing and early weight-bearing (nonoperative management)?

Explanation

Modern nonoperative management with functional bracing and early, protected weight-bearing has been shown to have rerupture rates equivalent to operative repair. However, surgical repair is associated with higher risks of wound complications and infection.

Question 38

A 28-year-old patient presents with a knee dislocation following a motorcycle accident. The knee has been reduced, and pedal pulses are palpable. What is the most appropriate next step in evaluating the vascular status of the limb?

Explanation

An ankle-brachial index (ABI) is the most appropriate initial screening tool for vascular injury following a knee dislocation, even when pulses are palpable. An ABI < 0.9 necessitates further advanced imaging, such as a CT angiogram, to rule out a popliteal artery injury.

Question 39

The anterior bundle of the ulnar collateral ligament (UCL) of the elbow originates on the anteroinferior medial epicondyle and inserts on the:

Explanation

The anterior bundle of the UCL is the primary restraint to valgus stress at the elbow. It originates on the anteroinferior aspect of the medial epicondyle and inserts on the sublime tubercle of the proximal ulna.

Question 40

A "ramp lesion" of the knee is most commonly associated with which of the following injury patterns?

Explanation

Ramp lesions represent tears of the peripheral meniscocapsular attachment of the posterior horn of the medial meniscus. They are highly associated with acute ACL tears and can lead to increased anterior tibial translation if left unrepaired.

Question 41

Microfracture for the treatment of full-thickness articular cartilage defects of the knee is most suitable for which of the following lesion characteristics?

Explanation

Microfracture is indicated for small, contained, full-thickness cartilage defects (typically less than 2 cm^2) in young, active patients. Larger lesions or uncontained lesions have unacceptably high failure rates and are better managed with techniques like osteochondral autograft or MACI.

Question 42

Which of the following graft choices for ACL reconstruction has the highest initial ultimate tensile load?

Explanation

A quadrupled hamstring graft has an ultimate tensile load of approximately 4000 N, which is the highest among common autografts and significantly stronger than the native ACL (approx. 2160 N) or a 10 mm bone-patellar tendon-bone graft (approx. 2977 N).

Question 43

During which phase of the overhead throwing motion do the highest compressive forces occur at the radiocapitellar joint, potentially leading to valgus extension overload?

Explanation

During the acceleration phase of throwing, tremendous valgus torque is placed on the elbow. This causes medial tension (stressing the UCL) and lateral compression, which can lead to radiocapitellar chondromalacia and valgus extension overload.

Question 44

To confirm the diagnosis of chronic exertional compartment syndrome, intracompartmental pressure testing is performed. According to the Pedowitz criteria, which of the following post-exercise measurements is diagnostic?

Explanation

Pedowitz criteria for chronic exertional compartment syndrome include a resting pressure >= 15 mm Hg, a 1-minute post-exercise pressure >= 30 mm Hg, or a 5-minute post-exercise pressure >= 20 mm Hg. The 1-minute post-exercise measurement is heavily relied upon for confirmation.

Question 45

A 26-year-old weightlifter feels a tearing sensation in his anterior chest while performing a bench press. Examination shows loss of the normal axillary fold and weakness in internal rotation. Surgical repair of a complete pectoralis major tendon rupture typically involves reattachment to which anatomic location?

Explanation

The pectoralis major inserts onto the lateral lip of the bicipital groove of the humerus. Complete ruptures, especially in active individuals, are typically managed with surgical reattachment to this anatomic footprint to restore strength and cosmesis.

Question 46

A 24-year-old cyclist falls directly onto his shoulder. Radiographs show 100% superior displacement of the clavicle relative to the acromion, with a coracoclavicular distance increased by 50% compared to the contralateral side. The deltotrapezial fascia remains intact. This represents which Rockwood classification type?

Explanation

A Rockwood Type III AC joint separation involves rupture of both the AC and coracoclavicular (CC) ligaments, leading to 25% to 100% superior displacement of the clavicle. The deltotrapezial fascia is intact, distinguishing it from a Type V injury (which has >100% displacement and stripped fascia).

Question 47

A 32-year-old water skier sustains a hyperflexion injury of the hip with an extended knee. MRI demonstrates a complete proximal hamstring avulsion with 4 cm of retraction. What is the most appropriate surgical approach for repair?

Explanation

Proximal hamstring avulsions are approached via a posterior subgluteal approach, often employing a transverse gluteal crease incision. This provides direct access to the ischial tuberosity and allows for identification and protection of the adjacent sciatic nerve during repair.

Question 48

A 14-year-old female gymnast presents with lateral elbow pain and catching. Radiographs show an unstable osteochondritis dissecans (OCD) lesion of the capitellum. Which of the following is the most likely etiology of this condition?

Explanation

Capitellar OCD lesions in young athletes (especially gymnasts and throwers) are primarily caused by repetitive valgus stress, leading to excessive lateral compartment compression. Unlike Panner's disease, which affects the entire capitellum in younger children, OCD causes localized focal defects.

Question 49

A 17-year-old female soccer player undergoes anterior cruciate ligament (ACL) reconstruction using a quadrupled hamstring autograft. Compared to a bone-patellar tendon-bone (BPTB) autograft, which of the following is the most likely long-term functional deficit associated with this graft choice?

Explanation

Hamstring autografts are associated with decreased deep knee flexion strength compared to BPTB autografts. BPTB grafts are more frequently associated with anterior knee pain and kneeling difficulty.

Question 50

A 25-year-old male complains of knee instability after receiving a blow to the anteromedial tibia. Physical examination reveals an isolated increase in external rotation of 15 degrees compared to the contralateral knee when tested at 30 degrees of knee flexion. There is no asymmetry in external rotation at 90 degrees of flexion. Which structure is most likely injured?

Explanation

An isolated increase in external rotation at 30 degrees of flexion, with symmetric rotation at 90 degrees, indicates an isolated posterolateral corner (PLC) injury. The popliteofibular ligament is a primary static stabilizer of the PLC.

Question 51

A 52-year-old male presents with acute medial knee pain after rising from a deep squat. MRI reveals a complete radial tear of the medial meniscus posterior root. Biomechanically, this injury is most similar to which of the following conditions?

Explanation

A complete tear of the posterior root of the medial meniscus disrupts the circumferential hoop stresses, leading to extrusion of the meniscus. Biomechanically, this results in peak contact pressures equivalent to a total meniscectomy.

Question 52

A 21-year-old collegiate rugby player presents with recurrent anterior shoulder instability. A 3D CT scan demonstrates 28% anterior glenoid bone loss. Which of the following surgical interventions provides the most reliable long-term stability for this patient?

Explanation

In the setting of critical glenoid bone loss (>20-25%), soft tissue stabilization (Bankart repair) has an unacceptably high failure rate. The Latarjet procedure (coracoid transfer) restores the bony arc and provides a sling effect via the conjoint tendon.

Question 53

A 45-year-old active laborer presents with chronic, severe shoulder weakness. MRI demonstrates a massive, retracted, and fatty-infiltrated tear of the supraspinatus and infraspinatus tendons. The subscapularis and teres minor are intact. He has a normal coracoacromial arch and no significant glenohumeral arthritis. Which tendon transfer is most appropriate to restore external rotation?

Explanation

For isolated irreparable posterosuperior rotator cuff tears, a lower trapezius transfer closely mimics the line of pull of the infraspinatus to restore external rotation. Latissimus dorsi transfer is also an option but has a less anatomic line of pull.

Question 54

A 42-year-old construction worker presents with persistent deep shoulder pain. MRI arthrogram reveals an isolated Type II Superior Labrum Anterior to Posterior (SLAP) tear. Nonoperative management has failed. What is the most appropriate surgical management to minimize postoperative stiffness and allow a return to heavy labor?

Explanation

In patients over 35-40 years old, especially manual laborers, SLAP repair is associated with a high rate of postoperative stiffness and persistent pain. Biceps tenodesis provides more reliable pain relief and functional recovery.

Question 55

A 20-year-old collegiate baseball pitcher complains of medial elbow pain and decreased pitching velocity. The pain is most severe during the late cocking and early acceleration phases of throwing. A moving valgus stress test is positive. Which bundle of the involved ligament is the primary restraint to valgus stress at 90 degrees of elbow flexion?

Explanation

The anterior bundle of the ulnar collateral ligament (UCL) is the primary restraint to valgus stress at the elbow between 30 and 120 degrees of flexion. It is the structure most commonly injured in overhead throwing athletes.

Question 56

A 45-year-old female presents with acute onset of medial knee pain after squatting. MRI shows a complete radial tear of the posterior horn of the medial meniscus at its root attachment. Which of the following best describes the biomechanical consequence of this injury?

Explanation

Medial meniscal root tears severely disrupt hoop stresses, functioning biomechanically like a total meniscectomy. This results in decreased contact area and significantly increased peak contact pressures in the medial compartment.

Question 57

A 16-year-old female experiences recurrent lateral patellar dislocations. She has failed conservative management. Imaging reveals a tibial tubercle-trochlear groove (TT-TG) distance of 14 mm, normal patellar height, and a dysplastic trochlea. Reconstruction of the medial patellofemoral ligament (MPFL) is planned. The femoral footprint of the MPFL is anatomically located:

Explanation

The Schöttle point for the femoral origin of the MPFL is located anterior to the adductor tubercle, proximal to the medial epicondyle, and distal to the medial physis.

Question 58

A 22-year-old competitive rugby player sustains his third anterior shoulder dislocation. CT scan with 3D reconstruction demonstrates 25% glenoid bone loss. A Latarjet procedure is performed. The classic "sling effect" of the Latarjet procedure is provided by which of the following structures?

Explanation

The Latarjet procedure provides stability via the bone block, the capsular repair, and the "sling effect" of the conjoint tendon compressing the inferior subscapularis and capsule when the arm is abducted and externally rotated.

Question 59

A 20-year-old collegiate baseball pitcher presents with medial elbow pain and decreased throwing velocity. Valgus stress testing reveals pain and laxity at 30 degrees of elbow flexion. MRI arthrogram shows a high-grade partial tear of the anterior bundle of the ulnar collateral ligament (UCL). Which specific portion is the primary restraint to valgus stress at 30, 60, and 90 degrees of flexion?

Explanation

The anterior bundle of the UCL is the primary restraint to valgus stress. Its anterior band is taut throughout the range of motion, whereas the posterior band is taut primarily in higher degrees of flexion (>90 degrees).

Question 60

A 30-year-old weightlifter feels a "pop" in his anterior chest wall while performing a heavy bench press. Examination reveals ecchymosis and a palpable defect in the anterior axillary fold. He is diagnosed with a pectoralis major rupture. Which portion of the tendon is most commonly injured and where does it insert relative to the other head?

Explanation

Pectoralis major tears most commonly involve the sternal head. Due to a 180-degree twist of the tendon, the sternal head inserts deep and proximal to the clavicular head on the lateral lip of the bicipital groove.

Question 61

When counseling a 17-year-old female soccer player regarding ACL reconstruction, which of the following is true comparing bone-patellar tendon-bone (BPTB) autograft to hamstring autograft?

Explanation

Multiple registries and studies have demonstrated that hamstring autografts carry a higher failure and revision rate compared to BPTB autografts in young, highly active patients.

Question 62

A 24-year-old male hockey player presents with right groin pain exacerbated by hip flexion and internal rotation. Radiographs reveal a crossover sign, prominent ischial spines, and an alpha angle of 65 degrees. During hip arthroscopy, a cam lesion is resected. Care must be taken to avoid over-resection of the femoral neck to prevent which of the following complications?

Explanation

Over-resection of a cam deformity (>30% of the femoral neck diameter) significantly alters load-bearing mechanics and increases the risk of a post-operative femoral neck fracture.

Question 63

A 28-year-old male sustains a traumatic knee dislocation. Following reduction, his pedal pulses are symmetric, but he has an inability to dorsiflex his ankle or extend his toes. Which of the following ligamentous injuries is most commonly associated with this neurologic deficit?

Explanation

Common peroneal nerve palsy is highly associated with posterolateral corner (PLC) injuries due to the anatomic proximity of the nerve to the fibular head and the severe varus/hyperextension traction forces involved.

Question 64

A 35-year-old male construction worker has deep shoulder pain. MRI shows a Type II Superior Labrum Anterior Posterior (SLAP) tear. He elects for biceps tenodesis. Where is the preferred location for subpectoral biceps tenodesis to minimize the risk of a "Popeye" deformity and residual bicipital groove pain?

Explanation

Subpectoral biceps tenodesis is typically performed distal to the pectoralis major insertion (or deep to its lower border) to remove the tendon entirely from the bicipital groove, which reliably alleviates groove pain and restores length-tension.

Question 65

A 12-year-old male presents with non-specific knee pain. Radiographs demonstrate an osteochondritis dissecans (OCD) lesion of the medial femoral condyle. The physes are widely open. MRI shows no fluid behind the lesion. What is the most appropriate initial management?

Explanation

In a skeletally immature patient with a stable OCD lesion (intact cartilage with no subchondral fluid on MRI), the initial management is nonoperative, primarily consisting of activity restriction and cessation of sports.

Question 66

A 42-year-old male feels a pop in his heel while playing basketball. Examination reveals a positive Thompson test. He opts for nonoperative management. What is the most significant disadvantage of nonoperative management compared to operative repair of an acute Achilles tendon rupture?

Explanation

Historically and in several studies, nonoperative management of Achilles tendon ruptures is associated with a higher re-rupture rate compared to operative repair, though functional outcomes are often similar with modern rehabilitation protocols.

Question 67

A 26-year-old cyclist falls directly onto his shoulder. Radiographs show a Type III acromioclavicular (AC) joint separation. The decision is made to manage him nonoperatively. He asks about his long-term prognosis. Which of the following is the most likely outcome?

Explanation

Type III AC separations managed nonoperatively typically result in excellent functional outcomes. Patients often have a persistent cosmetic deformity (prominent distal clavicle), but the vast majority do not require late surgical intervention.

Question 68

A 40-year-old male sustains a knee injury while jumping. On exam, he has a palpable defect proximal to the patella and cannot perform a straight leg raise. Lateral radiographs would most likely demonstrate which of the following?

Explanation

The clinical presentation is classic for a quadriceps tendon rupture (defect proximal to the patella). Disruption of the quadriceps tendon allows the intact patellar tendon to pull the patella distally, resulting in patella baja on lateral radiographs.

Question 69

A 68-year-old female with chronic pseudoparalysis of the right shoulder and a massive irrepairable rotator cuff tear undergoes a reverse total shoulder arthroplasty (RTSA). The biomechanical advantage of RTSA that restores active elevation is primarily achieved by:

Explanation

RTSA moves the center of rotation inferiorly and medially. This distalizes the humerus, tensioning the deltoid and increasing its moment arm, which allows it to effectively elevate the arm in the absence of a functional rotator cuff.

Question 70

A 21-year-old collegiate runner reports bilateral aching leg pain that begins reliably 15 minutes into a run and resolves 30 minutes after stopping. Resting compartment pressures are 18 mmHg, 1 minute post-exercise pressures are 35 mmHg, and 5 minutes post-exercise pressures are 28 mmHg. What is the most appropriate definitive treatment if conservative measures fail?

Explanation

The clinical history and compartment pressure readings (resting >15, 1-min post >30, or 5-min post >20) are diagnostic of chronic exertional compartment syndrome (CECS). Surgical fasciotomy is the definitive treatment after conservative failure.

Question 71

A 10-year-old Tanner stage 1 male sustains a complete mid-substance anterior cruciate ligament (ACL) tear. Which surgical reconstruction technique minimizes the risk of physeal arrest while providing adequate stability?

Explanation

In Tanner 1 patients, an all-epiphyseal technique avoids crossing the open physes entirely. This minimizes the risk of iatrogenic growth arrest compared to transphyseal methods.

Question 72

A 19-year-old female gymnast presents with recurrent bilateral shoulder pain and subluxation associated with generalized ligamentous laxity. After 6 months of dedicated physical therapy, she continues to have disabling instability in her dominant shoulder. What is the most appropriate surgical intervention?

Explanation

Arthroscopic capsular plication is the surgical treatment of choice for multidirectional instability that fails a prolonged course of physical therapy. It effectively reduces capsular redundancy without the morbidity of open shifts.

Question 73

A 45-year-old active male feels a 'pop' in his posterior knee while squatting. MRI demonstrates a complete radial tear of the posterior horn of the medial meniscus exactly at its tibial attachment. Biomechanically, this injury is equivalent to which of the following?

Explanation

Medial meniscus posterior root tears completely disrupt the hoop stresses of the meniscus. Biomechanically, this effectively renders the knee equivalent to one that has undergone a total meniscectomy.

Question 74

A 28-year-old weightlifter experiences a sudden tearing sensation in his anterior chest while performing a heavy bench press. Examination reveals loss of the anterior axillary fold. MRI confirms a complete rupture of the pectoralis major. Which head of the muscle is most commonly injured, and where does it typically fail?

Explanation

Pectoralis major ruptures almost exclusively occur during heavy eccentric loading like bench pressing. The most common site of failure is the sternocostal (sternal) head avulsing from its humeral insertion.

Question 75

A 22-year-old collegiate rugby player has sustained three recurrent anterior shoulder dislocations. CT scan with 3D reconstruction reveals 25% anterior glenoid bone loss. What is the most appropriate definitive surgical management?

Explanation

Substantial anterior glenoid bone loss (>20%) in a collision athlete is a strong indication for a bony augmentation procedure like the Latarjet. Isolated soft tissue repairs have an unacceptably high failure rate in this setting.

Question 76

A 20-year-old collegiate baseball pitcher presents with medial elbow pain and decreased pitching velocity. Valgus stress testing reveals gapping at 30 degrees of flexion. Which bundle of the ulnar collateral ligament (UCL) is the primary restraint to valgus stress during the late cocking and early acceleration phases of throwing?

Explanation

The anterior band of the anterior bundle is the primary restraint to valgus stress at the elbow between 30 and 120 degrees of flexion. It is the specific structure reconstructed in overhead throwing athletes (Tommy John surgery).

Question 77

A 24-year-old professional hockey player sustains an external rotation injury to his right ankle and has severe pain over the anterior inferior tibiofibular ligament (AITFL). Weight-bearing radiographs are normal. What is the most appropriate next step in management to rule out syndesmotic instability?

Explanation

In patients with suspected syndesmotic injuries and normal static radiographs, gravity or external rotation stress radiographs are necessary. This identifies dynamic syndesmotic instability requiring fixation.

Question 78

A 26-year-old male hockey player presents with chronic groin pain exacerbated by hip flexion and internal rotation. Radiographs reveal a prominent alpha angle of 75 degrees on the modified Dunn view. This radiographic finding is characteristic of which pathology?

Explanation

An increased alpha angle (typically >50-55 degrees) indicates an aspherical femoral head-neck junction. This is the anatomical hallmark of Cam-type femoroacetabular impingement (FAI).

Question 79

A 14-year-old female gymnast complains of lateral elbow pain, clicking, and a 15-degree extension block. MRI demonstrates a 12 mm unstable osteochondritis dissecans (OCD) lesion of the capitellum with loose bodies. What is the most appropriate surgical treatment?

Explanation

In an unstable capitellar OCD lesion with loose bodies and a defect, the standard of care is arthroscopic removal of the loose body followed by debridement and microfracture of the base. Drilling in situ is reserved for stable, intact lesions.

Question 80

A 30-year-old mountain biker falls directly onto his shoulder. Radiographs demonstrate a 150% superior displacement of the clavicle relative to the acromion, and the coracoclavicular distance is doubled compared to the contralateral side. What type of acromioclavicular (AC) joint injury is this, and what is the standard management?

Explanation

A Type V AC joint injury is defined by superior displacement of the distal clavicle between 100% and 300%. These injuries severely disrupt the deltotrapezial fascia and typically require surgical reconstruction.

Question 81

A 35-year-old recreational basketball player feels a 'pop' in his knee while landing from a jump and cannot actively perform a straight leg raise. Lateral radiographs show patella baja. Which of the following is the most likely diagnosis?

Explanation

Quadriceps tendon ruptures disrupt the superior pull on the patella, resulting in a low-riding patella (patella baja) on lateral radiographs. In contrast, patellar tendon ruptures lead to patella alta.

Question 82

A 25-year-old soccer player sustains a hyperextension varus knee injury. Examination shows a positive dial test at 30 degrees of flexion, but symmetric rotation compared to the contralateral knee at 90 degrees. What isolated structure is most likely injured?

Explanation

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

Question 83

A 20-year-old female dancer complains of an audible, painless snapping on the lateral aspect of her hip when she flexes and extends it. Ultrasound demonstrates a thick band of tissue snapping over the greater trochanter. What is the initial treatment of choice?

Explanation

External snapping hip syndrome is caused by the iliotibial band snapping over the greater trochanter. It is initially managed non-operatively with stretching, core strengthening, and activity modification.

Question 84

A 21-year-old collegiate basketball player sustains a fracture of the fifth metatarsal at the metaphyseal-diaphyseal junction. He is exactly 2 weeks away from the playoffs and demands aggressive treatment. What is the most appropriate management?

Explanation

A Zone 2 fracture of the fifth metatarsal (Jones fracture) has a high rate of nonunion due to watershed vascularity. In elite athletes, early intramedullary screw fixation is recommended to minimize nonunion risk and expedite return to play.

Question 85

A 29-year-old elite volleyball attacker reports deep, poorly localized shoulder pain during the cocking phase of his swing. An MR arthrogram demonstrates a Type II SLAP tear. If non-operative management fails, what is the most appropriate surgical intervention to optimize his return to overhead sports?

Explanation

In young overhead athletes (typically <35 years), arthroscopic SLAP repair remains the procedure of choice for symptomatic Type II SLAP tears. Biceps tenodesis is often preferred for older patients or those failing primary repair.

Question 86

A 19-year-old female cross-country runner presents with a femoral neck stress fracture. She has a BMI of 17.5 and reports amenorrhea for the last 8 months. What is the third component of the clinical triad most commonly associated with her condition?

Explanation

The Female Athlete Triad consists of low energy availability (with or without disordered eating), menstrual dysfunction (amenorrhea), and decreased bone mineral density (osteopenia or osteoporosis).

Question 87

A 22-year-old Marine recruit presents with bilateral anterolateral leg pain that occurs consistently after 15 minutes of running and resolves after 30 minutes of rest. Intracompartmental pressure testing is performed. Which of the following resting pressures is diagnostic for chronic exertional compartment syndrome?

Explanation

According to the Pedowitz criteria, a resting intracompartmental pressure greater than or equal to 15 mm Hg is diagnostic for chronic exertional compartment syndrome. Post-exercise metrics include 1-minute pressure ≥30 mm Hg or 5-minute pressure ≥20 mm Hg.

Question 88

A 6-year-old boy presents with a painless 'clunking' in his left knee. Examination reveals a lateral joint line prominence that reduces with knee flexion. MRI confirms an abnormally thickened and wide lateral meniscus. What is the most appropriate management for this asymptomatic, stable discoid meniscus?

Explanation

An asymptomatic discoid meniscus discovered incidentally or presenting solely with painless popping requires no surgical intervention. Observation preserves meniscal tissue and prevents early progression to osteoarthritis.

Question 89

A 24-year-old professional football player hyperextends his great toe on artificial turf. Examination shows extreme tenderness over the plantar aspect of the first MTP joint. MRI confirms a complete rupture of the plantar plate with retraction of the sesamoids. What is the most appropriate treatment?

Explanation

A Grade III turf toe injury with complete plantar plate rupture and sesamoid retraction in a high-level athlete requires surgical repair. Non-operative management typically leads to chronic instability and weak push-off.

Question 90

A 22-year-old collegiate athlete reports persistent "giving way" of his knee 9 months after an anterior cruciate ligament (ACL) reconstruction. Physical examination reveals a negative Lachman test but a markedly positive pivot shift test. What is the most likely technical error made during the index procedure?

Explanation

A vertically oriented femoral tunnel restores sagittal stability (negative Lachman) but fails to restore rotational stability, resulting in a persistent positive pivot shift. Anatomic placement requires positioning the femoral footprint lower on the lateral notch wall (e.g., 10 o'clock or 2 o'clock).

Question 91

A 19-year-old gymnast is scheduled for a medial patellofemoral ligament (MPFL) reconstruction for recurrent patellar instability. To avoid altering normal patellofemoral kinematics and restricting flexion, the femoral tunnel must be placed at the anatomic footprint. Where is this point located anatomically?

Explanation

The anatomic femoral footprint of the MPFL (the Schöttle point) is located just proximal and posterior to the medial epicondyle, and distal to the adductor tubercle. Non-anatomic placement leads to graft mal-tensioning, abnormal tracking, and loss of knee flexion.

Question 92

A 28-year-old competitive weightlifter feels a sudden pop in his anterior chest wall while performing a heavy bench press. Examination reveals loss of the anterior axillary fold contour and weakness in internal rotation. MRI confirms a pectoralis major rupture. Which of the following statements regarding this injury is true?

Explanation

Pectoralis major ruptures most commonly involve the sternal head avulsing from its insertion on the humerus during eccentric loading. Early surgical repair in athletes provides significantly superior strength and functional outcomes compared to nonoperative management.

Question 93

A 48-year-old recreational tennis player presents with vague, deep shoulder pain exacerbated by serving. MRI demonstrates an isolated Type II Superior Labrum Anterior and Posterior (SLAP) tear. Which of the following surgical approaches is most supported by current literature for this specific demographic?

Explanation

In patients older than 35-40 years, primary biceps tenodesis for Type II SLAP tears results in better patient-reported outcomes, lower revision rates, and less postoperative stiffness compared to arthroscopic SLAP repair. SLAP repair is generally reserved for younger, high-demand overhead athletes.

Question 94

A 52-year-old woman experiences a sharp pop in her posterior knee while squatting. MRI reveals a complete posterior root tear of the medial meniscus with 4 mm of radial meniscal extrusion. Which of the following best describes the biomechanical consequence of this injury if left untreated?

Explanation

A posterior root tear of the medial meniscus completely disrupts the circumferential hoop stresses, leading to radial extrusion. Biomechanically, this results in peak tibiofemoral contact pressures equivalent to those seen after a total meniscectomy, rapidly accelerating osteoarthritis.

Question 95

A 21-year-old collegiate baseball pitcher presents with a 5-mph decrease in throwing velocity and posterior shoulder pain during the late cocking phase. Examination reveals a Glenohumeral Internal Rotation Deficit (GIRD) of 25 degrees compared to the contralateral shoulder, but a symmetric total arc of motion. What is the most appropriate initial management?

Explanation

GIRD in throwers is characterized by a loss of internal rotation with a preserved total arc of motion, typically caused by a contracted posteroinferior capsule. The initial and most effective management is a targeted physical therapy program utilizing posterior capsular stretching, which resolves symptoms in the vast majority of cases.

Question 96

A 25-year-old ice hockey player presents with chronic groin pain exacerbated by hip flexion and internal rotation. Radiographs demonstrate an alpha angle of 72 degrees on the Dunn view. Which of the following accurately describes the pathophysiology of his condition?

Explanation

An elevated alpha angle (>55 degrees) is diagnostic of a Cam deformity, characterized by an aspherical femoral head-neck junction. During hip flexion, this prominence enters the joint, creating shear stresses that predictably cause anterosuperior labral tears and adjacent acetabular cartilage delamination.

Question 97

A 26-year-old running back sustains a direct blow to the anteromedial tibia. Examination reveals increased varus laxity at 30 degrees of knee flexion. A dial test demonstrates 15 degrees of increased external rotation at 30 degrees of flexion compared to the uninjured side, but symmetric external rotation at 90 degrees. What is the most likely diagnosis?

Explanation

The dial test measures external tibial rotation to evaluate the PLC and PCL. An asymmetry of >10 degrees at 30 degrees of flexion, but symmetric rotation at 90 degrees, is diagnostic of an isolated posterolateral corner (PLC) injury. Combined PLC and PCL injuries show asymmetry at both 30 and 90 degrees.

Question 98

A 30-year-old rugby player presents with recurrent anterior shoulder instability after a traumatic dislocation. An MRI arthrogram reveals contrast extravasation into the dependent portion of the axillary recess, creating a classic "J" sign. Which of the following lesions is most likely present?

Explanation

A Humeral Avulsion of the Glenohumeral Ligament (HAGL) lesion involves the tearing of the inferior glenohumeral ligament complex from its humeral insertion. On MRI arthrogram, contrast leaks inferiorly through the defect into the soft tissues, creating the pathognomonic "J" sign.

Question 99

A 34-year-old male ruptures his Achilles tendon while playing basketball. He is evaluating surgical versus nonoperative management. Based on recent Level I evidence regarding acute Achilles tendon ruptures, what should he be counseled regarding outcomes?

Explanation

Recent high-quality Level I evidence demonstrates that nonoperative management utilizing a strict, early functional rehabilitation protocol (incorporating early weight-bearing and ROM) results in re-rupture rates equivalent to surgical repair, while avoiding surgical wound and nerve complications.

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

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

Key Takeaway

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

Chapter Index