OITE & ABOS Board Prep: Knee & Shoulder MCQs Part 54

Question 1

What is the most common behavioral effect of anabolic steroid use in athletes?

Explanation

DISCUSSION: Users of anabolic steroids often display increased feelings of hostility and aggression. Although reports of psychotic, depressive, and manic behavior have been reported with the use of steroids, they are rare. Drug dependence, such as seen with narcotics, is not a feature of steroid use.
REFERENCES: Hartgens F, Kuipers H: Effects of androgenic-anabolic steroids in athletes. Sports Med 2004;34:513-554.
Blue JG, Lombardo JA: Steroids and steroid-like compounds. Clin Sports Med
1999;19:667-689.

Question 2

What is the effect on knee kinematics following placement of an anterior cruciate ligament (ACL) graft at the 12 o’clock position?

Explanation

DISCUSSION: Endoscopic ACL reconstructive techniques may result in a vertical graft placement. The reconstructed ligament will resist anterior translation of the tibia but the graft will not restore rotatory stability. Decreased flexion and extension are caused by placement of the femoral tunnel too anterior and posterior, respectively. Impingement of the graft on the femoral notch is caused by anterior placement of the tibial tunnel or inadequate notchplasty.
REFERENCES: Scopp JM, Jasper LE, Belkoff SM, et al: The effect of oblique femoral tunnel placement on rotational constraint of the knee reconstructed using patellar tendon autografts. Arthroscopy 2004;20:294-299.
Carson EW, Simonian PT, Wickiewicz TL, et al: Revision anterior cruciate ligament reconstruction. Instr Course Lect 1998;47:361-368.

Question 3

The superior glenohumeral ligament primarily restrains

Explanation

DISCUSSION: Several cutting studies have evaluated the primary static restraints and the role of the glenohumeral ligaments in providing static stability. With the arm at the side in adduction, the superior glenohumeral ligament and coracohumeral ligament are the primary restraints to inferior translation. The middle glenohumeral ligament functions with the arm in 45 degrees of abduction and resists anterior translation. The inferior glenohumeral ligament is the primary restraint to anterior translation at 90 degrees of abduction.
REFERENCES: Warner JJ, Deng XH, Warren RF, et al: Static capsuloligamentous restraints to superior-inferior translation of the glenohumeral joint. Am J Sports Med 1992;20:675-685.
Griffin LY (ed): Orthopaedic Knowledge Update: Sports Medicine. Rosemont, IL, American Academy Orthopaedic Surgeons, 1994, pp 165-177.

Question 4

Which of the following best describes carbohydrate loading?

Explanation

DISCUSSION: Carbohydrate loading is the practice of maximizing glycogen stores by decreasing training and increasing carbohydrate intake the week before an endurance event. Nonendurance athletes do not benefit from this because glycogen depletion is not the limiting factor during a normal competition. Potential side effects of carbohydrate loading are water retention, muscle stiffness, and weight gain.
REFERENCES: Coyle EF, Hagberg JM, Hurley BF, et al: Carbohydrate feeding during prolonged strenuous exercise can delay fatigue. J Appl Physiol 1983;55:230-235.
Costill DL, Sherman WM, Fink WJ, et al: The role of dietary carbohydrates in muscle glycogen resynthesis after strenuous running. Am J Clin Nutr 1981;34:1831-1836.
Sherman WM, Doyle JA, Lamb DR, et al: Dietary carbohydrate, muscle glycogen, and exercise performance during 7 d of training. Am J Clin Nutr 1993;57:27-31.

Question 5

A 29-year-old quarterback falls onto his dominant shoulder and sustains the injury shown in Figures 14a and 14b. Management should consist of

Explanation

DISCUSSION: Type V acromioclavicular dislocations are characterized by elevation of the clavicle of 100% to 300% and involve extensive soft-tissue stripping. The treatment of choice is surgical reduction of the acromioclavicular joint and some type of stabilization. Treatment of type III injuries is controversial.
REFERENCES: Lemos MJ: The evaluation and treatment of the injured acromioclavicular joint in athletes. Am J Sports Med 1998;26:137-144.
Rockwood CA Jr, Green DP, Bucholz RW, et al: Fractures in Adults, ed 5. Philadelphia, PA, Lippincott-Raven, 2001, pp 1209-1240.

Question 6

A 27-year-old professional baseball pitcher who underwent arthroscopic olecranon debridement continues to have medial-sided elbow pain during late cocking. Physical examination reveals laxity and pain with valgus stress testing. What is the most likely cause of his pain?

Explanation

DISCUSSION: Both the medial collateral ligament and the olecranon contribute to valgus stability of the elbow. Excessive olecranon resection increases the demand placed on the medial collateral ligament in resisting valgus forces during throwing. Bone removal from the olecranon should be limited to osteophytes.
REFERENCES: Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 101-111.
Kamineni S, Hirahara H, Pomianowski S, et al: Partial posteromedial olecranon resection:
A kinematic study. J Bone Joint Surg Am 2003;85:1005-1011.

Question 7

A 22-year-old professional baseball catcher has posterior shoulder pain and severe external rotation weakness with the arm in adduction. Radiographs are normal. MRI scans are shown in Figures 15a through 15c. Management should consist of

Explanation

DISCUSSION: The MRI scans reveal a large posterior paralabral cyst associated with a posterior-superior labral tear. The cyst appears as a well-defined, smoothly marginated mass with low signal intensity on T₁-weighted MRI scans and with high signal intensity on T₂-weighted MRI scans. MRI also reveals changes in the supraspinatus and infraspinatus muscles secondary to denervation, including decreased muscle bulk and fatty infiltration. MRI has the added advantage, compared with other imaging modalities, of detecting intra-articular lesions, such as labral tears, which are frequently associated with ganglion cysts of the shoulder. In this case of a professional baseball player with a space-occupying lesion causing nerve compression with an associated labral tear, the treatment of choice is arthroscopic decompression of the cyst and repair of the tear. Acromioplasty would not address the primary pathology in this patient.
REFERENCES: Cummins CA, Messer TM, Nuber GW: Suprascapular nerve entrapment.
J Bone Joint Surg Am 2000;82:415-424.
Martin SD, Warren RF, Martin TL, et al: Suprascapular neuropathy: Results of non-operative treatment. J Bone Joint Surg Am 1997;79:1159-1165.

Question 8

A 21-year-old collegiate scholarship football player has an episode of transient quadriplegia. An MRI scan of the cervical spine reveals cord edema and severe congenital spinal stenosis. The athlete has aspirations of playing on a professional level and demands that he be allowed to play. The team physician should give what recommendation to the college?

Explanation

DISCUSSION: Federal courts have ruled that a student-athlete does not have a constitutional right to participate in athletics against medical advice. As long as the student retains his scholarship, the college is under no legal or ethical obligation to allow the student to participate in sports. A waiver would not hold up in court and would not indemnify the college or the team physician against suit. No equipment has been shown to be effective in preventing transient quadriplegia.
REFERENCES: Mathias MB: The competing demands of sport and health: An essay on the history of ethics in sports medicine. Clin Sports Med 2004;23:195-214.
Bernstein J, Perlis C, Bartolozzi AR: Ethics in sports medicine. Clin Orthop 2000;378:50-60.

Question 9

When performing a posterior cruciate ligament reconstruction with a tibial inlay-type approach, what is the approximate anatomic distance of the popliteal artery from the screws used for fixation of the bone block?

Explanation

DISCUSSION: Miller and associates reported the results of a cadaveric study of the vascular risk of a posterior approach for posterior cruciate ligament reconstruction using the tibial inlay technique. The average distance from the screw to the popliteal artery was 21.1 mm
(range, 18.1 mm to 31.7 mm). Other approaches, such as the transtibial tunnel technique which involves drilling an anterior-posterior tunnel, have also been studied in cadavers. Matava and associates noted that increasing flexion reduces but does not completely eliminate the risk of arterial injury during arthroscopic posterior cruciate ligament reconstruction. However, this study did not use the small, medial utility incision recommended by Fanelli and associates, which creates an interval for the surgeon’s finger between the medial gastrocnemius and the posteromedial capsule so that any migration of the guidepin can be palpated and changed prior to any injury to the posterior neurovascular bundle.
REFERENCES: Matava MJ, Sethi NS, Totty WG: Proximity of the posterior cruciate ligament insertion to the popliteal artery as a function of the knee flexion angle: Implications for posterior cruciate ligament reconstruction. Arthroscopy 2000;16:796-804.
Miller MD, Kline AJ, Gonzales J, et al: Vascular risk associated with posterior approach for posterior cruciate ligament reconstruction using the tibial inlay technique. J Knee Surg 2002;15:137-140.
Johnson DH, Fanelli GC, Miller MD: PCL 2002: Indications, double-bundle versus inlay technique and revision surgery. Arthroscopy 2002;18:40-52.

Question 10

Which of the following knee ligament injury patterns is most associated with an increase in external tibial rotation with the knee at 90 degrees of flexion?

Explanation

DISCUSSION: Cadaveric studies have shown that external rotation of the tibia is most pronounced following transection of the posterior cruciate and lateral collateral ligaments with the knee at 90 degrees of flexion. Isolated release of the lateral collateral ligament results in increased external tibial rotation at 30 degrees.
REFERENCES: Gollehon DL, Torzilli PA, Warren RF: The role of the posterolateral and cruciate ligaments in the stability of the human knee: A biomechanical study. J Bone Joint Surg Am 1987;69:233-242.
Cooper DE: Tests for posterolateral instability of the knee in normal subjects: Results of examination under anesthesia. J Bone Joint Surg Am 1991;73:30-36.
Veltri DM, Xeng XH, Torzilli PA, et al: The role of the cruciate and posterolateral ligaments in stability of the knee: A biomechanical study. Am J Sports Med 1995;23:436-443.

Question 11

A 28-year-old professional dancer reports a 3-month history of progressive pain in the posterior aspect of the left ankle. Her symptoms are worse when she assumes the en pointe position. Examination reveals tenderness to palpation at the posterolateral aspect of the ankle posterior to the peroneal tendons which is made worse with passive plantar flexion. There is no nodularity, fluctuance, or tenderness of the Achilles tendon. The neurovascular examination is unremarkable. A lateral radiograph and MRI scan are shown in Figures 16a and 16b, respectively. Management should consist of

Explanation

DISCUSSION: The imaging studies reveal findings typical of the os trigonum syndrome. This condition results from inflammation between the os trigonum and the adjacent talus. The symptoms of posterior ankle pain are exacerbated by plantar flexion, which stresses the fibrous union between these two bones. Definitive management of the high-level athlete involves excision of the os trigonum from a medial approach, although arthroscopic excision has also been described. The os trigonum is not an intra-articular structure; therefore, ankle arthroscopy is neither diagnostic nor therapeutic.
REFERENCES: Abramowitz Y, Wollstein R, Barzilay Y, et al: Outcome of resection of a symptomatic os trigonum. J Bone Joint Surg Am 2003;85:1051-1057.
Mouhsine E, Crevoisier X, Leyvraz P, et al: Post-traumatic overload or acute syndrome of the os trigonum: A possible cause of posterior ankle impingement. Knee Surg Sports Traumatol Arthrosc 2004;12:250-253.
Wredmark T, Carlstedt CA, Bauer H, et al: Os trigonum syndrome: A clinical entity in ballet dancers. Foot Ankle 1991;11:404-406.

Question 12

A professional pitcher reports pain localized to the medial aspect of his throwing elbow. History reveals that he was pitching in a playoff game and heard and felt a pop in his elbow. MRI reveals a complete ulnar-sided avulsion of the medial collateral ligament (MCL). Examination reveals valgus instability and ulnar nerve involvement. What recommendations should be made based on the patient’s desire to return to sport?

Explanation

DISCUSSION: Injuries to the MCL usually result from repetitive high valgus stress on the medial aspect of the elbow joint due to overhead throwing or racquet sports. Excessive stresses during the late cocking and acceleration phase of throwing can injure the anterior band of the MCL. Clinically, the injuries may present as chronic or acute, and a pop may be noted in the latter. Associated ulnar nerve involvement is common. Valgus instability is present in about 25% of patients. Patients typically are athletes who participate in throwing and have localized medial elbow pain and tenderness along the course of a ligament that extends from the medial epicondyle of the distal humerus to the sublime tubercle of the ulna. Surgical reconstruction is the procedure of choice in an athlete desiring a return to a high level of throwing.
REFERENCES: Miller MD, Cooper DE, Warner JJP (eds): Review of Sports Medicine and Arthroscopy. Philadelphia, PA, WB Saunders, 1995, p 230.
Arendt EA (ed): Orthopaedic Knowledge Update: Sports Medicine 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, p 227.
Altchek DW, Andrews JR (eds): The Athlete’s Elbow. Philadelphia, PA, Lippincott Williams
& Wilkins, 2001, p 91.

Question 13

A 20-year-old collegiate football player who sustained blunt head trauma during the first half of a game is emotional and confused. During the halftime intermission, his affect, memory, and disorientation are totally resolved and have returned to preinjury baseline. The only residual finding is a very mild headache. He wants to play the second half. What is the most appropriate course of action?

Explanation

DISCUSSION: There is almost universal acceptance that an athlete may return to play after blunt head trauma only if he or she is totally asymptomatic. Mild residual symptoms are considered an absolute contraindication for return to play. Returning to play after a cardiovascular challenge or sport-specific activities is permitted on the pretext that the athlete is totally asymptomatic prior to these maneuvers. Neuropsychiatric testing is being used more frequently to monitor residual cognitive effects after head trauma. It has not been used as a return to play criterion.
REFERENCES: Garrick J (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 29-48.
Guskiewicz KM, McCrea, Marshall SW, et al: Cumulative effects associated with recurrent concussion in collegiate football players: The NCAA Concussion Study. JAMA
2003;290:2549-2555.

Question 14

Which of the following actions best enhances performance when an athlete is participating in a 10K race?

Explanation

DISCUSSION: Proper hydration prior to an athletic event is the most important determinant of performance. It is virtually impossible to keep pace with fluid loss during an athletic competition. When a net loss of fluid occurs and the athlete is properly prehydrated, this fluid loss will not adversely affect performance. It is not necessary to load up on carbohydrates prior to a 10K race, or to replace calories burned during the race. Hyponatremia can develop in ultra-endurance athletes, especially marathoners, if they hydrate without replacing electrolytes lost through sweating; however, this is highly unlikely for a 10K race.
REFERENCES: Newmark SR, Toppo FR, Adams G: Fluid and electrolyte replacement in the ultramarathon runner. Am J Sports Med 1991;19:389-391.
Noakes T: Fluid replacement during marathon running. Clin J Sports Med 2003;13:309-318.

Question 15

A 25-year-old competitive skier sustains a twisting injury to the right ankle while skiing. She is unable to continue the activity secondary to severe lateral ankle pain. Examination reveals ecchymosis and fullness over the lateral malleolus with pain and weakness on active ankle dorsiflexion and external rotation. There is no medial-sided pain. Neurovascular examination is normal. An AP radiograph and MRI scan are shown in Figures 17a and 17b, respectively. Management should consist of

Explanation

DISCUSSION: The MRI scan shows a dislocated peroneus brevis tendon with disruption of the peroneal retinaculum. This injury is commonly seen in skiers and is the result of peroneal contraction with the ankle everted and dorsiflexed. Nonsurgical management is rarely successful; therefore, repair of the peroneal retinaculum is the treatment of choice.
REFERENCES: Eckert WR, Davis EA Jr: Acute rupture of the peroneal retinaculum. J Bone Joint Surg Am 1976;58:670-672.
Murr S: Dislocation of the peroneal tendons with marginal fracture of the lateral malleolus.
J Bone Joint Surg Br 1961;43:563-565.
Zoellner G, Clancy W Jr: Recurrent dislocation of the peroneal tendon. J Bone Joint Surg Am 1979;61:292-294.

Question 16

Nonsurgical management of pectoralis major tears is likely to result in weakness of glenohumeral

Explanation

DISCUSSION: Nonsurgical management is considered for proximal tears as well as partial tears in some individuals. Surgical management is often not appropriate in older or sedentary patients. However, patients treated nonsurgically will have a significant cosmetic defect, as well as weakness in adduction and internal rotation.
REFERENCES: Schepsis AA, Grafe MW, Jones HP, et al: Rupture of the pectoralis major muscle: Outcome or repair of acute and chronic injuries: Am J Sports Med 2000;28:9-15.
Petilon J, Carr DR, Sekiya JK, et al: Pectoralis major muscle injuries: Evaluation and management. J Am Acad Orthop Surg 2005;13:59-68.

Question 17

A 20-year-old man reports painless snapping about the lateral aspect of the right hip. He denies any history of trauma. Examination reveals no limp or tenderness. Hip range of motion is full, and there is good strength. Radiographs are normal. What anatomic structure is most likely causing these symptoms?

Explanation

DISCUSSION: Coxa saltans (snapping hip syndrome) can occur in two forms: external/lateral or interior/medial/anterior. This patient has the external/lateral form. The external/lateral form involves the iliotibial band, tensor fascia, or gluteus medius, which snaps over the greater trochanter. The external form usually can be treated with physical therapy alone; however, several recent studies report satisfactory results with surgical treatment. Faraj and associates reported good results from surgical Z-plasty in a series of 10 patients. White and associates reported good results in a series of 16 patients with 17 hips who underwent surgical release of an external snapping hip. The interior/medial/anterior form can involve the iliopsoas tendon, acetabular labrum, subluxation of the hip, and loose bodies.
REFERENCES: White RA, Hughes MS, Burd T, et al: A new operative approach in the correction of external coxa saltans: The snapping hip. Am J Sports Med 2004;32:1504-1508.
Faraj AA, Moulton A, Sirivastava VM: Snapping iliotibial band: Report of ten cases and review of the literature. Acta Orthop Belg 2001;67:19-23.
Choi YS, Lee SM, Song BY, et al: Dynamic sonography of external snapping hip syndrome.
J Ultrasound Med 2002;21:753-758.

Question 18

Which of the following statements correctly describes the results of gamma irradiation of musculoskeletal allograft?

Explanation

DISCUSSION: Low dose gamma irradiation (less than 3.0 megarads) with antibiotic soaks is one of the most common techniques for secondary sterilization. Elimination of HIV with gamma irradiation requires doses estimated to be greater than 3.5 megarads. Gamma irradiation levels of
4 megarads have been shown to alter the mechanical properties of human infrapatellar tendons. Ethylene oxide, also used for allograft sterilization, has been associated with a chronic inflammatory process that resolved after graft removal.
REFERENCES: Jackson DW, Windler GE, Simon TM: Intraarticular reaction associated with the use of freeze-dried, ethylene oxide-sterilized bone-patella tendon-bone allografts in the reconstruction of the anterior cruciate ligament. Am J Sports Med 1990;18:1-10.
Conway B, Tomford W, Mankin HJ, et al: Radiosensitivity of HIV-1: Potential application to sterilization of bone allografts. AIDS 1991;5:608-609.
Rasmussen TJ, Feder SM, Butler DL, et al: The effects of 4 Mrad of gamma irradiation on the initial mechanical properties of bone-patellar tendon-bone grafts. Arthroscopy 1994;10:188-197.

Question 19

A 35-year-old woman who is a recreational runner reports posterior knee pain and tightness in the knee with flexion during running. She denies any history of trauma. Examination reveals normal patellar glide and tilt and no patellar apprehension. Range of motion is 5 degrees to 120 degrees, and quadriceps function and knee ligamentous examination are normal. Radiographs are normal. An MRI scan is shown Figure 18. What is the most likely diagnosis?

Explanation

DISCUSSION: Ganglia involving the cruciate ligaments have been recently reported as a cause of knee pain that interferes with knee flexion and extension. The symptoms are poorly localized in this patient and not along the medial joint line, making the diagnosis of a torn medial meniscus less likely. In addition, the MRI findings do not show a significant medial meniscal lesion. A Baker’s cyst is usually posteromedial and extends posterior to the interval between the medial head of the gastrocnemius and semimembranosus. MRI scans show a fluid-filled lesion with an increased signal on T₁- and T₂-weighted images. A lipoma would be bright on the T₁-weighted image only.
REFERENCES: Deutsch A, Veltri DM, Altchek DW, et al: Symptomatic intraarticular ganglia of the cruciate ligaments of the knee. Arthroscopy 1994;10:219-223.
Brown MF, Dandy DJ: Intra-articular ganglia of the knee. Arthroscopy 1990;6:322-323.

Question 20

A 12-year-old boy who pitches on two “select” baseball teams has had pain in his dominant right shoulder for the past 6 weeks. The pain is present only with throwing and is associated with decreased throwing velocity and control. He has no radiation of pain or paraesthesias of the upper extremity. An AP radiograph and MRI scan are shown in Figures 19a and 19b, respectively. Management should consist of

Explanation

DISCUSSION: The imaging study demonstrates characteristics of Little Leaguer’s shoulder, including physeal widening. This condition is secondary to overuse (typically throwing) and responds well to rest from the inciting activity. There is no evidence from the patient’s history or examination that he has an impingement syndrome, nor is there any indication of labral pathology on the MRI scan. The changes in the proximal humerus are classic for this condition and are not suggestive of a neoplastic process requiring biopsy for definitive diagnosis.
REFERENCES: Lipscomb AB: Baseball pitching injuries in growing athletes. J Sports Med 1975;3:25-34.
Cahill BR, Tullos HS, Fain RH: Little league shoulder: Lesions of the proximal humeral epiphyseal plate. J Sports Med 1974;2:150-152.
Barnett LS: Little league shoulder syndrome: Proximal humeral epiphysis in adolescent baseball pitchers: A case report. J Bone Joint Surg Am 1985;67:495-496.

Question 21

An 18-year-old man underwent open reduction and internal fixation of a tibial spine avulsion and a posterolateral corner repair. Two years later, he underwent lateral collateral ligament (LCL) and posterolateral corner reconstruction because of instability. Examination reveals a pronounced lateral varus knee thrust when ambulating. Varus stress in 30 degrees of flexion produces a 10-mm opening that is eliminated in extension. The Lachman’s test is 2 mm with a firm end point, and the posterior drawer test is negative. Standing radiographs show widening of the lateral joint space and a 5-degree mechanical varus alignment. What is the most effective course of treatment?

Explanation

DISCUSSION: The patient has chronic posterolateral instability with a varus knee alignment; therefore, the most effective treatment is a valgus-producing HTO. A repeat soft-tissue reconstruction without correction of the varus alignment will most likely fail. An ACL reconstruction is not indicated with a normal Lachman’s test. Physical therapy and bracing will have little effect.
REFERENCES: Naudie DD, Amendola A, Fowler PJ: Opening wedge high tibial osteotomy for symptomatic hyperextension-varus thrust. Am J Sports Med 2004;32:60-70.
Covey DC: Injuries of the posterolateral corner of the knee. J Bone Joint Surg Am
2001;83:106-118.

Question 22

As a baseball player dives to catch a line drive in the outfield, the ball strikes the tip of the player’s finger when extended, causing forcible flexion to avulse the extensor tendon from the distal phalanx. Following evaluation and normal radiographic findings, initial management should include

Explanation

DISCUSSION: Avulsion of the terminal extensor tendon from the distal phalanx (mallet or baseball finger) may or may not be associated with a bony avulsion. The injury is caused by forcible flexion of the DIP joint while catching a ball or hitting an object with the finger extended. Most authorities recommend continuous extension splinting to the DIP joint for
6 weeks, followed by nighttime splinting for an additional 6 weeks. It must be emphasized to the patient that at no time during the initial 6 weeks of treatment should the DIP joint be allowed to fall into flexion or an additional 6 weeks of continuous splinting is required.
REFERENCES: Miller MD, Cooper DE, Warner JP (eds): Review of Sports Medicine and Arthroscopy. Philadelphia, PA, WB Saunders, 1995, p 255.
Rettig AC: Closed tendon injuries of the hand and wrist in the athlete. Clin Sports Med 1992;11:77-99.
Arendt EA (ed): Orthopaedic Knowledge Update: Sports Medicine 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 229-230.

Question 23

A favorable outcome following nonsurgical management of a partial tear of the posterior cruciate ligament (PCL) is best associated with

Explanation

DISCUSSION: Rehabilitation of the quadriceps muscle following a partial tear of the PCL has been associated with a favorable outcome. The quadriceps acts an antagonist to the PCL because its contraction results in anterior tibial translation, which reduces the tensile stress on the injured ligament. Strengthening of the hamstring musculature increases posterior tibial translation and is contraindicated during the early rehabilitative phase following a PCL injury. Brace use has not been found to significantly alter the outcome following nonsurgical management of PCL tears.
REFERENCES: Parolie JM, Bergfeld JA: Long-term results of nonoperative treatment of isolated posterior cruciate ligament injuries in the athlete. Am J Sports Med 1986;14:35-38.
Griffin JR, Annunziata CC, Harner CD: Posterior cruciate ligament injuries in the adult, in Drez D, DeLee JD, Miller MD (eds): Orthopaedic Sports Medicine Principles and Practice, ed 2. Philadelphia, PA, WB Saunders, 2003, pp 2083-2106.

Question 24

A player on a professional football team sustains a knee injury and is diagnosed with an anterior cruciate ligament rupture. When employed as the team physician, your ethical obligation is to inform

Explanation

DISCUSSION: When you are employed as a team physician, you are obligated to inform the players and the team organization of all athletically relevant medical issues. This differs significantly from the normal rule of patient confidentiality. If the player came to see you and you were not the team physician, you may not inform the team unless the player so desires. As the team physician, you are not obligated to inform the media.
REFERENCES: Tucker AM: Ethics and the professional team physician. Clin Sports Med 2004;23:227-241.
Johnson R: The unique ethics of sports medicine. Clin Sports Med 2004;23:175-182.

Question 25

A 20-year-old basketball player reports a 6-month history of right groin pain that radiates into his testicles with activities of daily living. He denies any history of trauma. Examination reveals tenderness about the groin, and he has full hip range of motion. The abdomen is soft. Radiographs are normal. Nonsurgical management has consisted of rest and physical therapy, but he continues to have pain. What is the next step in management?

Explanation

DISCUSSION: Sports hernias may be one of the most common causes of groin pain in athletes. Resisted hip adduction is painful in the case of groin disruption. Radiation of pain into the testicles and/or adductor region is often present. Sports hernias are associated with weakening of the posterior inguinal wall. In contrast with sports hernias, traditional or classic hernias can be readily detected on physical examination. Diagnostic imaging studies are not helpful and only serve to help exclude other diagnoses. Systemic high-dose steroids or sacroiliac joint injections have no role in treatment. High success rates have been reported for laparoscopic hernia repair in athletes.
REFERENCES: Kluin J, den Hoed PT, van Linschoten R, et al: Endoscopic evaluation and treatment of groin pain in the athlete. Am J Sports Med 2004;32:944-949.
Genitsaris M, Goulimaris I, Sikas N: Laparoscopic repair of groin pain in athletes. Am J Sports Med 2004;32:1238-1242.
Meyers WC, Foley DP, Garrett WE, et al: Management of severe lower abdominal or inguinal pain in high-performance athletes: PAIN (Performing Athletes with Abdominal or Inguinal Neuromuscular Pain Study Group). Am J Sports Med 2000;28:2-8.

Question 26

A 45-year-old tennis player undergoes surgery for chronic lateral epicondylitis. After returning to play, he notes increasing lateral elbow pain with mechanical catching and locking. Examination shows positive supine posterolateral rotatory instability. What ligament has been injured?

Explanation

DISCUSSION: The patient has sustained an iatrogenic injury to the lateral ulnar collateral ligament. This injury has been reported after lateral approaches to the elbow. The orbicular, annular, and lateral radial collateral ligaments have a much less important role in lateral elbow stability. The anterior band of the ulnar collateral ligament is on the medial side of the elbow and is important for valgus stability.
REFERENCES: O’Driscoll SW, Bell DF, Morrey BF: Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am 1991;73:440-446.
O’Driscoll SW, Morrey BF: Surgical reconstruction of the lateral collateral ligament, in Morrey BF (ed): The Elbow. Philadelphia, PA, Lippincott, Williams and Wilkins, 1994, pp 169-182.

Question 27

A female cross-country runner has an insidious onset of right groin pain. Radiographs of the right hip reveal a tension-side stress fracture. History reveals that she was treated for a “foot” fracture 1 year ago. In addition to performing internal fixation of the femoral neck, which of the following should be obtained?

Explanation

DISCUSSION: Stress fractures in female long distance runners are frequently associated with the Female Athletic Triad. The triad consists of osteoporosis, amenorrhea, and altered eating habits. A thorough menstrual history, including age of menarche, history of amenorrhea, and use of oral contraceptives, is imperative. Amenorrhea leads to osteoporosis and predisposes the athlete to fractures. An MRI of the hip is not necessary because a fracture is evident on the radiograph. Serum calcium levels are normal in osteoporosis, a family history would be noncontributory, and it is highly unlikely that a contralateral hip radiograph will yield useful information.
REFERENCES: Bennell KL, Malcolm SA, Thomas SA, et al: Risk factors for stress fractures in track and field athletes: A twelve-month prospective study. Am J Sports Med 1996;24:810-818.
Barrow GW, Saha H: Menstrual irregularity and stress fractures in collegiate female distance runners. Am J Sports Med 1988;16:209-216.

Question 28

An 18-year-old gymnast has had a 1-year history of foot pain. Examination reveals medial midfoot tenderness without swelling. Non-weight-bearing in a cast for 6 weeks has failed to provide relief. An axial CT scan of the midfoot is shown in Figure 20. What is the optimal treatment for this condition?

Explanation

DISCUSSION: Stress fractures of the navicular are often seen in running and jumping sports. Whereas most individuals heal with nonsurgical management consisting of 6 weeks of casting, this gymnast has had pain for 1 year and nonsurgical management has failed. Open reduction with bone grafting is the preferred treatment.
REFERENCES: Quirk RM: Stress fractures of the navicular. Foot Ankle Int 1998;19:494-496.
Saxena A, Fullem B, Hannaford D: Results of treatment of 22 navicular stress fractures and a new proposed radiographic classification system. J Foot Ankle Surg 2000;39:96-103.

Question 29

A 20-year-old soccer player who collapsed after a goal kick reports weakness and nausea. He appears slightly confused. Examination reveals that he is not sweating. His skin is warm and dry. The outdoor temperature is 80 degrees F (26.6 degrees C) with a relative humidity of 80%. Management should consist of

Explanation

DISCUSSION: There is a spectrum of heat-related conditions. Heat cramps are the mildest form of heat illness. In heat exhaustion, cramps are associated with headache and weakness, and the skin is pale and moist. Treatment of heat cramps or heat exhaustion consists of removing and loosening excess clothing, applying ice to the axilla and groin, ingestion of cool water, and cool water sprays. This patient demonstrates symptoms of heat stroke which is a medical emergency. The core body temperature may be as high as 106 to 110 degrees F (41.1 to 43.3 degrees C). In heat stroke, the patient may no longer be sweating, and the skin may be hot and red. The athlete is usually confused, weak, nauseated, and may have seizure activity. Central nervous system depression has been called the most important marker of heat stroke, and progresses from confusion and bizarre behavior to collapse, delirium, and coma. Bizarre behavior is often the first sign of heat stroke. The patient needs to be treated and moved to a medical facility rapidly. During transfer, IV fluids and cooling of the athlete should be initiated. The best treatment of heat-related illness appears to be prevention with adequate hydration and monitoring of conditions (temperature and humidity), with cancellation of competition when conditions do not comply with guidelines.
REFERENCES: Griffin LY: Emergency preparedness: Things to consider before the game starts. J Bone Joint Surg Am 2005;87:894-902.
Barker TA, Motz HA, Gersoff WK: Environmental factors in athletic performance, in Fu FH, Stone DA (eds): Sports Injuries, ed 2. Philadelphia, PA, Lippincott, 2001, pp 67-68.
Roberts WO: Environmental concerns, in Kibler WB (ed): ACSM’s Handbook for the Team Physician. Baltimore, MD, Williams & Wilkins, 1996, p 172.

Question 30

What is the most accurate description of the relationship between gender and knee loading during landing while playing basketball?

Explanation

DISCUSSION: Ford and associates studied 81 high school basketball players and found that females landed with greater total valgus knee loading and a greater maximum valgus knee angle than male athletes. Hewett and associates reported in a study of 205 female athletes that those with increased dynamic valgus and high abduction loads were at increased risk of anterior cruciate ligament injury.
REFERENCES: Hewett TE, Myer GD, Ford KR, et al: Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: A prospective study. Am J Sports Med 2005;33:492-501.
Ford KR, Meyer GD, Hewett TE: Valgus knee motion during landing in high school female and male basketball players. Med Sci Sports Exer 2003;35:1745-1750.

Question 31

What is the most common cause of the new onset of amenorrhea in a female endurance athlete who is not sexually active?

Explanation

DISCUSSION: Insufficient caloric intake caused by either a poor diet or an eating disorder is the most common cause for the loss of menses in a female athlete. In the face of adequate caloric intake, stress is unlikely to cause amenorrhea. Oral contraceptives control menses but do not eliminate it. Diabetes mellitus does not cause the new onset of amenorrhea. Pregnancy can be a cause in a sexually active athlete. Chromosomal abnormalities can result in delayed or absent menarche but not the onset of amenorrhea in a postmenarchal female.
REFERENCES: Constantini NW: Clinical consequences of amenorrhea. Sports Med 1994;17:213-223.
Bennell KL, Malcolm SA, Thomas SA, et al: Risk factors for stress fractures in track and field athletes: A twelve-month prospective study. Am J Sports Med 1996;24:810-818.

Question 32

Closure of the rotator cuff interval results in elimination of which direction of shoulder instability?

Explanation

DISCUSSION: The rotator cuff interval consists of the superior glenohumeral and coracohumeral ligaments. Injury to this ligament complex leads to posteroinferior shoulder instability. Tightening of these tissues through surgical means has been shown to result in a significant reduction in posteroinferior translation of the humerus in relation to the glenoid.
REFERENCES: Harryman DT II, Sidles JA, Harris SL, et al: The role of the rotator interval capsule in passive motion and stability of the shoulder. J Bone Joint Surg Am 1992;74:53-66.
O’Brien SJ, Schwartz RS, Warren RF, et al: Capsular restraints to anterior-posterior motion of the abducted shoulder: A biomechanical study. J Shoulder Elbow Surg 1995;4:298-308.
Warner JJ, Deng XH, Warren RF, et al: Static capsuloligamentous restraints to superior-inferior translation of the glenohumeral joint. Am J Sports Med 1992;20:675-685.

Question 33

In overhead athletic activities, the kinetic chain generates what percentage of force from the leg and trunk segments of the chain?

Explanation

DISCUSSION: The leg and trunk provide a stable base for arm motion, supply rotational momentum for force generation, and generate 50% to 55% of the total force and kinetic energy in the tennis serve.
REFERENCES: Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, p 47.
McClure PW, Michener LA, Sennett BJ, et al: Direct 3-dimensional measurement of scapular kinematics during dynamic movements in vivo. J Shoulder Elbow Surg 2001;10:269-277.
Burkhart SS, Morgan CD, Kibler WB: The disabled throwing shoulder: Spectrum of pathology. Part III: The SICK scapula, scapular dyskinesis, the kinetic chain, and rehabilitation. Arthroscopy 2003;19:641-661.

Question 34

A 40-year-old right-handed professional football player reports persistent right wrist pain after falling during a game 5 days ago. A radiograph is shown in Figure 21. Management should consist of

Explanation

DISCUSSION: The radiograph reveals an increased distance between the scaphoid and the lunate, which is indicative of scapholunate disassociation. A ring sign is also present, which represents the distal pole of the scaphoid viewed end on in a palmarly flexed position. In the acute setting, the scapholunate can be repaired. Open repair and percutaneous pinning is the treatment of choice. Dorsal capsulodesis is performed in the chronic setting if such an injury is initially missed.
REFERENCES: Cohen MS: Ligamentous injuries of the wrist in the athlete. Clin Sports Med 1998;17:533-552.
Taleisnik J: Carpal instability. J Bone Joint Surg Am 1988;70:1262-1268.

Question 35

A 29-year-old ultramarathoner, who is halfway into a 50-mile race, is sweating profusely. He suddenly collapses, is unresponsive, and has violent muscle contractions. Prior to these symptoms, he had been drinking water at every water stop (every 1 mile). What is the most likely diagnosis?

Explanation

DISCUSSION: Hyponatremia (“water intoxication”) can occur in endurance athletes such as ultramarathoners who are sweating profusely and drinking only water as fluid replacement. Sports drinks which contain electrolytes are a better replacement in this group of athletes. Sodium is the mineral most commonly affected by physical exercise. Sodium concentration in sweat depends on diet, hydration, and heat acclimation. In most cases, sodium lost in sweat can be replaced by regular diet. Potassium plays an important role in nerve conduction and muscle contraction but is not lost in excessive amounts in sweat during exercise. The most frequent loss of potassium is through gastrointestinal disorders or excessive loss from the kidneys. Rehrer reported that overhydrating during very long-lasting exercise in the heat with low or negligible sodium intake can result in reduced performance and hyponatremia. With hyponatremia, the serum sodium is abnormally low, resulting in brain swelling, seizures, coma, and potentially death. Interestingly, hyponatremia is rarely seen in adolescent athletes and young children.
REFERENCES: Griffin LY: Emergency preparedness: Things to consider before the game starts. J Bone Joint Surg Am 2005;87:894-902.
Rehrer NJ: Fluid and electrolyte balance in ultra-endurance sport. Sports Med 2001;31:701-715.

Question 36

A 12-year-old Little League pitcher reports lateral elbow pain and “catching.” Examination reveals painful pronation and supination and tenderness over the lateral elbow. Radiographs are shown in Figures 22a and 22b. Initial management should consist of

Explanation

DISCUSSION: Osteochondritis of the capitellum is a common problem in young throwing athletes and gymnasts. The mechanism of injury involves lateral compression and axial loading of the capitellum. Repetitive trauma causes ischemia with resultant osteochondral necrosis and sometimes eventual separation. Initial management includes rest for a minimum of 6 weeks; occasionally bracing is used. At long-term follow-up, there is typically an observed radiographic abnormality indicating incomplete healing even in asymptomatic patients. Arthroscopy with in situ drilling is reserved for symptomatic lesions that have an intact articular surface. Lesions with partial separation often require fixation. Lateral column osteotomy is a new investigational procedure designed to relieve lateral compression forces and may be used in salvage cases.
REFERENCES: Kobayashi K, Burton KJ, Rodner C, et al: Lateral compression injuries in the pediatric elbow: Panner’s disease and osteochondritis dissecans of the capitellum. J Am Acad Orthop Surg 2004;12:246-254.
Yadao MA, Field LD, Savoie FH III: Osteochondritis dissecans of the elbow. Instr Course Lect 2004;53:599-606.

Question 37

Medial dislocation of the long head of the biceps tendon in the shoulder is most commonly caused by a

Explanation

DISCUSSION: Medial dislocation of the biceps tendon in the shoulder is commonly associated with subscapularis tendon tears. Although type II SLAP tears can result in bicipital instability, type I SLAP lesions do not. Congenitally shallow grooves and tears of the transverse ligaments usually do not lead to dislocation of the biceps tendon. Supraspinatus tendon tears are associated with long head of the biceps tendon ruptures but do not cause biceps tendon dislocations.
REFERENCES: Werner A, Mueller T, Boehm D, et al: The stabilizing sling for the long head of the biceps tendon in the rotator cuff interval: A histoanatomic study. Am J Sports Med 2000;28:28-31.
Arendt EA (ed): Orthopaedic Knowledge Update: Sports 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 165-189.

Question 38

Tension force in the anterior cruciate ligament during passive range of motion is highest at

Explanation

DISCUSSION: Tension forces in the healthy, as well as the reconstructed, anterior cruciate ligament were measured and found to be highest with the knee in full extension and decreased as the flexion increased.
REFERENCES: Markolf KL, Burchfield DM, Shapiro MM, et al: Biomechanical consequences of replacement of the anterior cruciate ligament with a patellar ligament allograft. Part II: Forces in the graft compared with forces in the intact ligament. J Bone Joint Surg Am 1996;78:1728-1734.
Beynnon BD, Johnson RJ, Fleming BC, et al: The measurement of elongation of anterior cruciate-ligament grafts in vivo. J Bone Joint Surg Am 1994;76:520-531.

Question 39

Compared to eumenorrheic athletes, amenorrheic athletes have more frequent occurrences of

Explanation

DISCUSSION: In secondary amenorrhea, women do not receive the estrogen needed to maintain adequate bone mineralization. This hypoestrogenic state affects bone density, and there is evidence that stress fractures are more frequent in amenorrheic than eumenorrheic athletes. The other conditions are not seen with increased frequency in amenorrheic athletes.
REFERENCES: Warren MP: Health issues for women athletes: Exercise-induced amenorrhea.
J Clin Endocrinol Metab 1999;84:1892-1896.
Rencken ML, Chesnut CH III, Drinkwater BL: Bone density at multiple skeletal sites in amenorrheic athletes. JAMA 1996;276:238-240.

Question 40

Figure 23 shows the postoperative radiograph of a patient who underwent an anterior cruciate ligament (ACL) reconstruction (with bone-patella tendon-bone autograft) that failed. He initially had loss of flexion postoperatively. What is the most likely cause of this failure?

Explanation

DISCUSSION: The key to this question is the fact that the patient initially lost flexion postoperatively and this relates to anterior placement of the femoral tunnel, thus capturing the knee. The bone plug seen on the radiograph is actually from the tibial tunnel, but this occurred as the patient forced flexion until failure of the ACL graft and pullout of the plug from the tunnel. Although it could be argued that better tibial fixation would have prevented this failure, poor placement of the femoral tunnel led to the failure of this ACL reconstruction.
REFERENCES: Fu FH, Bennett CH, Latterman C, et al: Current trends in anterior cruciate ligament reconstruction: Part 1. Biology and biomechanics of reconstruction. Am J Sports Med 1999;27:821-830.
Fu FH, Bennett CH, Ma CB, et al: Current trends in anterior cruciate ligament reconstruction: Part II. Operative procedures and clinical correlations. Am J Sports Med 2000;28:124-130.

Question 41

A 22-year-old man reports anterior knee pain, swelling, and is unable to perform a straight leg raise after undergoing endoscopic anterior cruciate ligament (ACL) reconstruction with a bone-patellar tendon-bone autograft 1 week ago. He is afebrile. Examination reveals a clean incision, moderate effusion, a weak isometric quadriceps contraction, active knee range of motion of 5 degrees to 45 degrees, and the patella is ballottable. Knee radiographs show postoperative changes with good femoral and tibial tunnel placements, and normal patellar height. What is the next most appropriate step in management?

Explanation

DISCUSSION: Knee pain and swelling in the first week after ACL reconstruction is usually related to a postoperative hemarthrosis. A large hemarthrosis creates capsular distension, which inhibits active quadriceps contraction by a neurologic reflex, the H. reflex. Kennedy and associates reported that an experimentally induced knee effusion at 60 mL was found to result in profound inhibition of reflexly evoked quadriceps contraction. Removal of the hemarthrosis by aspiration will improve strength and often instantaneously restore the ability to contract the quadriceps muscle. A large effusion will also limit knee flexion. EMG and NCVS are not necessary unless there is a high index of suspicion of a femoral neuropathy. Diagnostic ultrasonography is not necessary in this patient but can be useful in the assessment of patellar tendon integrity. MRI is not indicated and would most likely be limited by artifact and postoperative changes. Continuous passive motion is not indicated and would most likely worsen the patient’s symptoms.
REFERENCES: Kennedy JC, Alexander IJ, Hayes KC: Nerve supply of the human knee and its functional importance. Am J Sports Med 1982;10:329-335.
Fahrer H, Rentsch HU, Gerber NJ, et al: Knee effusion and reflex inhibition of the quadriceps: A bar to effective retraining. J Bone Joint Surg Br 1988;70:635-638.

Question 42

A 46-year-old woman fell from her bicycle and sustained the injury shown in Figure 24. Which of the following ligaments has been disrupted?

Explanation

DISCUSSION: The radiograph shows a type V acromioclavicular joint injury. Type V injuries involve disruption of the acromioclavicular and coracoclavicular ligaments. Type I injuries involve a sprain of the acromioclavicular joint ligaments. Type II injuries involve disruption of the acromioclavicular joint ligaments; the coracoclavicular ligaments are partially injured. Sternoclavicular ligaments stabilize the medial clavicle and the sternum; they are not damaged with acromioclavicular joint dislocations.
REFERENCES: Fukuda K, Craig EV, An KN, et al: Biomechanical study of the ligamentous system of the acromioclavicular joint. J Bone Joint Surg Am 1986;68:434-439.
Bosworth B: Complete acromioclavicular dislocation. N Engl J Med 1949;241:221-225.

Question 43

The use of knee arthroscopy following total knee arthroplasty is most effective in treating which of the following conditions?

Explanation

DISCUSSION: Patellar clunk syndrome is associated with certain types of posterior stabilized knee arthroplasties. Arthroscopic resection of the band of inflammatory tissue inferior to the patellar component is effective in treating this condition. Arthroscopic lavage of infected knee arthroplasties is not associated with an acceptable success rate. Diagnostic arthroscopy for nonspecific pain following arthroplasty is not uniformly successful. Patellar component maltracking is frequently associated with component malposition and is not alleviated by an arthroscopic lateral release. Synovitis secondary to polyethylene wear is best treated by exchange of the polyethylene spacer and not arthroscopic synovectomy.
REFERENCES: Lucas TS, DeLuca PF, Nazarian DG, et al: Arthroscopic treatment of patellar clunk. Clin Orthop 1999;367:226-229.
Takahashi M, Miyamoto S, Nagano A: Arthroscopic treatment of soft-tissue impingement under the patella after total knee arthroplasty. Arthroscopy 2002;18:E20.

Question 44

Significant anterior tibial translation occurs during which of the following rehabilitation exercises?

Explanation

DISCUSSION: Terminal non-weight-bearing knee extension exercises from 60 degrees
to 0 degrees of flexion increase anterior tibial translation. It is for this reason that this type of exercise should be avoided in the early phase of rehabilitation following anterior cruciate ligament reconstruction so as not to place a tensile strain on the graft. The other rehabilitation exercises either lead to posterior tibial translation in relation to the femur or have no significant effect on tibial translation.
REFERENCES: Grood ES, Suntay WJ, Noyes FR, et al: Biomechanics of the knee
extension exercise: Effect of cutting the anterior cruciate ligament. J Bone Joint Surg Am 1984;66:725-734.
Lutz GE, Palmitier RA, An KN: Comparison of tibiofemoral joint forces during open-kinetic-chain and closed-kinetic-chain exercises. J Bone Joint Surg Am 1993;75:732-739.
Wilk KE, Escamilla RF, Fleisig GS, et al: A comparison of tibiofemoral joint forces and electromyographic activity during open and closed kinetic chain exercises. Am J Sports Med 1996;24:518-527.

Question 45

A 22-year-old volleyball player reports the insidious onset of superior and posterior shoulder pain. Radiographs are normal. An MRI scan is shown in Figure 25. What is the most specific physical examination finding?

Explanation

DISCUSSION: Overhead athletes are prone to a number of problems involving the shoulder. Pitchers and volleyball players are susceptible to posterior superior labral tears and internal impingement. These patients will have posterior superior shoulder pain, a positive relocation sign, and a positive active compression test. Occasionally, these posterior superior labral tears are associated with a spinoglenoid cyst as seen in the MRI scan. These cysts cause compression of the suprascapular nerve which manifests primarily as weakness of the infraspinatus, resulting in weakness of external rotation.
REFERENCES: Romeo AA, Rotenberg DD, Bach BR Jr: Suprascapular neuropathy. J Am Acad Orthop Surg 1999;7:358-367.
Cummins CA, Messer TM, Nuber GW: Suprascapular nerve entrapment. J Bone Joint Surg Am 2000;82:415-424.

Question 46

A 20-year-old male lacrosse player sustains an anterior dislocation of the shoulder. He is extremely concerned about recurrent dislocations. Which of the following treatments has been shown to reduce the risk of recurrent dislocation?

Explanation

DISCUSSION: Recent evidence has shown that the position of immobilization of the shoulder after a dislocation influences the reduction of the Bankart lesion. In an MRI study in patients who sustained an anterior dislocation, the Bankart lesion was reduced to the glenoid anatomically with the arm in 30 degrees of external rotation. Subsequently, a clinical follow-up study has shown a reduction in recurrence rates when the arm is immobilized in external rotation compared to internal rotation.
REFERENCES: Itoi E, Hatakeyama Y, Kido T, et al: A new method of immobilization after traumatic anterior dislocation of the shoulder: A preliminary study. J Shoulder Elbow Surg 2003;12:413-415.
Itoi E, Sashi R, Minagawa H, et al: Position of immobilization after dislocation of the glenohumeral joint: A study with use of magnetic resonance imaging. J Bone Joint Surg Am 2001;83:661-667.

Question 47

A 43-year-old soccer player who had knee pain following a twisting injury underwent an arthroscopic meniscectomy 6 months ago. He continues to report posterior knee pain. Examination reveals soft-tissue fullness and tenderness just above the popliteal fossa, trace knee effusion, full range of knee motion, no instability, and negative meniscal signs. Radiographs show some mild medial joint space narrowing but no other bony changes. What is the next most appropriate step in management?

Explanation

DISCUSSION: The phenomenon of tumors misdiagnosed as athletic injuries has been termed “sports tumors.” Lewis and Reilly presented a series of 36 patients who initially were thought to have a sports-related injury but ultimately were diagnosed with a primary bone tumor, soft-tissue tumor, or tumor-like condition. Muscolo and associates presented a series of 25 tumors that had been previously treated with an intra-articular procedure as a result of a misdiagnosis of an athletic injury. Initial diagnoses included 21 meniscal lesions, one traumatic synovial cyst, one patellofemoral subluxation, one anterior cruciate ligament tear, and one case of nonspecific synovitis. The final diagnoses were a malignant tumor in 14 patients and a benign tumor in
11 patients. The authors noted that oncologic surgical treatment was affected in 15 of the
25 patients. The most frequent causes of erroneous diagnosis were initial poor quality radiographs and an unquestioned original diagnosis despite persistent symptoms. Persistent symptoms warrant further diagnostic studies, not additional treatment such as physical therapy, corticosteroid injection, or an unloader brace. Although a bone scan may be helpful in this case and confirm arthrosis of the medial compartment, the suspicion of a soft-tissue mass makes MRI the imaging modality of choice.
REFERENCES: Muscolo DL, Ayerza MA, Makino A, et al: Tumors about the knee misdiagnosed as athletic injuries. J Bone Joint Surg Am 2003;85:1209-1214.
Lewis MM, Reilly JF: Sports tumors. Am J Sports Med 1987;15:362-365.

Question 48

Figures 26a through 26c show the MRI scans of a 47-year-old man who underwent arthroscopic shoulder surgery 6 months ago and continues to have pain despite a prolonged course of rehabilitation. Management should now consist of

Explanation

DISCUSSION: The MRI scans show an os acromiale of the mesoacromion type. This represents an unfused acromial apophysis. Pain is thought to be caused by either motion at the site or downward displacement of the anterior aspect of the acromion onto the rotator cuff, causing impingement. Most patients can be treated nonsurgically as they are usually asymptomatic. In those patients with persistent symptoms of pain and tenderness over the acromion, surgery consisting of rigid internal fixation and bone grafting has yielded satisfactory results. Excision may be a viable treatment option for the preacromion type.
REFERENCES: Herzog RJ: Magnetic resonance imaging of the shoulder. Instr Course Lect 1998;47:3-20.
Warner JP, Beim GM, Higgins L: The treatment of symptomatic os acromiale. J Bone Joint Surg Am 1998;80:1320-1326.
Sammarco VJ: Os acromiale: Frequency, anatomy, and clinical implications. J Bone Joint Surg Am 2000;82:394-400.

Question 49

An 18-year-old rugby player has had pain in his ring finger after missing a tackle 1 week ago. Examination reveals tenderness in the distal palm, and he is unable to actively flex the distal interphalangeal (DIP) joint. Radiographs are normal. What is the most appropriate management?

Explanation

DISCUSSION: Flexor digitorum profundus rupture or “rugger jersey finger” often occurs in the ring finger after the player misses a tackle and catches the digit on the shirt of the opposing player. Surgical repair is required for zone I-type injuries.
REFERENCES: Moiemen NS, Elliot D: Primary flexor tendon repair in zone I. J Hand Surg Br 2000;25:78-84.
Strickland JW: Flexor tendon injuries: I. Foundations of treatment. J Am Acad Orthop Surg 1995;3:44-54.

Question 50

Storage of musculoskeletal allografts by cryopreservation is achieved by

Explanation

DISCUSSION: Cryopreservation uses chemicals to remove cellular water and controlled rate freezing to prevent ice crystal formation. The tissue is procured, cooled to wet ice temperature for quarantine, and then stored in a container with cryoprotectant solution of dimethyl
sulfoxide or glycerol which displaces the cellular water. The controlled rate freezing is then done to prevent ice crystal formation. Fresh allografts are not frozen in order to maintain maximum cellular viability, and this process limits the shelf life of osteochondral allografts. Freeze-drying involves replacement of water in the tissue with alcohol to a moisture level of
5% and then uses a vacuum process to remove the alcohol from the tissue. Preparation of fresh frozen grafts involves freezing the graft twice and packaging the tissue without solution at
minus 80 degrees C.
REFERENCES: American Association of Tissue Banks: Standards for Tissue Banking. MacLean, VA, American Association of Tissue Banks, 1999.
Vangsness CT Jr, Triffon MJ, Joyce MJ, et al: Soft tissue allograft reconstruction of the human knee: A survey of the American Association of Tissue Banks. Am J Sports Med 1996;24:230-234.
Brautigan BE, Johnson DL, Caborn DM, et al: Allograft tissues, in DeLee JC, Drez D Jr (eds): Orthopaedic Sports Medicine: Principles and Practice. Philadelphia, PA, WB Saunders, 2003, pp 205-213.

Question 51

During reconstruction of the acromioclavicular joint, a graft is used to recreate the conoid and trapezoid ligaments. Which of the following best describes the anatomic footprint and biomechanical role of the conoid ligament?

Explanation

The conoid ligament inserts on the posteromedial aspect of the distal clavicle and is the primary restraint to superior translation. The trapezoid ligament inserts anterolaterally and resists posterior translation.

Question 52

Which of the following describes the tensioning pattern of the native posterior cruciate ligament (PCL) bundles during knee range of motion?

Explanation

The PCL consists of two main bundles: the anterolateral (AL) and posteromedial (PM). The larger AL bundle tightens during knee flexion, while the smaller PM bundle tightens in extension.

Question 53

During a Latarjet procedure, the coracoid process is osteotomized and transferred to the anterior glenoid. Which nerve is at greatest risk of injury during the approach and retraction medial to the conjoint tendon?

Explanation

The musculocutaneous nerve enters the coracobrachialis approximately 5 to 8 cm distal to the coracoid process. Vigorous medial retraction of the conjoint tendon places this nerve at high risk for a traction injury.

Question 54

A 55-year-old female presents with acute posterior knee pain after descending stairs. MRI reveals a posterior root tear of the medial meniscus. Biomechanically, this injury is most equivalent to which of the following?

Explanation

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

Question 55

Which of the following best describes the biomechanical rationale of a reverse total shoulder arthroplasty in the setting of rotator cuff tear arthropathy?

Explanation

A reverse total shoulder arthroplasty medializes and distalizes the center of rotation. This increases the moment arm of the deltoid, allowing it to initiate and maintain abduction in the absence of a functioning supraspinatus.

Question 56

During a posterior-stabilized total knee arthroplasty, the surgeon finds the knee to be well-balanced in full extension but excessively tight in 90 degrees of flexion. Which of the following is the most appropriate next step to correct this mismatch?

Explanation

A knee that is tight in flexion but balanced in extension requires an adjustment to the flexion gap only. Downsizing the femoral component (using an anterior referencing system) or increasing the posterior tibial slope will increase the flexion gap.

Question 57

In medial patellofemoral ligament (MPFL) reconstruction, identifying the correct femoral attachment (Schottle point) is critical. Where is this point located on a true lateral radiograph of the knee?

Explanation

Schottle point is located radiographically 1 mm anterior to the extension of the posterior femoral cortical line, 2.5 mm distal to the posterior origin of the medial femoral condyle, and proximal to the Blumensaat line.

Question 58

A 45-year-old construction worker presents with persistent shoulder pain. MRI arthrogram demonstrates a Type II SLAP tear without rotator cuff pathology. Conservative management has failed. Which surgical intervention provides the most reliable return to function in this demographic?

Explanation

In patients over 40 years old, particularly laborers or those who do not participate in overhead throwing sports, primary biceps tenodesis offers superior outcomes and a lower complication rate compared to SLAP repair.

Question 59

A 24-year-old athlete presents with medial scapular winging noticeable during forward elevation of the arm. EMG confirms an isolated nerve injury. Which muscle is primarily affected and what is the typical mechanism of injury?

Explanation

Medial scapular winging is caused by paralysis of the serratus anterior, which is innervated by the long thoracic nerve. Lateral winging is typically due to trapezius dysfunction caused by a spinal accessory nerve injury.

Question 60

A 28-year-old male sustains a high-energy knee dislocation (KD-III) that is reduced in the ER. His distal pulses are palpable, but the ankle-brachial index (ABI) is 0.85. What is the most appropriate next step in management?

Explanation

In the setting of a knee dislocation, an ABI less than 0.9 indicates a high suspicion for vascular injury despite palpable pulses. A CT angiogram is the gold standard next step to evaluate for a popliteal artery intimal tear or occlusion.

Question 61

Which of the following factors is most strongly associated with a poor prognosis for nonoperative healing in a patient with an osteochondritis dissecans (OCD) lesion of the medial femoral condyle?

Explanation

Signs of instability on MRI, such as high T2 signal behind the fragment or cystic changes deep to the lesion, indicate a poor prognosis for conservative management. Closed physes are also a strong predictor of non-healing.

Question 62

Which vessel provides the primary blood supply to the humeral head, and what is its anatomic course?

Explanation

Recent anatomic and perfusion studies have demonstrated that the posterior humeral circumflex artery, running through the quadrangular space, provides the majority of the blood supply to the humeral head. Historically, the anterior circumflex artery was thought to be the primary supply.

Question 63

A 65-year-old female presents with an audible and palpable 'clunk' at the anterior knee when extending her leg from 40 degrees of flexion to full extension, one year after a total knee arthroplasty. What implant design characteristic is most frequently associated with this complication?

Explanation

Patellar clunk syndrome is most commonly associated with posterior-stabilized (PS) implants that have a high or sharp anterior intercondylar box. Fibrous tissue forms at the superior pole of the patella and catches in the box during extension.

Question 64

During a medial opening wedge high tibial osteotomy (HTO) for medial compartment osteoarthritis, which of the following technical errors will most likely result in an unintended increase in the posterior tibial slope?

Explanation

Because the proximal tibia is triangular, opening the wedge uniformly or more anteriorly will inadvertently increase the posterior tibial slope. To maintain normal slope, the wedge must be opened approximately twice as much posteromedially as anteromedially.

Question 65

What is the primary static restraint to superior translation of the humeral head in a patient with a massive, irreparable rotator cuff tear?

Explanation

The coracoacromial (CA) ligament forms the CA arch, serving as a crucial static restraint to superior humeral head escape. Preservation of this ligament is critical in patients with massive, irreparable cuff tears who are not undergoing reverse total shoulder arthroplasty.

Question 66

Regarding the anatomy and biomechanics of the anterior cruciate ligament (ACL), which of the following statements best describes the anteromedial (AM) bundle?

Explanation

The anteromedial (AM) bundle of the ACL is tightest in knee flexion and primarily restrains anterior tibial translation. Conversely, the posterolateral (PL) bundle is tightest in extension and primarily controls rotatory stability.

Question 67

A baseball pitcher complains of posterior shoulder pain during the late cocking phase of throwing. He is diagnosed with internal impingement. Which of the following is the hallmark pathological finding?

Explanation

Internal impingement occurs in the abducted and externally rotated (ABER) position, causing the articular surface of the supraspinatus and infraspinatus to abut against the posterosuperior glenoid labrum. This can lead to partial articular-sided cuff tears and labral fraying.

Question 68

During a medial patellofemoral ligament (MPFL) reconstruction, accurate identification of the femoral attachment (Schöttle's point) is critical to prevent graft anisometry. Radiographically, this anatomic point is located:

Explanation

The anatomical femoral origin of the MPFL sits in a saddle between the medial epicondyle and the adductor tubercle. On a true lateral radiograph, Schöttle's point is 1 mm anterior to the posterior cortex line, 2.5 mm distal to the posterior border of the medial femoral condyle, and proximal to Blumensaat's line.

Question 69

A 35-year-old male presents with isolated weakness in external rotation of his dominant shoulder. MRI reveals a paralabral cyst in the spinoglenoid notch. Which of the following physical examination findings is most likely?

Explanation

Entrapment of the suprascapular nerve at the spinoglenoid notch affects only the infraspinatus muscle, leading to external rotation weakness. Supraspinatus function remains intact, allowing for normal initial shoulder abduction.

Question 70

During an open subpectoral biceps tenodesis, deep medial retraction places which of the following neurovascular structures at greatest risk of iatrogenic injury?

Explanation

The musculocutaneous nerve courses medially beneath the biceps muscle belly. Excessive medial retraction during a subpectoral biceps tenodesis places this nerve at significant risk for traction injury.

Question 71

Which structure serves as the primary restraint to varus stress of the knee at 30 degrees of flexion?

Explanation

The fibular collateral ligament (LCL) is the primary restraint to varus stress at both 0 and 30 degrees of knee flexion. The popliteus and popliteofibular ligament primarily restrain external rotation.

Question 72

In a Latarjet procedure for recurrent anterior shoulder instability, the crucial 'sling effect' that dynamically stabilizes the anterior shoulder is primarily provided by:

Explanation

The Latarjet procedure provides stability via three mechanisms: the bony block, the capsulolabral repair, and the dynamic 'sling effect.' The sling effect is generated by the conjoined tendon passing through the split lower subscapularis, tensioning it in abduction and external rotation.

Question 73

Which MRI finding is most classically associated with a posterior medial meniscus root tear, functionally representing a loss of meniscal hoop stresses?

Explanation

A posterior root tear disrupts the circumferential hoop stresses of the meniscus, causing it to functionally behave like a total meniscectomy. This loss of tension leads to meniscal extrusion of > 3 mm beyond the tibial margin on a coronal MRI.

Question 74

Which mechanism of injury is most classically responsible for an acute rupture of the pectoralis major tendon?

Explanation

Pectoralis major ruptures almost exclusively occur during heavy weightlifting, particularly the bench press. The injury happens when the muscle undergoes maximal eccentric contraction with the shoulder extended and externally rotated.

Question 75

Physical examination of a knee injury reveals increased external tibial rotation at 30 degrees of flexion compared to the contralateral side, but symmetric external rotation at 90 degrees. This finding indicates an isolated injury to the:

Explanation

A positive dial test at 30 degrees but normal at 90 degrees indicates an isolated posterolateral corner (PLC) injury. If external rotation is increased at both 30 and 90 degrees, it suggests a combined PLC and posterior cruciate ligament (PCL) injury.

Question 76

In a patient presenting with early idiopathic adhesive capsulitis of the shoulder, which physical exam finding is typically the earliest and most specific hallmark?

Explanation

The hallmark of adhesive capsulitis is a stiff, painful shoulder with a global decrease in active and passive range of motion. A symmetrical loss of passive external rotation with the arm adducted at the side is often the earliest and most reliable finding.

Question 77

The primary blood supply to the menisci of the knee, which supports healing in the peripheral 'red-red' zone, is derived from the:

Explanation

The peripheral 10% to 30% of the menisci is vascularized by a perimeniscal capillary plexus originating primarily from branches of the medial and lateral inferior genicular arteries. Tears in this zone have a higher healing potential.

Question 78

When performing an open or arthroscopic distal clavicle excision for osteolysis, what is the maximum amount of bone that should be resected to preserve the acromioclavicular (AC) ligaments and prevent anterior-posterior instability?

Explanation

Distal clavicle resection typically aims for 5 to 8 mm of bone removal. Resecting more than 10 mm risks compromising the superior and posterior AC capsular ligaments, leading to iatrogenic horizontal (AP) instability.

Question 79

During a high tibial osteotomy (HTO) for medial compartment knee osteoarthritis, creating excessive valgus overcorrection significantly increases the risk of which complication?

Explanation

The goal of HTO is to shift the mechanical weight-bearing axis slightly lateral to the midline (Fujisawa point). Valgus overcorrection shifts too much load laterally, predisposing the patient to accelerated lateral compartment osteoarthritis.

Question 80

In cases of recurrent anterior shoulder instability, a Hill-Sachs lesion is a common bony defect resulting from an impaction fracture on the:

Explanation

A Hill-Sachs lesion is a cortical depression in the posterosuperior lateral aspect of the humeral head. It occurs when the humeral head dislocates anteriorly and impacts against the firm anterior glenoid rim.

Question 81

During an anatomical single-bundle anterior cruciate ligament (ACL) reconstruction using a soft tissue autograft, the graft is typically tensioned and secured at what knee angle to avoid a capture deficit?

Explanation

Soft tissue (hamstring) ACL grafts are typically tensioned and fixed near extension (0 to 20 degrees of flexion) to ensure stability throughout the arc of motion and to prevent a loss of extension (capture deficit).

Question 82

During shoulder arthroscopy, the 'comma sign' is an important anatomical landmark indicating a subscapularis tear. This structure is formed by the avulsion and medial retraction of the:

Explanation

The 'comma sign' is a crescent-shaped arc of tissue formed by the torn and medially retracted superior glenohumeral ligament (SGHL) and coracohumeral ligament (CHL). It serves as a guide to locate the retracted superior edge of the subscapularis tendon.

Question 83

Osteochondritis dissecans (OCD) lesions of the knee most frequently occur in which of the following anatomical locations?

Explanation

The classic and most common location for osteochondritis dissecans in the knee is the lateral aspect of the medial femoral condyle (LAME - Lateral Aspect Medial Epicondyle/Condyle), accounting for roughly 70% of cases.

Question 84

When performing a surgical repair of a complete proximal hamstring rupture, understanding the anatomy of the ischial tuberosity origin is essential. Which muscle's tendon originates most laterally and anteriorly on the tuberosity?

Explanation

At the ischial tuberosity footprint, the semimembranosus tendon has a distinct lateral and anterior origin. The long head of the biceps femoris and semitendinosus form a conjoined tendon that originates more medially and posteriorly.

Question 85

A reverse total shoulder arthroplasty (rTSA) improves active elevation in patients with rotator cuff tear arthropathy primarily through which of the following biomechanical alterations?

Explanation

rTSA shifts the center of rotation medially and inferiorly. This increases the deltoid moment arm and recruits more deltoid muscle fibers to compensate for the deficient rotator cuff.

Question 86

Which of the following describes the biomechanical effect of an untreated posterior medial meniscus root tear?

Explanation

A posterior medial meniscus root tear disrupts hoop stresses, causing functional extrusion of the meniscus. Biomechanically, this results in peak contact pressures equivalent to a total medial meniscectomy, predisposing the joint to rapid osteoarthritis.

Question 87

A 25-year-old football player presents with a knee injury. On physical examination, the dial test shows 15 degrees of increased external rotation at 30 degrees of flexion compared to the contralateral knee, but equal external rotation at 90 degrees of flexion. Which structure is most likely injured?

Explanation

Increased external rotation on the dial test at 30 degrees of flexion, but not at 90 degrees, indicates an isolated posterolateral corner (PLC) injury. If asymmetry persists at both 30 and 90 degrees, a combined PLC and PCL injury is present.

Question 88

In the setting of an acromioclavicular (AC) joint dislocation, which of the following ligaments provides the primary restraint to superior translation of the distal clavicle?

Explanation

The conoid ligament is the primary restraint to superior translation of the distal clavicle. The trapezoid ligament primarily resists axial compression to the shoulder.

Question 89

During medial patellofemoral ligament (MPFL) reconstruction, femoral tunnel placement proximal to Schöttle's point will result in which of the following graft kinematics?

Explanation

Placing the MPFL femoral attachment too proximal results in the graft being overly tight in flexion and loose in extension, risking loss of knee flexion and medial patellar overload. Correct placement is slightly anterior to the posterior femoral cortex extension line.

Question 90

A 22-year-old collegiate baseball pitcher presents with posterior shoulder pain during the late cocking phase of throwing. MRI arthrogram reveals a SLAP tear and partial articular-sided supraspinatus tendon avulsion (PASTA). What is the primary pathomechanical etiology of this injury?

Explanation

Internal impingement in overhead throwers is driven by repetitive late-cocking motions causing a tight posterior capsule (GIRD). This leads to a posterosuperior shift of the humeral head, pinching the rotator cuff and peeling back the superior labrum.

Question 91

What is the most common anatomic location for an osteochondritis dissecans (OCD) lesion in the knee?

Explanation

The lateral aspect of the medial femoral condyle is the classic and most common location for osteochondritis dissecans (OCD) lesions of the knee. This is often remembered by the mnemonic 'LAME' (Lateral Aspect Medial Epicondyle/condyle).

Question 92

A 65-year-old patient with a massive, chronic, retracted rotator cuff tear involving the supraspinatus and infraspinatus develops fatty infiltration and marked atrophy. EMG studies show denervation changes in the infraspinatus only. Where is the most likely site of nerve compression?

Explanation

The suprascapular nerve innervates the supraspinatus before passing through the spinoglenoid notch to innervate the infraspinatus. Isolated denervation of the infraspinatus indicates compression at the spinoglenoid notch, often by a paralabral cyst.

Question 93

When performing a single-bundle posterior cruciate ligament (PCL) reconstruction, recreating the anterolateral (AL) bundle is prioritized. During which phase of knee range of motion is the native AL bundle most taut?

Explanation

The anterolateral (AL) bundle of the PCL is the larger, stiffer bundle and is most taut at 90 degrees of knee flexion. The posteromedial (PM) bundle is tight in extension and deep flexion.

Question 94

According to the Instability Severity Index Score (ISIS), which of the following preoperative factors significantly increases the risk of recurrence after an isolated arthroscopic Bankart repair?

Explanation

The ISIS score helps predict failure of arthroscopic Bankart repair. Risk factors for recurrence include age under 20 at surgery, competitive/contact sports participation, anterior hyperlaxity, visible Hill-Sachs on AP view, and loss of sclerotic contour on the glenoid.

Orthopedic Surgery Board Review MCQs: Arthroplasty, Trauma & Spine Part 255

OITE & ABOS Orthopedic Board Prep: Knee & Shoulder MCQs | Part 54

Key Takeaway

OITE & ABOS Orthopedic Board Prep: Knee & Shoulder MCQs | Part 54

Chapter Index