2019

Sports Medicine Scored and Recorded Self-Assessment Examination 2019

Question 1 of 100

Based on the injury shown on the axial MRI scan of the shoulder in Figure 1, what other pathology
should be closely examined for during surgery?

Figure 1

A. Subscapularis tear
B. Supraspinatus tear
C. Superior labral anterior-posterior (SLAP) tear
D. Bankart tear

Correct answer: A

 Discussion

The axial MRI scan reveals a subluxated biceps tendon. In the study by Koh and associates, 85% of
patients with a biceps subluxation on MRI were found to have a subscapularis tear at the time of
arthroscopy. These are not always obvious on the MRI, and close inspection of the leading edge/upper
border of the subscapularis tendon at the time of arthroscopy is necessary. Although supraspinatus
tears, SLAP tears, and Bankart tears can all occur in conjunction with a biceps subluxation, none have
been shown to be strongly correlated with this pathology, nor as specific to this pathology.

 Recommended Readings
Shi LL, Mullen MG, Freehill MT, Lin A, Warner JJ, Higgins LD. Accuracy of long head of the
biceps subluxation as a predictor for subscapularis tears. Arthroscopy. 2015 Apr;31(4):615-9.
doi: 10.1016/j.arthro.2014.11.034. Epub 2015 Jan 28. PubMed

Koh KH, Kim SC, Yoo JC. Arthroscopic Evaluation of Subluxation of the Long Head of the
Biceps Tendon and Its Relationship with Subscapularis Tears. Clin Orthop Surg. 2017
Sep;9(3):332-339. doi: 10.4055/cios.2017.9.3.332. Epub 2017 Aug 4. PubMed

Question 2 of 100

Figure 1 is the radiograph of a 31-year-old man who had left shoulder pain after a fall during a
snowboarding jump. Residual displacement of 5 mm after closed reduction is most likely to result in

Figure 1

A. nonunion.
B. osteonecrosis.
C. altered rotator cuff mechanics.
D. normal shoulder function.
Correct answer: C

 Discussion

Humerus fractures account for 11% of all fractures among snowboarders and are the second-most-
common upper-extremity fracture after radius fractures (48%). Surgical fixation is recommended for
fractures with residual displacement >5 mm, or >3 mm in active patients involved in frequent overhead
activity. Malunion can result in a mechanical block to shoulder abduction or external rotation and
altered rotator cuff mechanics, causing weakness. A rich arterial network provides a favorable healing
environment for greater tuberosity fractures. Consequently, nonunion and osteonecrosis are
uncommon.

 Recommended Readings

Bissell BT, Johnson RJ, Shafritz AB, Chase DC, Ettlinger CF. Epidemiology and risk factors of
humerus fractures among skiers and snowboarders. Am J Sports Med. 2008 Oct;36(10):1880-8.
Epub 2008 Jul 1. PubMed

George MS. Fractures of the greater tuberosity of the humerus. J Am Acad Orthop Surg. 2007
Oct;15(10):607-13. Full text

Question 3 of 100

A 23-year-old student complains of recurrent left shoulder instability. He first dislocated his shoulder in
high school while playing lacrosse and was managed with physical therapy. A second dislocation
occurred one year later while skiing. He has since sustained two more dislocations and says that his
shoulder feels “loose.” Examination reveals grade II anterior load and shift, positive apprehension and
relocation tests, and normal rotator cuff strength. An MRI arthrogram is ordered and surgical treatment
is recommended. What factor would most strongly represent an indication for a procedure including
bone augmentation (e.g. Latarjet) rather than a soft-tissue-only stabilization (isolated labral
repair/capsulorrhaphy)?

A. Patient’s intention to resume lacrosse and other contact sports after surgery
B. Presence of a 270° labral tear
C. 2-cm “on-track” Hill-Sachs lesion
 D. Anterior bony loss measuring 30% of inferior glenoid width

Correct answer: D

 Discussion

There is much debate in the literature regarding optimal techniques for treatment of shoulder
instability. Barring other factors or concomitant pathology, however, there is no persuasive literature to
suggest routine use of bone augmentation for contact athletes. Extensive labral involvement (here
specifically implying posterior labral involvement, as well) will require a more extensive repair but does
not, in and of itself, suggest the necessity for glenoid bone augmentation. A large Hill-Sachs lesion may
be an indication for glenoid augmentation, primarily if it is in a location/orientation that engages the
anterior glenoid rim. These are referred to as “off-track” lesions. Of these choices, the strongest
indication for a Latarjet coracoid transfer or similar bone augmentation (other options include iliac crest
autograft or distal tibial allograft) is high-grade glenoid bone loss. Classically, this is performed through
an open approach, although arthroscopic techniques are increasing in popularity. Although the critical
amount of bone loss is debated, most surgeons and studies suggest a cut-off of approximately 20% to
25%, above which isolated soft-tissue stabilization alone is less likely to be successful in the long-term.

 Recommended Readings

Mologne TS, Provencher MT, Menzel KA, Vachon TA, Dewing CB. Arthroscopic stabilization
in patients with an inverted pear glenoid: results in patients with bone loss of the anterior
glenoid. Am J Sports Med. 2007 Aug;35(8):1276-83. PubMed

Forsythe B, Frank RM, Ahmed M, Verma NN, Cole BJ, Romeo AA, Provencher MT, Nho SJ.
Identification and treatment of existing copathology in anterior shoulder instability repair.
Arthroscopy. 2015 Jan;31(1):154-66. doi: 10.1016/j.arthro.2014.06.014. Epub 2014 Sep 8.
PubMed

Godin J, Sekiya JK. Systematic review of arthroscopic versus open repair for recurrent anterior
shoulder dislocations. Sports Health. 2011 Jul;3(4):396-404. PubMed

Harris JD, Gupta AK, Mall NA, Abrams GD, McCormick FM, Cole BJ, Bach BR Jr, Romeo
AA, Verma NN. Long-term outcomes after Bankart shoulder stabilization. Arthroscopy. 2013
May;29(5):920-33. doi: 10.1016/j.arthro.2012.11.010. Epub 2013 Feb 5. PubMed
Question 4 of 100

A 32-year-old volleyball player has dull posterior shoulder pain. An examination reveals moderate
external rotation weakness with his arm at his side but normal strength on supraspinatus isolation.
Deltoid and supraspinatus bulk appear normal, although there appears to be mild infraspinatus atrophy.
Sensation is normal throughout the shoulder and shoulder girdle. What is the most likely diagnosis?

A. Calcified transverse scapular ligament

B. Parsonage-Turner syndrome
C. Spinoglenoid notch cyst
D. Quadrilateral space syndrome

Correct answer: C

 Discussion

This clinical scenario describes a patient with an isolated injury affecting the infraspinatus muscle. The
anatomic location of such a lesion would be at the spinoglenoid notch, at which the suprascapular nerve
may be compressed distal to its innervation of the supraspinatus but proximal to the infraspinatus
innervation. A calcified transverse scapular ligament would also affect the suprascapular nerve but is
proximal to the innervation of both muscles. Quadrilateral space syndrome would affect innervation of
the deltoid (and teres minor). Parsonage-Turner syndrome is a more diffuse, and often severely painful,
brachial plexus neuropathy.

 Recommended Readings

Aval SM, Durand P Jr, Shankwiler JA. Neurovascular injuries to the athlete's shoulder: part II. J
Am Acad Orthop Surg. 2007 May;15(5):281-9. PubMed

Piasecki DP, Romeo AA, Bach BR Jr, Nicholson GP. Suprascapular neuropathy. J Am Acad
Orthop Surg. 2009 Nov;17(11):665-76. Full text

Safran MR. Nerve injury about the shoulder in athletes, part 1: suprascapular nerve and axillary
nerve. Am J Sports Med. 2004 Apr-May;32(3):803-19. Review.PubMed
Question 5 of 100

Figure 1 is an MRI scan of the right hip of a 19-year-old woman with a 6-month history of right groin
pain. She was diagnosed with a stress fracture and was treated with 3 months of limited weight bearing.
Figure 2 is a repeat MRI scan in which the edema pattern changed minimally but the pain worsened.
Ibuprofen alleviates most of her pain. What is the best next step?

Figure 1 Figure 2

A. Hip arthroscopy with labrum repair

B. MRI arthrogram
C. Percutaneous screw fixation
D. CT scan with fine cuts

Correct answer: D
  Discussion

An osteoid osteoma is a benign bone tumor. Osteoid osteomas tend to be small—typically <1.5 cm.
Regardless of their size, they cause a large amount of reactive bone to form around them, and they
make a new type of abnormal bone material called osteoid bone. This osteoid bone, along with the
tumor cells, forms the nidus of the tumor, which is easily identified on CT scans.

 Recommended Readings

Boscainos PJ, Cousins GR, Kulshreshtha R, Oliver TB, Papagelopoulos PJ. Osteoid osteoma.
Orthopedics. 2013 Oct 1;36(10):792-800. doi: 10.3928/01477447-20130920-10. PubMed

Klontzas ME, Zibis AH, Karantanas AH. Osteoid Osteoma of the Femoral Neck: Use of the
Half-Moon Sign in MRI Diagnosis. AJR Am J Roentgenol. 2015 Aug;205(2):353-7. doi:
10.2214/AJR.14.13689. PubMed

Question 6 of 100

When reconstructing the anterior cruciate ligament (ACL) with autograft, what is the most common
source of surgical failure?

A. Graft choice
B. Tunnel position
C. Tibial fixation
D. Femoral fixation

Correct answer: B

 Discussion

Technical failure is the most common reason for ACL reconstruction failure. Tunnel position is the most
frequent cause for technical failure. Malpositioning of the tunnel affects the length of the graft, causing
either decreased range of motion or increased graft laxity. Although graft choice is an important factor
when planning an ACL reconstruction, overall outcomes with autograft tissues are fairly similar. Fixation
of the graft at the femoral or tibial end is not as important as tunnel position.
  Recommended Readings

Battaglia TC, Miller MD. Management of bony deficiency in revision anterior cruciate ligament
reconstruction using allograft bone dowels: surgical technique. Arthroscopy. 2005 Jun;21(6):767.
PubMed

Beynnon BD, Johnson RJ, Fleming BC, Kannus P, Kaplan M, Samani J, Renström P. Anterior
cruciate ligament replacement: comparison of bone-patellar tendon-bone grafts with two-strand
hamstring grafts. A prospective, randomized study. J Bone Joint Surg Am. 2002 Sep;84-
A(9):1503-13. PubMed

Question 7 of 100

An otherwise healthy 31-year-old man has had right knee pain for the past 9 months. His former
physician administered a cortisone injection and ordered 6 months of physical therapy. The patient later
had an arthroscopy with debridement of the right knee by another physician and completed another
course of physical therapy. The patient received minimal relief from these treatments and still is not
able to walk longer distances or go on hikes. On examination, he is a healthy appearing male with a body
mass index of 24 kg/m2. He has a small effusion, minimal quadriceps atrophy, no tenderness about the
knee, full range of motion, stable to varus and valgus stress at 30° of flexion, a grade 1 Lachman test,
and a normal posterior drawer. Figures 1 through 4 are his arthroscopic views, radiograph and MRI scan
from his prior surgical procedure. What is the next most appropriate step in treatment?

Figure 1 Figure 2
 Figure 3 Figure 4

A. Bracing with physical therapy focusing on quadriceps/vastus medialis obliquus (VMO) and
hamstring strengthening
B. Osteotomy
C. Osteochondral allograft to femoral condyle
D. Arthroscopy with femoral condyle microfracture

Correct answer: C

 Discussion

The patient has a symptomatic cartilage lesion of his medial femoral condyle, which has not responded
to nonsurgical measures, and he failed a prior arthroscopy with debridement. Based on his examination
and imaging, he is ligamentously stable, has normal mechanical alignment, and has intact menisci,
making him a candidate for a cartilage restoration procedure. The accompanying MRI also indicates
subchondral bone involvement with increased T2 signal underlying the cartilage defect. Osteochondral
allograft is the only choice that addresses both the cartilage defect, as well as compromised subchondral
bone. Depending on lesion size, osteochondral autograft transfer may also be considered, but this is not
presented as an answer choice.

Given the radiographic finding of neutral mechanical alignment, bracing would be less effective, and the
patient has already tried extensive physical therapy. Lack of malalignment also excludes tibial osteotomy
as a preferred answer choice. Microfracture is best for small cartilage lesions without significant bone
marrow involvement.

 Recommended Readings

Bedi A, Feeley BT, Williams RJ 3rd. Management of articular cartilage defects of the knee. J
Bone Joint Surg Am. 2010 Apr;92(4):994-1009. doi: 10.2106/JBJS.I.00895. PubMed

Krych AJ, Pareek A, King AH, Johnson NR, Stuart MJ, Williams RJ 3rd. Return to sport after
the surgical management of articular cartilage lesions in the knee: a meta-analysis. Knee Surg
Sports Traumatol Arthrosc. 2017 Oct;25(10):3186-3196. doi: 10.1007/s00167-016-4262-3. Epub
2016 Aug 18. PubMed

Question 8 of 100

A collegiate lacrosse player is struck on the head by an opposing player’s stick. She is initially
unresponsive. She regains consciousness within 2 minutes but remains confused and uncooperative,
complaining of head and neck pain. This is her second concussion of the calendar year. Initial
management should consist of

A. calculation of Glasgow Coma Scale score.

B. evaluation with a sideline assessment tool, such as the SCAT-3.
C. urgent hospital transfer for CT scan.
D. stabilization of the cervical spine and placement of a collar.

Correct answer: D
  Discussion

This patient has sustained a significant concussion or minor brain injury. Although all answer options
reflect important steps in her management, the initial primary concern in any player who is confused or
combative is protection of the cervical spine until formal clearance can be performed. This patient
requires immediate immobilization, collar placement, and, ultimately, transportation to a hospital.
Cervical immobilization should be achieved before transport, given her complaints of neck pain and
inability to provide a reliable examination.

 Recommended Readings

Durand P Jr, Adamson GJ. On-the-field management of athletic head injuries. J Am Acad Orthop
Surg. 2004 May-Jun;12(3):191-5. Full text

Cahill PJ, Refakis C, Storey E, Warner WC Jr. Concussion in Sports: What Do Orthopaedic
Surgeons Need to Know? J Am Acad Orthop Surg. 2016 Dec;24(12):e193-e201. Full text

Question 9 of 100

Figures 1 and 2 are the MR arthrogram images of a 16-year-old, right-hand-dominant baseball player
who injured his left shoulder 4 weeks ago during a game. He now has pain, weakness, and the inability
to swing a bat and can no longer do push-ups. He denies prior injury to his left shoulder. Radiographs
are unremarkable.

Which of the four muscles of the rotator cuff provides the most resistance to this patient's direction of
instability?
 Figure 1 Figure 2

A. Subscapularis
B. Supraspinatus
C. Infraspinatus
D. Teres minor

Correct answer: A

 Discussion

Posterior shoulder instability is a rare form of instability that often presents with pain rather than
feelings of instability. It often occurs in young athletes during activities that put the shoulder in an “at-
risk position” (flexion, adduction, internal rotation). Repetitive microtrauma can lead to posterior
shoulder instability such as seen in football linemen. Swinging a bat or golf club places the lead arm in a
flexed, adducted, and internally rotated position, which can lead to posterior translation of the humeral
head that is forcibly reduced in follow-through, as seen in this patient.

The glenohumeral joint relies on static and dynamic stabilizers. Static stabilizers help prevent instability
at the end ranges of motion when the ligaments are taut. Dynamic stabilizers work to prevent
subluxation at midranges of motion, at which the ligaments are lax. The rotator cuff is integral as a
dynamic stabilizer of the shoulder. It works through a process called concavity compression. The four
muscles of the rotator cuff compress the humeral head into the concavity of the glenoid-labrum. This
prevents the humeral head from subluxing during the midranges of motion. Of the four rotator cuff
muscles, the subscapularis is most important at preventing posterior subluxation.

This patient has posterior instability, and various surgical techniques may be indicated depending on
findings. Arthroscopic labral repair is indicated for anterior instability. Arthroscopic posterior labral
repair is indicated for this patient because he has a posterior labral tear and posterior instability. If a
patient has ligamentous laxity (not seen in this scenario because sulcus and Beighton sign findings would
be negative), a posterior capsular shift with rotator interval closure is indicated. If a patient has
excessive glenoid retroversion (not seen in this scenario with 5 degrees of retroversion), a posterior
opening-wedge osteotomy is appropriate.

The most common complication seen after arthroscopic posterior labral repair is stiffness, followed by
recurrent instability and degenerative joint disease.

 Recommended Readings

Millett PJ, Clavert P, Hatch GF 3rd, Warner JJ. Recurrent posterior shoulder instability. J Am
Acad Orthop Surg. 2006 Aug;14(8):464-76. Full text

Hawkins RJ, Schutte JP, Janda DH, Huckell GH. Translation of the glenohumeral joint with the
patient under anesthesia. J Shoulder Elbow Surg. 1996 Jul-Aug;5(4):286-92. PubMed

Kido T, Itoi E, Lee SB, Neale PG, An KN. Dynamic stabilizing function of the deltoid muscle in
shoulders with anterior instability. Am J Sports Med. 2003 May-Jun;31(3):399-403. PubMed

Lee SB, An KN. Dynamic glenohumeral stability provided by three heads of the deltoid muscle.
Clin Orthop Relat Res. 2002 Jul;(400):40-7. PubMed

Question 10 of 100

Figures 1 and 2 are the MR arthrogram images of a 16-year-old, right-hand-dominant baseball player
who injured his left shoulder 4 weeks ago during a game. He now has pain, weakness, and the inability
to swing a bat and can no longer do push-ups. He denies prior injury to his left shoulder. Radiographs
are unremarkable.

The patient fails an extensive course of physical therapy and is unable to return to baseball. He and his
orthopaedic surgeon elect to proceed with surgery. During a repeat evaluation, he has negative sulcus
and Beighton sign findings, and radiographs show 5° of glenoid retroversion. What is the most
appropriate surgical plan?

Figure 1 Figure 2

A. Arthroscopic infraspinatus tenodesis

B. Arthroscopic posterior labral repair
C. Arthroscopic capsular shift and rotator interval closure
D. Posterior glenoid opening-wedge osteotomy

Correct answer: B

 Discussion

Posterior shoulder instability is a rare form of instability that often presents with pain rather than
feelings of instability. It often occurs in young athletes during activities that put the shoulder in an “at-
risk position” (flexion, adduction, internal rotation). Repetitive microtrauma can lead to posterior
shoulder instability such as seen in football linemen. Swinging a bat or golf club places the lead arm in a
flexed, adducted, and internally rotated position, which can lead to posterior translation of the humeral
head that is forcibly reduced in follow-through, as seen in this patient.

The glenohumeral joint relies on static and dynamic stabilizers. Static stabilizers help prevent instability
at the end ranges of motion when the ligaments are taut. Dynamic stabilizers work to prevent
subluxation at midranges of motion, at which the ligaments are lax. The rotator cuff is integral as a
dynamic stabilizer of the shoulder. It works through a process called concavity compression. The four
muscles of the rotator cuff compress the humeral head into the concavity of the glenoid-labrum. This
prevents the humeral head from subluxing during the midranges of motion. Of the four rotator cuff
muscles, the subscapularis is most important at preventing posterior subluxation.

This patient has posterior instability, and various surgical techniques may be indicated depending on
findings. Arthroscopic labral repair is indicated for anterior instability. Arthroscopic posterior labral
repair is indicated for this patient because he has a posterior labral tear and posterior instability. If a
patient has ligamentous laxity (not seen in this scenario because sulcus and Beighton sign findings would
be negative), a posterior capsular shift with rotator interval closure is indicated. If a patient has
excessive glenoid retroversion (not seen in this scenario with 5 degrees of retroversion), a posterior
opening-wedge osteotomy is appropriate.

The most common complication seen after arthroscopic posterior labral repair is stiffness, followed by
recurrent instability and degenerative joint disease.

 Recommended Readings

Millett PJ, Clavert P, Hatch GF 3rd, Warner JJ. Recurrent posterior shoulder instability. J Am
Acad Orthop Surg. 2006 Aug;14(8):464-76. Full text

Hawkins RJ, Schutte JP, Janda DH, Huckell GH. Translation of the glenohumeral joint with the
patient under anesthesia. J Shoulder Elbow Surg. 1996 Jul-Aug;5(4):286-92. PubMed

Kido T, Itoi E, Lee SB, Neale PG, An KN. Dynamic stabilizing function of the deltoid muscle in
shoulders with anterior instability. Am J Sports Med. 2003 May-Jun;31(3):399-403. PubMed

Lee SB, An KN. Dynamic glenohumeral stability provided by three heads of the deltoid muscle.
Clin Orthop Relat Res. 2002 Jul;(400):40-7. PubMed

Question 11 of 100

Figures 1 and 2 are the MR arthrogram images of a 16-year-old, right-hand-dominant baseball player
who injured his left shoulder 4 weeks ago during a game. He now has pain, weakness, and the inability
to swing a bat and can no longer do push-ups. He denies prior injury to his left shoulder. Radiographs
are unremarkable.

If present, what is the most likely complication after surgical treatment in this scenario?
 Figure 1 Figure 2

A. Recurrent instability
B. Degenerative joint disease
C. Shoulder stiffness
D. Axillary nerve injury

Correct answer: C

 Discussion

Posterior shoulder instability is a rare form of instability that often presents with pain rather than
feelings of instability. It often occurs in young athletes during activities that put the shoulder in an “at-
risk position” (flexion, adduction, internal rotation). Repetitive microtrauma can lead to posterior
shoulder instability such as seen in football linemen. Swinging a bat or golf club places the lead arm in a
flexed, adducted, and internally rotated position, which can lead to posterior translation of the humeral
head that is forcibly reduced in follow-through, as seen in this patient.

The glenohumeral joint relies on static and dynamic stabilizers. Static stabilizers help prevent instability
at the end ranges of motion when the ligaments are taut. Dynamic stabilizers work to prevent
subluxation at midranges of motion, at which the ligaments are lax. The rotator cuff is integral as a
dynamic stabilizer of the shoulder. It works through a process called concavity compression. The four
muscles of the rotator cuff compress the humeral head into the concavity of the glenoid-labrum. This
prevents the humeral head from subluxing during the midranges of motion. Of the four rotator cuff
muscles, the subscapularis is most important at preventing posterior subluxation.

This patient has posterior instability, and various surgical techniques may be indicated depending on
findings. Arthroscopic labral repair is indicated for anterior instability. Arthroscopic posterior labral
repair is indicated for this patient because he has a posterior labral tear and posterior instability. If a
patient has ligamentous laxity (not seen in this scenario because sulcus and Beighton sign findings would
be negative), a posterior capsular shift with rotator interval closure is indicated. If a patient has
excessive glenoid retroversion (not seen in this scenario with 5 degrees of retroversion), a posterior
opening-wedge osteotomy is appropriate.

The most common complication seen after arthroscopic posterior labral repair is stiffness, followed by
recurrent instability and degenerative joint disease.

 Recommended Readings

Millett PJ, Clavert P, Hatch GF 3rd, Warner JJ. Recurrent posterior shoulder instability. J Am
Acad Orthop Surg. 2006 Aug;14(8):464-76. Full text

Hawkins RJ, Schutte JP, Janda DH, Huckell GH. Translation of the glenohumeral joint with the
patient under anesthesia. J Shoulder Elbow Surg. 1996 Jul-Aug;5(4):286-92. PubMed

Kido T, Itoi E, Lee SB, Neale PG, An KN. Dynamic stabilizing function of the deltoid muscle in
shoulders with anterior instability. Am J Sports Med. 2003 May-Jun;31(3):399-403. PubMed

Lee SB, An KN. Dynamic glenohumeral stability provided by three heads of the deltoid muscle.
Clin Orthop Relat Res. 2002 Jul;(400):40-7. PubMed

Question 12 of 100

A 24-year-old collegiate pitcher has had increasing pain over his medial elbow for 3 months. He has
point tenderness over his medial epicondyle and reproduction of his symptoms with a valgus stress test.
What phase of the throwing cycle most likely will reproduce his symptoms?

A. Early cocking
B. Late cocking
C. Acceleration
D. Deceleration
Correct answer: B

 Discussion

This patient is experiencing soreness over his medial (ulnar) collateral ligament. Valgus overload is likely
to reproduce his symptoms and is most pronounced during the late cocking phase of the throwing cycle.
In wind up, very little elbow torque is required. In early cocking, the arm is getting loaded and maximum
valgus is not yet achieved at the elbow. In acceleration and deceleration, more force is generated at the
level of the shoulder joint.

 Recommended Readings

Safran M, Ahmad CS, Elattrache NS. Ulnar collateral ligament of the elbow. Arthroscopy. 2005
Nov;21(11):1381-95. PubMed

Safran MR. Ulnar collateral ligament injury in the overhead athlete: diagnosis and treatment.
Clin Sports Med. 2004 Oct;23(4):643-63, x. PubMed

Question 13 of 100

A 9-year-old girl, who is an avid soccer player, has intermittent spontaneous snapping in her left knee
that has worsened. There is no reported trauma or prior surgeries to her knee. Despite working with her
trainer, she has developed anterior-based knee pain and lacks full extension. Her knee skin is
unremarkable, but there is fullness to palpation on the lateral aspect of her knee. Her range of motion
demonstrates a lack of 15° of terminal extension and ligamentous examination is unremarkable.
Considering possible surgical treatments for this patient, what is the most appropriate surgical
treatment?

A. Arthroscopic lateral release with reconstruction of medial patellofemoral ligament

B. Growth plate sparing anterior cruciate ligament reconstruction
C. Arthroscopic meniscal saucerization
D. Microfracture versus stabilization of osteochondral lesion
Correct answer: C

 Discussion

Surgical intervention of discoid meniscus is based on symptomatic patients. Complete discoid menisci
are typically stable but are expected to have >4.5 times incidence of surgical intervention. Saucerization
of symptomatic discoid meniscus is associated with better results with younger patients with increases
of poor outcomes in adult-aged patients. Meniscal transplant may be an option, although long-term
results are unknown.

 Recommended Readings

Kocher MS, Logan CA, Kramer DE. Discoid Lateral Meniscus in Children: Diagnosis,
Management, and Outcomes. J Am Acad Orthop Surg. 2017 Nov;25(11):736-743. Full text

Northam MC. Imaging of the knee. In: Miller MD, ed. Orthopaedic Knowledge Update 5: Sports
Medicine. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2016:747-753.

Question 14 of 100

Figure 1 is the MR image of a high school soccer player who sustained a right knee injury during a game
while making a cut toward the ball. He felt a pop and his leg gave way. During physical examination, as
the knee is moved from full extension into flexion with an internal rotation and valgus force, you notice
a "clunk" within the knee. What is the most likely biomechanical basis for the "clunk"?
 Figure 1

A. In extension with internal rotation/valgus force, the medial tibial plateau is subluxated; with
flexion, the medial tibial plateau reduces.
B. In extension with internal rotation/valgus force, the medial tibial plateau is reduced; with
flexion, the medial tibial plateau subluxates.
C. In extension with internal rotation/valgus force, the lateral tibial plateau is reduced; with
flexion, the lateral plateau subluxates.
D. In extension with internal rotation/valgus force, the lateral tibial plateau is subluxated; with
flexion, the lateral plateau reduces.

Correct answer: D

 Discussion

This patient sustained an isolated anterior cruciate ligament (ACL) injury based upon the mechanism
described and examination findings. The finding that produces the “clunk” is the pivot-shift maneuver,
which is positive in a knee with an incompetent ACL. With an ACL-deficient knee in full extension and
internal rotation, the lateral tibial plateau subluxates anteriorly. As the knee is flexed, the lateral tibial
plateau slides posteriorly into a reduced position, causing an audible clunk. Response D correctly
describes the pathomechanics that result in the audible clunk heard during the pivot-shift maneuver.
Responses A and B are incorrect because they describe the medial tibial plateau, which is not part of the
pathomechanics of the pivot shift. Response C is incorrect because in extension, the lateral tibial plateau
is subluxated, not reduced.

 Recommended Readings

Galway HR, MacIntosh DL. The lateral pivot shift: a symptom and sign of anterior cruciate
ligament insufficiency. Clin Orthop Relat Res. 1980 Mar-Apr;(147):45-50. PubMed

Lane CG, Warren R, Pearle AD. The pivot shift. J Am Acad Orthop Surg. 2008 Dec;16(12):679-
88. Full text

Question 15 of 100

A 9-year-old boy is injured while playing soccer. His examination reveals painful range of motion
between 5° and 75°. There is tenderness on the medial side of his knee. There is no effusion, a grade 1A
Lachman test, and severe pain over the medial epicondyle of the knee. Varus stress is negative and pain
is elicited with valgus stress. Initial radiographs were negative for abnormality.

What is the next diagnostic step?

A. Repeat radiographs while the patient is weight bearing

B. Ultrasonography of the lower extremity and calf
C. Stress radiographs
D. CT scan

Correct answer: C

 Discussion

This patient likely has a physeal injury to the distal femoral physis. Stress radiographs or an MRI scan will
most reliably reveal this diagnosis. The growth plate, when injured, is most commonly fractured through
the hypertrophic zone of cartilage, its weakest point. This patient is optimally treated in a cylindrical or
long-leg cast.

 Recommended Readings

Wheeless C. Wheeless Textbook of Orthopaedics. Growth Plate Anatomy.

http://www.wheelessonline.com/ortho/growth_plate_anatomy

Zionts LE. Fractures around the knee in children. J Am Acad Orthop Surg. 2002 Sep-
Oct;10(5):345-55. Full text

Question 16 of 100

A 9-year-old boy is injured while playing soccer. His examination reveals painful range of motion
between 5° and 75°. There is tenderness on the medial side of his knee. There is no effusion, a grade 1A
Lachman test, and severe pain over the medial epicondyle of the knee. Varus stress is negative and pain
is elicited with valgus stress. Initial radiographs were negative for abnormality.

Stress radiographs show a 2-mm medial physeal widening with valgus stress. What is the best initial
treatment strategy for this patient?

A. Femoral medial collateral ligament repair, extraphyseal

B. Arthroscopically assisted medial collateral ligament repair
C. Crutch ambulation without immobilization and weight bearing as tolerated
D. Protected weight bearing with cast immobilization

Correct answer: D

 Discussion

This patient likely has a physeal injury to the distal femoral physis. Stress radiographs or an MRI scan will
most reliably reveal this diagnosis. The growth plate, when injured, is most commonly fractured through
the hypertrophic zone of cartilage, its weakest point. This patient is optimally treated in a cylindrical or
long-leg cast.
  Recommended Readings

Wheeless C. Wheeless Textbook of Orthopaedics. Growth Plate Anatomy.

http://www.wheelessonline.com/ortho/growth_plate_anatomy

Zionts LE. Fractures around the knee in children. J Am Acad Orthop Surg. 2002 Sep-
Oct;10(5):345-55. Full text

Question 17 of 100

A 9-year-old boy is injured while playing soccer. His examination reveals painful range of motion
between 5° and 75°. There is tenderness on the medial side of his knee. There is no effusion, a grade 1A
Lachman test, and severe pain over the medial epicondyle of the knee. Varus stress is negative and pain
is elicited with valgus stress. Initial radiographs were negative for abnormality.

What is the most likely area of injury?

A. Femoral attachment of the medial collateral ligament

B. Tibial attachment of the medial collateral ligament
C. Hypertrophic zone of the growth plate
D. Proliferative zone of the growth plate

Correct answer: C

 Discussion

This patient likely has a physeal injury to the distal femoral physis. Stress radiographs or an MRI scan will
most reliably reveal this diagnosis. The growth plate, when injured, is most commonly fractured through
the hypertrophic zone of cartilage, its weakest point. This patient is optimally treated in a cylindrical or
long-leg cast.
  Recommended Readings

Wheeless C. Wheeless Textbook of Orthopaedics. Growth Plate Anatomy.

http://www.wheelessonline.com/ortho/growth_plate_anatomy

Zionts LE. Fractures around the knee in children. J Am Acad Orthop Surg. 2002 Sep-
Oct;10(5):345-55. Full text

Question 18 of 100

Figures 1 through 4 are the CT scans and intraoperative image of a 17-year-old boy who sustained a
gunshot wound to his knee. What is the most appropriate definitive surgical management for his
articular cartilage defect?

Figure 1 Figure 2
 Figure 3 Figure 4

A. Microfracture
B. Autologous chondrocyte implantation
C. Osteochondral allograft transfer
D. Dejour trochleoplasty

Correct answer: C

 Discussion

The images show a full-thickness cartilage defect with significant bony involvement >4 cm 2.
Microfracture should be considered for lesions <2 cm2 without an underlying osseous defect.
Autologous chondrocyte implantation, although used for lesions between 1 and 10 cm 2, should be
restricted for defects with minimal (<8 mm depth) bone loss. Osteochondral allograft transfer with the
mosaicplasty technique (transfer of multiple plugs) would be well-suited for this large defect with
significant osseous involvement. Dejour trochleoplasty is performed for patellar instability to correct
trochlear dysplasia and would not be indicated in this case.

 Recommended Readings
Murray IR, Benke MT, Mandelbaum BR. Management of knee articular cartilage injuries in
athletes: chondroprotection, chondrofacilitation, and resurfacing. Knee Surg Sports Traumatol
Arthrosc. 2016 May;24(5):1617-26. doi: 10.1007/s00167-015-3509-8. Epub 2015 Feb 7.
PubMed

Yanke AB, Wuerz T, Saltzman BM, Butty D, Cole BJ. Management of patellofemoral chondral
injuries. Clin Sports Med. 2014 Jul;33(3):477-500. doi: 10.1016/j.csm.2014.03.004. Epub 2014
May 17. PubMed

Question 19 of 100

A 24-year-old former high school wrestler had anterior cruciate ligament (ACL) reconstruction with
hamstring autograft 6 years ago. He now experiences daily instability of his knee with routine activities
including walking. Examination reveals a grade 3+ Lachman test with a soft endpoint, varus laxity at 30°,
and a positive dial test at 30° that dissipates at 90° of knee flexion. He has mild medial joint line
tenderness. When walking, there is a slight varus thrust. What treatment is most likely to lead to a
successful outcome?

A. Hamstring autograft
B. Revision ACL reconstruction and posterior cruciate ligament (PCL) reconstruction
C. Revision ACL reconstruction and posteromedial corner reconstruction
D. Revision ACL reconstruction and posterolateral corner reconstruction

Correct answer: D

 Discussion

This patient underwent an ACL reconstruction that has now failed. Based on his examination, he also has
a posterolateral corner injury. Because this concomitant injury was not treated, the patient had undue
strain on his graft, resulting in ultimate failure. Hamstring grafts are as effective as other graft types for
ACL reconstruction. The medial meniscus provides secondary stabilization to the knee; however, this
patient has a missed lateral ligamentous injury, and meniscus tears do not result in the development of
a varus thrust. An unrecognized PCL tear likely results in mild-to-moderate medial and patellofemoral
osteoarthritis without significant lateral laxity and thrust.
  Recommended Readings

Ricchetti ET, Sennett BJ, Huffman GR. Acute and chronic management of posterolateral corner
injuries of the knee. Orthopedics. 2008 May;31(5):479-88; quiz 489-90. Review. Erratum in:
Orthopedics. 2008 Jul;31(7):725. PubMed

Fanelli GC. Treatment of combined anterior cruciate ligament-posterior cruciate ligament-lateral

side injuries of the knee. Clin Sports Med. 2000 Jul;19(3):493-502. PubMed

Question 20 of 100

Figures 1 and 2 are the MRI scans of a 35-year-old right-hand dominant man who has right elbow pain
after trying to lift a large television at home. An examination reveals ecchymosis, an abnormal hook test,
and altered biceps muscle contour. What treatment is most likely to result in a satisfactory and
predictable outcome?

Figure 1 Figure 2

A. Period of immobilization followed by physical therapy

B. Local corticosteroid injection
C. Surgical repair
D. Platelet-rich plasma (PRP)
Correct answer: C

 Discussion

Figures 1 and 2 show a full thickness distal biceps tendon rupture with proximal retraction. Edema is
seen along the course of the distal biceps tendon, and the axial cut demonstrates the absence of tendon
at the radial tuberosity. The sagittal cut demonstrates the stump of the proximally retracted biceps
tendon. The biceps muscle contour is abnormal in appearance, demonstrating the classic “popeye”
deformity. Nonsurgical treatment options result in predictable loss of supination and elbow flexion
strength that is not desirable. A local corticosteroid injection would not improve strength, and there is
no evidence to support the use of a PRP injection.

 Recommended Readings

Chavan PR, Duquin TR, Bisson LJ. Repair of the ruptured distal biceps tendon: a systematic
review. Am J Sports Med. 2008 Aug;36(8):1618-24. doi: 10.1177/0363546508321482. PubMed

Peeters T, Ching-Soon NG, Jansen N, Sneyers C, Declercq G, Verstreken F. Functional outcome

after repair of distal biceps tendon ruptures using the endobutton technique. J Shoulder Elbow
Surg. 2009 Mar-Apr;18(2):283-7. doi: 10.1016/j.jse.2008.10.004. Epub 2008 Dec 19. PubMed

McKee MD, Hirji R, Schemitsch EH, Wild LM, Waddell JP. Patient-oriented functional
outcome after repair of distal biceps tendon ruptures using a single-incision technique. J
Shoulder Elbow Surg. 2005 May-Jun;14(3):302-6. PubMed

Question 21 of 100

Figures 1 and 2 are the radiographs of a 20-year-old college multisport athlete who has had
longstanding pain in his left hip. He denies any specific event that initiated his pain, but he notes that he
had hip problems when he was an infant. He denies pain with activities of daily living, but he believes his
pain is increasingly limiting his ability to exercise. He localizes the pain to his groin. He denies low-back
or buttock pain or pain that radiates down his leg.

What examination findings are most consistent with the pathology seen in the radiographs?
 Figure 1 Figure 2

A. Pain with resisted hip flexion

B. Pain with a half sit-up, plus tenderness at the pubic ramus
C. Pain with a combination of hip flexion, adduction, and internal rotation
D. Tenderness to palpation at the greater trochanter

Correct answer: C

 Discussion

This patient has cam-type femoroacetabular impingement. Decreased internal rotation and a positive
impingement test (forced flexion, adduction, and internal rotation) are classic findings. The lack of pain
with resisted hip flexion makes hip flexor strain unlikely, and the lack of tenderness at the greater
trochanter renders trochanteric bursitis unlikely. Although athletic pubalgia can be a source of long-
standing groin pain, he lacks the pain with a resisted sit-up and tenderness along the pubic ramus that is
frequently noted in patients with pubalgia. His radiographs reveal a focal femoral neck prominence
consistent with cam impingement, although pistol grip deformities and flattening of the lateral femoral
head are often present as well. His MRI scan shows a labral tear, which is common in cam impingement.
Surgical treatment for cam impingement can be effective for symptomatic patients. Even among high-
level athletes, open surgical dislocation of the hip has been shown to have good results. Most patients
with cam impingement can be treated with arthroscopic osteoplasty and achieve results comparable
with those realized with open surgical dislocation. The literature describes success in terms of athletes
returning to sports (even professional athletes) to be approximately 90% after arthroscopic treatment.
Byrd and Jones described five patients who developed transient neurapraxias that resolved
uneventfully. The patients in his series who had concomitant microfracture had a 92% return to sports
within the follow-up period. Cam impingement has long been thought to be associated with a history of
a slipped capital femoral epiphysis. The capitis in these patients is displaced posteriorly, resulting in a
prominent anterior femoral neck and decreased hip internal rotation. Pincer impingement is associated
with a deep acetabulum, such as protrusion acetabula and acetabular retroversion. A patient who
underwent a periacetabular osteotomy can develop a more retroverted acetabulum as well.

 Recommended Readings

Philippon M, Schenker M, Briggs K, Kuppersmith D. Femoroacetabular impingement in 45

professional athletes: associated pathologies and return to sport following arthroscopic
decompression. Knee Surg Sports Traumatol Arthrosc. 2007 Jul;15(7):908-14. Epub 2007 May
4. PubMed

Bedi A, Zaltz I, De La Torre K, Kelly BT. Radiographic comparison of surgical hip dislocation
and hip arthroscopy for treatment of cam deformity in femoroacetabular impingement. Am J
Sports Med. 2011 Jul;39 Suppl:20S-8S. PubMed

Naal FD, Miozzari HH, Wyss TF, Nötzli HP. Surgical hip dislocation for the treatment of
femoroacetabular impingement in high-level athletes. Am J Sports Med. 2011 Mar;39(3):544-50.
Epub 2010 Dec 20. PubMed

Nepple JJ, Carlisle JC, Nunley RM, Clohisy JC. Clinical and radiographic predictors of intra-
articular hip disease in arthroscopy. Am J Sports Med. 2011 Feb;39(2):296-303. Epub 2010 Nov
23. PubMed

Minnich JM, Hanks JB, Muschaweck U, Brunt LM, Diduch DR. Sports hernia: diagnosis and
treatment highlighting a minimal repair surgical technique. Am J Sports Med. 2011
Jun;39(6):1341-9. Epub 2011 Apr 19. PubMed

Schoenecker PL, Clohisy JC, Millis MB, Wenger DR. Surgical management of the problematic
hip in adolescent and young adult patients. J Am Acad Orthop Surg. 2011 May;19(5):275-86.
Full text

Question 22 of 100

Figures 1 and 2 are the radiographs of a 20-year-old college multisport athlete who has had
longstanding pain in his left hip. He denies any specific event that initiated his pain, but he notes that he
had hip problems when he was an infant. He denies pain with activities of daily living, but he believes his
pain is increasingly limiting his ability to exercise. He localizes the pain to his groin. He denies low-back
or buttock pain or pain that radiates down his leg.

What is the most likely diagnosis for the source of this patient's pain?

Figure 1 Figure 2

A. Cam-type femoroacetabular impingement

B. Pincer-type femoroacetabular impingement
C. Hip flexor strain
D. Athletic pubalgia

Correct answer: A

 Discussion

This patient has cam-type femoroacetabular impingement. Decreased internal rotation and a positive
impingement test (forced flexion, adduction, and internal rotation) are classic findings. The lack of pain
with resisted hip flexion makes hip flexor strain unlikely, and the lack of tenderness at the greater
trochanter renders trochanteric bursitis unlikely. Although athletic pubalgia can be a source of long-
standing groin pain, he lacks the pain with a resisted sit-up and tenderness along the pubic ramus that is
frequently noted in patients with pubalgia. His radiographs reveal a focal femoral neck prominence
consistent with cam impingement, although pistol grip deformities and flattening of the lateral femoral
head are often present as well. His MRI scan shows a labral tear, which is common in cam impingement.
Surgical treatment for cam impingement can be effective for symptomatic patients. Even among high-
level athletes, open surgical dislocation of the hip has been shown to have good results. Most patients
with cam impingement can be treated with arthroscopic osteoplasty and achieve results comparable
with those realized with open surgical dislocation. The literature describes success in terms of athletes
returning to sports (even professional athletes) to be approximately 90% after arthroscopic treatment.
Byrd and Jones described five patients who developed transient neurapraxias that resolved
uneventfully. The patients in his series who had concomitant microfracture had a 92% return to sports
within the follow-up period. Cam impingement has long been thought to be associated with a history of
a slipped capital femoral epiphysis. The capitis in these patients is displaced posteriorly, resulting in a
prominent anterior femoral neck and decreased hip internal rotation. Pincer impingement is associated
with a deep acetabulum, such as protrusion acetabula and acetabular retroversion. A patient who
underwent a periacetabular osteotomy can develop a more retroverted acetabulum as well.

 Recommended Readings

Philippon M, Schenker M, Briggs K, Kuppersmith D. Femoroacetabular impingement in 45

professional athletes: associated pathologies and return to sport following arthroscopic
decompression. Knee Surg Sports Traumatol Arthrosc. 2007 Jul;15(7):908-14. Epub 2007 May
4. PubMed

Naal FD, Miozzari HH, Wyss TF, Nötzli HP. Surgical hip dislocation for the treatment of
femoroacetabular impingement in high-level athletes. Am J Sports Med. 2011 Mar;39(3):544-50.
Epub 2010 Dec 20. PubMed

Nepple JJ, Carlisle JC, Nunley RM, Clohisy JC. Clinical and radiographic predictors of intra-
articular hip disease in arthroscopy. Am J Sports Med. 2011 Feb;39(2):296-303. Epub 2010 Nov
23. PubMed

Minnich JM, Hanks JB, Muschaweck U, Brunt LM, Diduch DR. Sports hernia: diagnosis and
treatment highlighting a minimal repair surgical technique. Am J Sports Med. 2011
Jun;39(6):1341-9. Epub 2011 Apr 19. PubMed

Schoenecker PL, Clohisy JC, Millis MB, Wenger DR. Surgical management of the problematic
hip in adolescent and young adult patients. J Am Acad Orthop Surg. 2011 May;19(5):275-86.
Full text

Question 23 of 100
Figures 1 and 2 are the radiographs of a 20-year-old college multisport athlete who has had
longstanding pain in his left hip. He denies any specific event that initiated his pain, but he notes that he
had hip problems when he was an infant. He denies pain with activities of daily living, but he believes his
pain is increasingly limiting his ability to exercise. He localizes the pain to his groin. He denies low-back
or buttock pain or pain that radiates down his leg.

Images from an MRI scan of this patient's left hip are shown in Figures 3 through 5. What is the most
likely cause of his acute pain?

Figure 1 Figure 2

Figure 3 Figure 4
 Figure 5

A. Significant cartilage loss on the acetabulum

B. Labral tear
C. Femoral neck stress fracture
D. Tendinopathy of the rectus femoris

Correct answer: B

 Discussion

This patient has cam-type femoroacetabular impingement. Decreased internal rotation and a positive
impingement test (forced flexion, adduction, and internal rotation) are classic findings. The lack of pain
with resisted hip flexion makes hip flexor strain unlikely, and the lack of tenderness at the greater
trochanter renders trochanteric bursitis unlikely. Although athletic pubalgia can be a source of long-
standing groin pain, he lacks the pain with a resisted sit-up and tenderness along the pubic ramus that is
frequently noted in patients with pubalgia. His radiographs reveal a focal femoral neck prominence
consistent with cam impingement, although pistol grip deformities and flattening of the lateral femoral
head are often present as well. His MRI scan shows a labral tear, which is common in cam impingement.
Surgical treatment for cam impingement can be effective for symptomatic patients. Even among high-
level athletes, open surgical dislocation of the hip has been shown to have good results. Most patients
with cam impingement can be treated with arthroscopic osteoplasty and achieve results comparable
with those realized with open surgical dislocation. The literature describes success in terms of athletes
returning to sports (even professional athletes) to be approximately 90% after arthroscopic treatment.
Byrd and Jones described five patients who developed transient neurapraxias that resolved
uneventfully. The patients in his series who had concomitant microfracture had a 92% return to sports
within the follow-up period. Cam impingement has long been thought to be associated with a history of
a slipped capital femoral epiphysis. The capitis in these patients is displaced posteriorly, resulting in a
prominent anterior femoral neck and decreased hip internal rotation. Pincer impingement is associated
with a deep acetabulum, such as protrusion acetabula and acetabular retroversion. A patient who
underwent a periacetabular osteotomy can develop a more retroverted acetabulum as well.

 Recommended Readings

Philippon M, Schenker M, Briggs K, Kuppersmith D. Femoroacetabular impingement in 45

professional athletes: associated pathologies and return to sport following arthroscopic
decompression. Knee Surg Sports Traumatol Arthrosc. 2007 Jul;15(7):908-14. Epub 2007 May
4. PubMed

Bedi A, Zaltz I, De La Torre K, Kelly BT. Radiographic comparison of surgical hip dislocation
and hip arthroscopy for treatment of cam deformity in femoroacetabular impingement. Am J
Sports Med. 2011 Jul;39 Suppl:20S-8S. PubMed

Naal FD, Miozzari HH, Wyss TF, Nötzli HP. Surgical hip dislocation for the treatment of
femoroacetabular impingement in high-level athletes. Am J Sports Med. 2011 Mar;39(3):544-50.
Epub 2010 Dec 20. PubMed

Nepple JJ, Carlisle JC, Nunley RM, Clohisy JC. Clinical and radiographic predictors of intra-
articular hip disease in arthroscopy. Am J Sports Med. 2011 Feb;39(2):296-303. Epub 2010 Nov
23. PubMed

Minnich JM, Hanks JB, Muschaweck U, Brunt LM, Diduch DR. Sports hernia: diagnosis and
treatment highlighting a minimal repair surgical technique. Am J Sports Med. 2011
Jun;39(6):1341-9. Epub 2011 Apr 19. PubMed

Schoenecker PL, Clohisy JC, Millis MB, Wenger DR. Surgical management of the problematic
hip in adolescent and young adult patients. J Am Acad Orthop Surg. 2011 May;19(5):275-86.
Full text

Question 24 of 100

A 13-year-old right-hand dominant pitcher was treated for Little League shoulder. What finding
increases his risk of recurrence?

A. Hyperlaxity
B. Rotator cuff weakness
C. Increased height
D. Glenohumeral internal rotation deficit
Correct answer: D

 Discussion

Little League shoulder is a physeal injury increasingly seen in young throwers. The primary treatment is
refraining from throwing with rehabilitation, followed by a throwing program. The risk of recurrence is
approximately 7%. The risk of recurrence is three times higher in athletes with glenohumeral internal
rotation deficit. Hyperlaxity, rotator cuff weakness, and increased height have not been shown to
correlate with recurrent symptoms.

 Recommended Readings

Harada M, Takahara M, Maruyama M, Kondo M, Uno T, Takagi M, Mura N. Outcome of

conservative treatment for Little League shoulder in young baseball players: factors related to
incomplete return to baseball and recurrence of pain. J Shoulder Elbow Surg. 2018 Jan;27(1):1-9.
doi: 10.1016/j.jse.2017.08.018. Epub 2017 Oct 17. PubMed

Heyworth BE, Kramer DE, Martin DJ, Micheli LJ, Kocher MS, Bae DS. Trends in the
Presentation, Management, and Outcomes of Little League Shoulder. Am J Sports Med. 2016
Jun;44(6):1431-8. doi: 10.1177/0363546516632744. Epub 2016 Mar 16. PubMed

Question 25 of 100

Figure 1 is the T2 axial MRI scan of a 21-year-old man who was injured while playing for his college
football team. His pain was aggravated with blocking maneuvers and alleviated with rest, and he had to
stop playing because of the pain. What examination maneuver most likely will reproduce his pain?
 Figure 1

A. Forward elevation in the scapular plane

B. External rotation and abduction
C. Flexion, adduction, and internal rotation
D. Flexion and abduction

Correct answer: C

 Discussion

This patient has a mechanism of injury and MRI scan consistent with a posterior labral tear and posterior
instability. Flexion, adduction, and internal rotation produce a net posterior vector on the glenohumeral
joint and should reproduce this patient's symptoms. Pain or instability with the arm elevated in the
scapular plane describes an impingement sign. Pain or instability with the arm in external rotation and
abduction describes the apprehension sign. Pain or instability with the arm in flexion and abduction is a
nonspecific finding.

 Recommended Readings

Bradley JP, Forsythe B, Mascarenhas R. Arthroscopic management of posterior shoulder

instability: diagnosis, indications, and technique. Clin Sports Med. 2008 Oct;27(4):649-70.
PubMed
Tjoumakaris FP, Bradley JP. Posterior shoulder instability. In: Galatz LM, ed. Orthopaedic
Knowledge Update: Shoulder and Elbow 3. Rosemont, IL: American Academy of Orthopaedic
Surgeons; 2008:313-320.

Question 26 of 100

Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease that is characterized by

A. onset most often by age 30.

B. a temporary state of neuronal and axonal derangement.
C. manifestations of affect such as apathy, irritability, and suicidal ideation.
D. absence of gross pathological brain changes upon autopsy.

Correct answer: C

 Discussion

CTE is a neurodegenerative disease that occurs years or decades after recovery from acute or postacute
effects of head trauma. The exact relationship between concussion and CTE is not entirely clear;
however, early behavioral manifestations of CTE have been described by family and providers to include
apathy, irritability, and suicidal ideation. For some patients, cognitive difficulty such as poor episodic
memory and executive function may be the first signs of CTE. Onset most often occurs in midlife after
athletes have completed their sports careers, with mean age of onset at 42 years. The effects on the
brain are degenerative, leading to a permanent state of derangement. Autopsy findings demonstrate
multiple gross pathological findings. The condition is more common among contact athletes.

 Recommended Readings

Gavett BE, Stern RA, McKee AC. Chronic traumatic encephalopathy: a potential late effect of
sport-related concussive and subconcussive head trauma. Clin Sports Med. 2011 Jan;30(1):179-
88, xi. PubMed

McKee AC, Cantu RC, Nowinski CJ, Hedley-Whyte ET, Gavett BE, Budson AE, Santini VE,
Lee HS, Kubilus CA, Stern RA. Chronic traumatic encephalopathy in athletes: progressive
tauopathy after repetitive head injury. J Neuropathol Exp Neurol. 2009 Jul;68(7):709-35.
PubMed

Question 27 of 100

A 19-year-old female field hockey player sustains a right ankle injury last night during a game. The
patient is on crutches and reports that she has not been able to put any weight on her right ankle since
the injury. She was running alongside with another player when her right ankle “gave out” and she
twisted it, falling to the ground. Physical examination reveals discoloration similar to a hematoma and
significant swelling around the lateral ankle area. Pain is elicited during palpation of the anterior
talofibular ligament.

What test should be performed to aid in this diagnosis?

A. Thompson test
B. External rotation stress test
C. Anterior drawer test
D. Squeeze test

Correct answer: C

 Discussion

The anterior drawer test is performed with the ankle in 10° of plantar flexion, which results in the
greatest amount of translation. The test investigates the integrity of the anterior talofibular ligament
with a key distance of translation being 8 to 10 mm. While the patient is sitting and has her knees flexed
over the edge of a table or bench, the physician uses one hand to stabilize the distal leg and with the
other hand applies an anterior force to the heel in an attempt to gap the talus anteriorly from under the
tibia. The anterior talofibular ligament and calcaneofibular ligament are both compromised based on
the examination findings. The anterior drawer test result reflects injury to the anterior talofibular
ligament and a possible injury to the calcaneofibular ligament. A lateral talar tilt test angle measurement
>15° degrees reflects a rupture of both anterior talofibular ligament and calcaneofibular ligaments. The
diagnosis is a severe lateral ligament complex sprain. This is optimally managed with early mobilization
and a guided rehabilitation program that emphasizes proprioceptive stability.
  Recommended Readings

Tropp H, Askling C, Gillquist J. Prevention of ankle sprains. Am J Sports Med. 1985 Jul-
Aug;13(4):259-62. PubMed

Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Reardon M, Stewart JP,
Maloney J. Decision rules for the use of radiography in acute ankle injuries. Refinement and
prospective validation. JAMA. 1993 Mar 3;269(9):1127-32. PubMed

Hertel J. Immobilisation for acute severe ankle sprain. Lancet. 2009 Feb 14;373(9663):524-6.
PubMed

Osborne MD, Rizzo TD Jr. Prevention and treatment of ankle sprain in athletes. Sports Med.
2003;33(15):1145-50. PubMed

Anderson RB, James WC III, Lee S. Athletic foot disorders. In: Garrick JG, ed. Orthopaedic
Knowledge Update: Sports Medicine 3. Rosemont, IL: American Academy of Orthopaedic
Surgeons; 2004:249-261.

Question 28 of 100

A 19-year-old female field hockey player sustains a right ankle injury last night during a game. The
patient is on crutches and reports that she has not been able to put any weight on her right ankle since
the injury. She was running alongside with another player when her right ankle “gave out” and she
twisted it, falling to the ground. Physical examination reveals discoloration similar to a hematoma and
significant swelling around the lateral ankle area. Pain is elicited during palpation of the anterior
talofibular ligament.

Radiographs of the player’s right ankle confirm there are no fractures. With a lateral talar tilt test result
of 19°, which additional structure is most likely damaged?

A. Deltoid ligament
B. Calcaneofibular ligament
C. Anterior tibiofibular ligament
D. Posterior tibiofibular ligament

Correct answer: B
  Discussion

The anterior drawer test is performed with the ankle in 10° of plantar flexion, which results in the
greatest amount of translation. The test investigates the integrity of the anterior talofibular ligament
with a key distance of translation being 8 to 10 mm. While the patient is sitting and has her knees flexed
over the edge of a table or bench, the physician uses one hand to stabilize the distal leg and with the
other hand applies an anterior force to the heel in an attempt to gap the talus anteriorly from under the
tibia. The anterior talofibular ligament and calcaneofibular ligament are both compromised based on
the examination findings. The anterior drawer test result reflects injury to the anterior talofibular
ligament and a possible injury to the calcaneofibular ligament. A lateral talar tilt test angle measurement
>15° degrees reflects a rupture of both anterior talofibular ligament and calcaneofibular ligaments. The
diagnosis is a severe lateral ligament complex sprain. This is optimally managed with early mobilization
and a guided rehabilitation program that emphasizes proprioceptive stability.

 Recommended Readings

Tropp H, Askling C, Gillquist J. Prevention of ankle sprains. Am J Sports Med. 1985 Jul-
Aug;13(4):259-62. PubMed

Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Reardon M, Stewart JP,
Maloney J. Decision rules for the use of radiography in acute ankle injuries. Refinement and
prospective validation. JAMA. 1993 Mar 3;269(9):1127-32. PubMed

Hertel J. Immobilisation for acute severe ankle sprain. Lancet. 2009 Feb 14;373(9663):524-6.
PubMed

Osborne MD, Rizzo TD Jr. Prevention and treatment of ankle sprain in athletes. Sports Med.
2003;33(15):1145-50. PubMed

Anderson RB, James WC III, Lee S. Athletic foot disorders. In: Garrick JG, ed. Orthopaedic
Knowledge Update: Sports Medicine 3. Rosemont, IL: American Academy of Orthopaedic
Surgeons; 2004:249-261.

Question 29 of 100

A 19-year-old female field hockey player sustains a right ankle injury last night during a game. The
patient is on crutches and reports that she has not been able to put any weight on her right ankle since
the injury. She was running alongside with another player when her right ankle “gave out” and she
twisted it, falling to the ground. Physical examination reveals discoloration similar to a hematoma and
significant swelling around the lateral ankle area. Pain is elicited during palpation of the anterior
talofibular ligament.

What is the most appropriate course of action for this patient’s condition?

A. Early mobilization and a guided proprioceptive and strengthening

B. Extended immobilization in a cast
C. Surgical intervention
D. Weight bearing as tolerated in an ankle brace for 6 weeks

Correct answer: A

 Discussion

The anterior drawer test is performed with the ankle in 10° of plantar flexion, which results in the
greatest amount of translation. The test investigates the integrity of the anterior talofibular ligament
with a key distance of translation being 8 to 10 mm. While the patient is sitting and has her knees flexed
over the edge of a table or bench, the physician uses one hand to stabilize the distal leg and with the
other hand applies an anterior force to the heel in an attempt to gap the talus anteriorly from under the
tibia. The anterior talofibular ligament and calcaneofibular ligament are both compromised based on
the examination findings. The anterior drawer test result reflects injury to the anterior talofibular
ligament and a possible injury to the calcaneofibular ligament. A lateral talar tilt test angle measurement
>15° degrees reflects a rupture of both anterior talofibular ligament and calcaneofibular ligaments. The
diagnosis is a severe lateral ligament complex sprain. This is optimally managed with early mobilization
and a guided rehabilitation program that emphasizes proprioceptive stability.

 Recommended Readings

Tropp H, Askling C, Gillquist J. Prevention of ankle sprains. Am J Sports Med. 1985 Jul-
Aug;13(4):259-62. PubMed

Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Reardon M, Stewart JP,
Maloney J. Decision rules for the use of radiography in acute ankle injuries. Refinement and
prospective validation. JAMA. 1993 Mar 3;269(9):1127-32. PubMed

Hertel J. Immobilisation for acute severe ankle sprain. Lancet. 2009 Feb 14;373(9663):524-6.
PubMed
Osborne MD, Rizzo TD Jr. Prevention and treatment of ankle sprain in athletes. Sports Med.
2003;33(15):1145-50. PubMed

Anderson RB, James WC III, Lee S. Athletic foot disorders. In: Garrick JG, ed. Orthopaedic
Knowledge Update: Sports Medicine 3. Rosemont, IL: American Academy of Orthopaedic
Surgeons; 2004:249-261.

Question 30 of 100

Figures 1 and 2 are the radiograph and MRI scan of a 16-year-old boy who injured his right knee by a
lateral side impact while playing football. The MRI indicates what structure was most likely injured?

Figure 1 Figure 2
 A. Lateral collateral ligament
B. Tibial spine
C. Medial meniscus
D. Anterior cruciate ligament (ACL)

Correct answer: D

 Discussion

This is a rupture of the anterolateral ligament complex and a portion of the IT band. This injury is highly
correlated with a complete ACL injury. In the MRI, the curvilinear or elliptic bone fragment (Segond
fracture) projected parallel to the lateral aspect of the tibial plateau, the lateral capsular sign, is seen.
The lateral capsular sign is also associated with ACL tears. Thus, this is an MRI showing a complete ACL
tear.

 Recommended Readings

Claes S, Luyckx T, Vereecke E, Bellemans J. The Segond fracture: a bony injury of the
anterolateral ligament of the knee. Arthroscopy. 2014 Nov;30(11):1475-82. doi:
10.1016/j.arthro.2014.05.039. Epub 2014 Aug 8. PubMed

Lubowitz JH, Provencher MT, Brand JC, Rossi MJ. The knee anterolateral ligament.
Arthroscopy. 2014 Nov;30(11):1385-8. doi: 10.1016/j.arthro.2014.08.007. Epub 2014 Oct 23.
PubMed

Question 31 of 100

Figures 1 and 2 are intrasurgical photographs from the posterolateral viewing portal that were taken at
the beginning and end of a right shoulder arthroscopic procedure performed on a 54-year-old man. This
technique demonstrates superior results compared with traditional arthroscopic techniques when
evaluating which outcome?
 Figure 1 Figure 2

A. Time to healing
B. Retear rate
C. Functional outcome scores
D. Postsurgical pain scores

Correct answer: B

 Discussion

The images reveal a medium-sized tear of the rotator cuff. As more clinical studies are published
comparing double-row with single-row rotator cuff repair, it has become clear that the retear rate is
lower with a double-row construct for small and medium-sized tears. This may be attributable to the
stronger time-zero repair construct that double-row repair provides. No study to date has demonstrated
a significant difference in clinical outcomes (functional and pain scores at any time) or time to healing
between the two techniques.

 Recommended Readings

DeHaan AM, Axelrad TW, Kaye E, Silvestri L, Puskas B, Foster TE. Does double-row rotator
cuff repair improve functional outcome of patients compared with single-row technique? A
systematic review. Am J Sports Med. 2012 May;40(5):1176-85. doi:
10.1177/0363546511428866. Epub 2011 Dec 8. Review. PubMed
Millett PJ, Warth RJ, Dornan GJ, Lee JT, Spiegl UJ. Clinical and structural outcomes after
arthroscopic single-row versus double-row rotator cuff repair: a systematic review and meta-
analysis of level I randomized clinical trials. J Shoulder Elbow Surg. 2014 Apr;23(4):586-97.
doi: 10.1016/j.jse.2013.10.006. Epub 2014 Jan 8. PubMed

Question 32 of 100

A 16-year-old football player is participating in the second session of two-a-day preseason practices. He
complains of dizziness and fatigue. He is brought to the sideline by the athletic trainer where
examination demonstrates confusion and disorientation. Ambient temperature is 82°F. What would be
the next most appropriate step in his treatment?

A. Rapid cooling via ice bath, cold water and fans

B. Transportation via ambulance to a local emergency department
C. Rapid rehydration via oral and IV fluids
D. Immediate administration of acetaminophen or other anti-pyretics

Correct answer: A

 Discussion

Heat exhaustion and heat stroke reflect varying degrees of heat illness, with both marked by increased
heat production with impaired heat dissipation. Heat exhaustion typically involves a core body
temperature between 37°C (98.6°F) and 40°C (104°F) and usually presents with heavy sweating, as well
as nausea; vomiting; headache; fainting; weakness; and cold or clammy skin. Fatigue, malaise, and
dizziness may occur, but necessary to the diagnosis is normal mentation and stable neurologic status.
Heat stroke is defined by a core body temperature >40°C (>104°F) and disturbances of the central
nervous system, such as confusion, irritability, ataxia, and even coma. Heat exhaustion is a less urgent
scenario and can usually be treated with rest, elevation, and rehydration. Heat stroke, confirmed here
by the presence of mental status changes, is a more critical situation. The most important immediate
step is rapid body cooling through whatever means are available, as this has been clearly shown to
improve outcomes. Ideally, a whole body ice bath would be used, with ice towels, ice packs, cold water,
and air fans all utilized if needed. Emergency department transportation and rehydration may be
considered as well but are not as important as immediate lowering of body temperature. Anti-pyretics
have no role in this process.
  Recommended Readings

Noonan B, Bancroft RW, Dines JS, Bedi A. Heat- and cold-induced injuries in athletes:
evaluation and management. J Am Acad Orthop Surg. 2012 Dec;20(12):744-54. doi:
10.5435/JAAOS-20-12-744. Full text

Kerr ZY, Marshall SW, Comstock RD, Casa DJ. Exertional heat stroke management strategies in
United States high school football. Am J Sports Med. 2014 Jan;42(1):70-7. doi:
10.1177/0363546513502940. Epub 2013 Sep 6. PubMed

Howe AS, Boden BP. Heat-related illness in athletes. Am J Sports Med. 2007 Aug;35(8):1384-
95. Epub 2007 Jul 3. PubMed

Question 33 of 100

A coach of three football teams—the B team, junior varsity team, and varsity team—wants to study the
average times in the 40-yard dash for his players. Which test would help him determine if the mean 40-
yard dash times for the athletes on one team are different from those on the other teams?

A. Independent 2-sample t test

B. Analysis of variance (ANOVA)
C. Chi-square test
D. Fisher's exact test

Correct answer: B

 Discussion

Data collected in research studies fall into one of two categories—continuous or discrete. Continuous
data can be displayed on a curve. Examples include height, weight, and time recorded in a 40-yard dash.
Discrete data represent data that fall into specific categories such as gender or the presence or absence
of a risk factor.

ANOVA is used to determine statistical significance in mean values of continuous data when there are
more than two independent samples. The 2-sample t test compares mean values of continuous data
between two independent groups. The Chi-square test and Fisher's exact tests are tests used to analyze
discrete data.

 Recommended Readings

Kuhn JE, Greenfield ML, Wojtys EM. A statistics primer. Statistical tests for discrete data. Am J
Sports Med. 1997 Jul-Aug;25(4):585-6. PubMed

Greenfield ML, Wojtys EM, Kuhn JE. A statistics primer. Tests for continuous data. Am J Sports
Med. 1997 Nov-Dec;25(6):882-4. PubMed

Shantz JS, Morshed S. Orthopaedic research: Health research methodology, outcomes, and
biostatistics. In: Cannada LK, ed. Orthopaedic Knowledge Update 11. Rosemont, IL: American
Academy of Orthopaedic Surgeons; 2014:157-168.

Question 34 of 100

Figures 1 and 2 are the MRI scans of a 57-year-old man who dislocated his left shoulder after a fall while
playing tennis. On examination, he had full passive shoulder range of motion, but he was unable to
actively elevate his injured shoulder. Sensation was intact to light touch over the lateral shoulder. What
is the most likely etiology of his shoulder weakness?

Figure 1 Figure 2
 A. Axillary nerve injury
B. Cervical radiculopathy involving the C6 nerve root
C. Massive rotator cuff tear with loss of the transverse force couple
D. Long head of the biceps tendon rupture with loss of superior stabilizing effect

Correct answer: C

 Discussion

This patient has a massive rotator cuff tear resulting in disruption of the transverse force couple
between the subscapularis anteriorly and the infraspinatus and teres minor posteriorly. These muscles
provide dynamic shoulder stability throughout active elevation, and loss of the force couple produces a
pathologic increase in translation of the humeral head and decreased active abduction. Active shoulder
elevation <90 degrees in the presence of full passive motion is termed pseudoparalysis. The most
common neurologic deficit after shoulder dislocation is isolated injury to the axillary nerve. This
patient's sensory examination suggests that the axillary nerve is intact. Cervical radiculopathy is less
common after shoulder dislocation but has been reported. Conflicting evidence exists regarding the
contribution of the long head of the biceps tendon to glenohumeral stability. One study reported
minimal electromyographic activity in the biceps during ten basic shoulder motions.

 Recommended Readings

Getz CL, Buzzell JE, Krishnan SG. Shoulder instability and rotator cuff tears. In: Flynn JM, ed.
Orthopaedic Knowledge Update 10. Rosemont, IL: American Academy of Orthopaedic
Surgeons; 2011:299-314.

Robinson CM, Shur N, Sharpe T, Ray A, Murray IR. Injuries associated with traumatic anterior
glenohumeral dislocations. J Bone Joint Surg Am. 2012 Jan 4;94(1):18-26. PubMed

Question 35 of 100
A 53-year-old man sustains a fall while skiing. He experiences immediate pain and deformity in his lower
leg just above his ski boot top. Radiographs of his left lower leg are shown in Figures 1 and 2. After
discussing operative management with the patient, you choose to proceed with an intramedullary nail.
Where should blocking screws be placed to prevent the characteristic deformity of this fracture?

Figure 1

A. Posterior and medial aspect of the proximal fragment

B. Anterior aspect of the proximal fragment and medial half of the distal fragment
C. Posterior and lateral aspect of the proximal fragment
D. Anterior and lateral aspect of the proximal fragment

Correct answer: C

 Discussion

The patient has sustained a proximal third tibia and fibula fracture, sometimes referred to as a "boot
top" fracture when sustained while alpine skiing. These fractures frequently fall into apex anterior and
valgus angulation as shown in the radiographs. Great care needs to be taken during intramedullary
nailing to avoid fixing the fracture in a malreduced position. The use of Poller blocking screws in the
posterior and lateral aspects of the proximal fragment can help to avoid this complication (posterior
screw prevents flexion deformity while lateral screw prevents valgus deformity). Additional technical
pearls include starting with a more lateral entry point for the guidewire, placing a provisional unicortical
plate prior to nailing to maintain the reduction, or using a suprapatellar entry nail to allow for fixation
with the knee in a semi-extended position.
  Recommended Readings

Kulkarni SG, Varshneya A, Kulkarni S, Kulkarni GS, Kulkarni MG, Kulkarni VS, Kulkarni RM.
Intramedullary nailing supplemented with Poller screws for proximal tibial fractures. J Orthop
Surg (Hong Kong). 2012 Dec;20(3):307-11. PubMed

Stinner DJ, Mir H. Techniques for intramedullary nailing of proximal tibia fractures. Orthop Clin
North Am. 2014 Jan;45(1):33-45. doi: 10.1016/j.ocl.2013.09.001. Epub 2013 Oct 5. PubMed

Franke J, Hohendorff B, Alt V, Thormann U, Schnettler R. Suprapatellar nailing of tibial

fractures-Indications and technique. Injury. 2016 Feb;47(2):495-501. doi:
10.1016/j.injury.2015.10.023. Epub 2015 Oct 20. PubMed

Question 36 of 100

What is the most common complication after surgical management of chronic exertional compartment
syndrome (CECS) in the pediatric (≤18 years) population?

A. Recurrent CECS
B. Infection
C. Neurologic dysfunction
D. Hematoma or seroma formation

Correct answer: A

 Discussion

In the pediatric population, CECS most commonly presents in females involved in running sports. In this
cohort, recurrence occurs at a rate of 18%. Wound complications are the next most common at a rate of
11.2%.
  Recommended Readings

Beck JJ, Tepolt FA, Miller PE, Micheli LJ, Kocher MS. Surgical Treatment of Chronic
Exertional Compartment Syndrome in Pediatric Patients. Am J Sports Med. 2016
Oct;44(10):2644-2650. Epub 2016 Jun 30. PubMed

Packer JD, Day MS, Nguyen JT, Hobart SJ, Hannafin JA, Metzl JD. Functional outcomes and
patient satisfaction after fasciotomy for chronic exertional compartment syndrome. Am J Sports
Med. 2013 Feb;41(2):430-6. doi: 10.1177/0363546512471330. PubMed

Campano D, Robaina JA, Kusnezov N, Dunn JC, Waterman BR. Surgical Management for
Chronic Exertional Compartment Syndrome of the Leg: A Systematic Review of the Literature.
Arthroscopy. 2016 Jul;32(7):1478-86. doi: 10.1016/j.arthro.2016.01.069. Epub 2016 Mar 24.
PubMed

Question 37 of 100

What do the T2-weighted, fat-saturated MRI scans shown in Figures 1 through 4 reveal?

Figure 1 Figure 2
 Figure 3 Figure 4

A. Posterior cruciate ligament (PCL) tear, isolated

B. PCL tear and medial meniscus tear
C. Anterior cruciate ligament (ACL) tear, isolated
D. ACL tear and medial meniscus tear

Correct answer: D

 Discussion

The MRI scans show that edema is noted on the femoral insertion of the ACL consistent with a high-
grade or complete ACL tear. The ACL is not visualized on the sagittal view, although the torn meniscus
can be seen in the notch. On the coronal image, there is an empty lateral wall sign indicating proximal
disruption of the ACL. The medial meniscus images show a disruption of normal meniscus morphology
consistent with a bucket handle medial meniscus tear. Note the appearance on the sagittal MRI scan of
what appears to be a second soft-tissue density in line with the PCL. This "double PCL" sign is highly
indicative of a displaced medial meniscus tear rather than a displaced lateral meniscus tear.

 Recommended Readings
Weiss KL, Morehouse HT, Levy IM. Sagittal MR images of the knee: a low-signal band parallel
to the posterior cruciate ligament caused by a displaced bucket-handle tear. AJR Am J
Roentgenol. 1991 Jan;156(1):117-9. PubMed

Munk B, Madsen F, Lundorf E, Staunstrup H, Schmidt SA, Bolvig L, Hellfritzsch MB, Jensen J.
Clinical magnetic resonance imaging and arthroscopic findings in knees: a comparative
prospective study of meniscus anterior cruciate ligament and cartilage lesions. Arthroscopy. 1998
Mar;14(2):171-5. PubMed

Question 38 of 100

A 19-year-old collegiate offensive lineman injures his left elbow in a scrimmage. He reports reaching out
with his left arm to prevent the defensive player from getting around him, and, as he grabbed the
player, his elbow was forced into extension. He had immediate pain and weakness and heard a “pop.”
He has mild swelling in the antecubital fossa and a prominent-appearing biceps muscle belly. His hook
test result is abnormal at the elbow.

Which type of contraction of the involved muscle most likely resulted in this lineman's injury?

A. Eccentric
B. Concentric
C. Isometric
D. Isokinetic

Correct answer: A

 Discussion

This patient had an eccentric muscle contraction (muscle lengthening while contracting) of his biceps
muscle while trying to stop a defender from getting around him. This in turn caused failure of the distal
biceps tendon, as evidenced by pain in the antecubital fossa, lack of elbow supination strength, and his
positive biceps active test finding (supination/pronation of the forearm showing no motion of the biceps
muscle belly). Eccentric contractors have the highest potential for building strength but also are at
highest risk for injury. Concentric (muscle shortening with contraction), isometric (no change in muscle
length with contracture), and isokinetic (constant velocity of muscle contraction with a variable force)
do not describe the mechanism detailed.
The loss of distal biceps attachment will result in loss of elbow supination strength in flexion (the biceps
is the only supinator to cross the elbow) while still retaining elbow flexion (albeit weakened) because of
the other elbow flexors (brachioradialis and brachialis). Consequently, treatment should be anatomic
repair of the distal biceps insertion, which can be performed with a 2-incision or 1-incision technique.
Although all of the listed complications have been reported with these techniques, LABC neuropraxia is
by far the most common. Radiographs show that this athlete’s injury was repaired using a 1-incision
technique with a cortical fixation device and a radial bone tunnel. This technique has gained favor
because of its decreased incidence of heterotopic ossification and radioulnar synostosis compared with
the 2-incision technique. The most troubling complication for most surgeons is the development of a
posterior interosseous nerve (PIN) palsy, which this patient clearly demonstrates in addition to the more
common LABCN upon postsurgical examination. Because the LABCN injury is typically a neuropraxia
from retraction, a period of observation is indicated. PIN injury can result from excessive traction during
surgical exposure or from entrapment by the fixation button.

Considering the anatomy of the PIN, successful recovery of the nerve typically progresses based on the
distance from the origin of the nerve to the muscle indicated. The extensor indicis proprius (EIP) muscle
is the most distal muscle innervated and can be expected to recover last. First to return would be the
EDC followed by the ECU, EDQ, and, finally, the EIP.

 Recommended Readings

Bisson L, Moyer M, Lanighan K, Marzo J. Complications associated with repair of a distal

biceps rupture using the modified two-incision technique. J Shoulder Elbow Surg. 2008 Jan-
Feb;17(1 Suppl):67S-71S. Epub 2007 Nov 1. PubMed

Cusick MC, Cottrell BJ, Cain RA, Mighell MA. Low incidence of tendon rerupture after distal
biceps repair by cortical button and interference screw. J Shoulder Elbow Surg. 2014
Oct;23(10):1532-6. doi: 10.1016/j.jse.2014.04.013. PubMed

Watson JN, Moretti VM, Schwindel L, Hutchinson MR. Repair techniques for acute distal biceps
tendon ruptures: a systematic review. J Bone Joint Surg Am. 2014 Dec 17;96(24):2086-90. doi:
10.2106/JBJS.M.00481. PubMed

Schmidt CC, Brown BT, Sawardeker PJ, DeGravelle M Jr, Miller MC. Factors affecting
supination strength after a distal biceps rupture. J Shoulder Elbow Surg. 2014 Jan;23(1):68-75.
doi: 10.1016/j.jse.2013.08.019. PubMed

Abrams RA, Ziets RJ, Lieber RL, Botte MJ. Anatomy of the radial nerve motor branches in the
forearm. J Hand Surg Am. 1997 Mar;22(2):232-7. PubMed
Question 39 of 100

A 19-year-old collegiate offensive lineman injures his left elbow in a scrimmage. He reports reaching out
with his left arm to prevent the defensive player from getting around him, and, as he grabbed the
player, his elbow was forced into extension. He had immediate pain and weakness and heard a “pop.”
He has mild swelling in the antecubital fossa and a prominent-appearing biceps muscle belly. His hook
test result is abnormal at the elbow.

The most substantial functional deficit that may develop if no surgical treatment is provided is

A. elbow flexion strength.

B. elbow supination strength.
C. lack of terminal extension at the elbow.
D. decrease of elbow pronation strength.

Correct answer: B

 Discussion

This patient had an eccentric muscle contraction (muscle lengthening while contracting) of his biceps
muscle while trying to stop a defender from getting around him. This in turn caused failure of the distal
biceps tendon, as evidenced by pain in the antecubital fossa, lack of elbow supination strength, and his
positive biceps active test finding (supination/pronation of the forearm showing no motion of the biceps
muscle belly). Eccentric contractors have the highest potential for building strength but also are at
highest risk for injury. Concentric (muscle shortening with contraction), isometric (no change in muscle
length with contracture), and isokinetic (constant velocity of muscle contraction with a variable force)
do not describe the mechanism detailed.

The loss of distal biceps attachment will result in loss of elbow supination strength in flexion (the biceps
is the only supinator to cross the elbow) while still retaining elbow flexion (albeit weakened) because of
the other elbow flexors (brachioradialis and brachialis). Consequently, treatment should be anatomic
repair of the distal biceps insertion, which can be performed with a 2-incision or 1-incision technique.
Although all of the listed complications have been reported with these techniques, LABC neuropraxia is
by far the most common. Radiographs show that this athlete’s injury was repaired using a 1-incision
technique with a cortical fixation device and a radial bone tunnel. This technique has gained favor
because of its decreased incidence of heterotopic ossification and radioulnar synostosis compared with
the 2-incision technique. The most troubling complication for most surgeons is the development of a
posterior interosseous nerve (PIN) palsy, which this patient clearly demonstrates in addition to the more
common LABCN upon postsurgical examination. Because the LABCN injury is typically a neuropraxia
from retraction, a period of observation is indicated. PIN injury can result from excessive traction during
surgical exposure or from entrapment by the fixation button.

Considering the anatomy of the PIN, successful recovery of the nerve typically progresses based on the
distance from the origin of the nerve to the muscle indicated. The extensor indicis proprius (EIP) muscle
is the most distal muscle innervated and can be expected to recover last. First to return would be the
EDC followed by the ECU, EDQ, and, finally, the EIP.

 Recommended Readings

Bisson L, Moyer M, Lanighan K, Marzo J. Complications associated with repair of a distal

biceps rupture using the modified two-incision technique. J Shoulder Elbow Surg. 2008 Jan-
Feb;17(1 Suppl):67S-71S. Epub 2007 Nov 1. PubMed

Watson JN, Moretti VM, Schwindel L, Hutchinson MR. Repair techniques for acute distal biceps
tendon ruptures: a systematic review. J Bone Joint Surg Am. 2014 Dec 17;96(24):2086-90. doi:
10.2106/JBJS.M.00481. PubMed

Schmidt CC, Brown BT, Sawardeker PJ, DeGravelle M Jr, Miller MC. Factors affecting
supination strength after a distal biceps rupture. J Shoulder Elbow Surg. 2014 Jan;23(1):68-75.
doi: 10.1016/j.jse.2013.08.019. PubMed

Cusick MC, Cottrell BJ, Cain RA, Mighell MA. Low incidence of tendon rerupture after distal
biceps repair by cortical button and interference screw. J Shoulder Elbow Surg. 2014
Oct;23(10):1532-6. doi: 10.1016/j.jse.2014.04.013. PubMed

Abrams RA, Ziets RJ, Lieber RL, Botte MJ. Anatomy of the radial nerve motor branches in the
forearm. J Hand Surg Am. 1997 Mar;22(2):232-7. PubMed

Question 40 of 100

A 19-year-old collegiate offensive lineman injures his left elbow in a scrimmage. He reports reaching out
with his left arm to prevent the defensive player from getting around him, and, as he grabbed the
player, his elbow was forced into extension. He had immediate pain and weakness and heard a “pop.”
He has mild swelling in the antecubital fossa and a prominent-appearing biceps muscle belly. His hook
test result is abnormal at the elbow.

The athlete undergoes repair of the injury, and postsurgical radiographs are shown in Figures 1 and 2. At
his first postsurgical visit, he reports no pain but describes weakness in his hand and decreased
sensation over his lateral forearm. Upon examination, he has decreased 2-point discrimination over the
lateral forearm and an inability to actively extend his thumb and fingers at the metacarpophalangeal
joints. He can extend at the finger interphalangeal joints. He can extend his wrist weakly, and it deviates
radially as he extends. His distal sensation is intact. Considering his examination findings, which two
nerves are injured?

Figure 1 Figure 2

A. PIN and radial nerve

B. PIN and lateral antebrachial cutaneous nerve (LABCN)
C. Median nerve and LABCN
D. Radial nerve and LABCN

Correct answer: B

 Discussion

This patient had an eccentric muscle contraction (muscle lengthening while contracting) of his biceps
muscle while trying to stop a defender from getting around him. This in turn caused failure of the distal
biceps tendon, as evidenced by pain in the antecubital fossa, lack of elbow supination strength, and his
positive biceps active test finding (supination/pronation of the forearm showing no motion of the biceps
muscle belly). Eccentric contractors have the highest potential for building strength but also are at
highest risk for injury. Concentric (muscle shortening with contraction), isometric (no change in muscle
length with contracture), and isokinetic (constant velocity of muscle contraction with a variable force)
do not describe the mechanism detailed.
The loss of distal biceps attachment will result in loss of elbow supination strength in flexion (the biceps
is the only supinator to cross the elbow) while still retaining elbow flexion (albeit weakened) because of
the other elbow flexors (brachioradialis and brachialis). Consequently, treatment should be anatomic
repair of the distal biceps insertion, which can be performed with a 2-incision or 1-incision technique.
Although all of the listed complications have been reported with these techniques, LABC neuropraxia is
by far the most common. Radiographs show that this athlete’s injury was repaired using a 1-incision
technique with a cortical fixation device and a radial bone tunnel. This technique has gained favor
because of its decreased incidence of heterotopic ossification and radioulnar synostosis compared with
the 2-incision technique. The most troubling complication for most surgeons is the development of a
posterior interosseous nerve (PIN) palsy, which this patient clearly demonstrates in addition to the more
common LABCN upon postsurgical examination. Because the LABCN injury is typically a neuropraxia
from retraction, a period of observation is indicated. PIN injury can result from excessive traction during
surgical exposure or from entrapment by the fixation button.

Considering the anatomy of the PIN, successful recovery of the nerve typically progresses based on the
distance from the origin of the nerve to the muscle indicated. The extensor indicis proprius (EIP) muscle
is the most distal muscle innervated and can be expected to recover last. First to return would be the
EDC followed by the ECU, EDQ, and, finally, the EIP.

 Recommended Readings

Bisson L, Moyer M, Lanighan K, Marzo J. Complications associated with repair of a distal

biceps rupture using the modified two-incision technique. J Shoulder Elbow Surg. 2008 Jan-
Feb;17(1 Suppl):67S-71S. Epub 2007 Nov 1. PubMed

Watson JN, Moretti VM, Schwindel L, Hutchinson MR. Repair techniques for acute distal biceps
tendon ruptures: a systematic review. J Bone Joint Surg Am. 2014 Dec 17;96(24):2086-90. doi:
10.2106/JBJS.M.00481. PubMed

Schmidt CC, Brown BT, Sawardeker PJ, DeGravelle M Jr, Miller MC. Factors affecting
supination strength after a distal biceps rupture. J Shoulder Elbow Surg. 2014 Jan;23(1):68-75.
doi: 10.1016/j.jse.2013.08.019. PubMed

Cusick MC, Cottrell BJ, Cain RA, Mighell MA. Low incidence of tendon rerupture after distal
biceps repair by cortical button and interference screw. J Shoulder Elbow Surg. 2014
Oct;23(10):1532-6. doi: 10.1016/j.jse.2014.04.013. PubMed

Abrams RA, Ziets RJ, Lieber RL, Botte MJ. Anatomy of the radial nerve motor branches in the
forearm. J Hand Surg Am. 1997 Mar;22(2):232-7. PubMed
Question 41 of 100

A 20-year-old healthy female endurance athlete has lower leg pain and dorsal foot paresthesias after
running for 30 minutes. She has seen another physician and has been ruled out for a bone stress injury.
She has tried extensive nonsurgical measures such as shoe modification and an extended period without
running. You suspect chronic exertional compartment syndrome and perform intramuscular
compartment pressure measurements at three separate time points with the following results:

Baseline 1 Minute 5 Minutes

Anterior 7 32 25

Lateral 8 29 23

Superficial Posterior 12 25 17

Deep Posterior 14 22 16

The patient decides to pursue surgical intervention. Which compartments should be released?

A. Anterior and lateral

B. Anterior, lateral, and deep posterior
C. Anterior, lateral and superficial posterior
D. Lateral and superficial posterior

Correct answer: A

 Discussion

The diagnostic criteria for chronic exertional compartment syndrome is pressure >15 mm Hg at rest, or
>30 mm Hg at 1 minute post exercise, or >20 mm Hg at 5 minutes post-exercise. The anterior and lateral
compartments are the only ones that meet strict diagnostic criteria for chronic exertional compartment
syndrome. The superficial posterior compartment, although close to meeting criteria, is not responsible
for the patient's symptoms and falls below current thresholds for diagnosis.

 Recommended Readings
Roscoe D, Roberts AJ, Hulse D. Intramuscular compartment pressure measurement in chronic
exertional compartment syndrome: new and improved diagnostic criteria. Am J Sports Med. 2015
Feb;43(2):392-8. doi: 10.1177/0363546514555970. Epub 2014 Nov 18. PubMed

Question 42 of 100

Figures 1 and 2 are the most recent radiographs of an 18-year-old high school student who sustains an
anterior shoulder dislocation playing recreational football. He has a low Beighton score on physical
examination. He was closed reduced and underwent a course of physical therapy but had a second
dislocation playing recreational basketball. What is the most appropriate course of treatment, with the
lowest complication rate, to prevent further dislocation?

Figure 1 Figure 2

A. Arthroscopic Bankart procedure

B. Physical therapy
C. SAWA shoulder brace
D. Latarjet procedure
Correct answer: A

 Discussion

The patient has recurrent instability and is at a high rate of further dislocations due to his young age.
Therefore, therapy and bracing are unlikely to decrease his dislocation rate. The radiographs are normal,
and there is no Hill-Sachs lesion or bony Bankart lesion. His instability severity index score is 3, and;
therefore, a bony procedure such as Latarjet is not necessary. Furthermore, the rate of complication
following a Latarjet procedure, especially nerve injury and hardware problems, exceeds that of
arthroscopic Bankart repair.

 Recommended Readings

Hovelius L, Sandström B, Saebö M. One hundred eighteen Bristow-Latarjet repairs for recurrent
anterior dislocation of the shoulder prospectively followed for fifteen years: study II-the
evolution of dislocation arthropathy. J Shoulder Elbow Surg. 2006 May-Jun;15(3):279-89.
PubMed

Balg F, Boileau P. The instability severity index score. A simple pre-operative score to select
patients for arthroscopic or open shoulder stabilisation. J Bone Joint Surg Br. 2007
Nov;89(11):1470-7. PubMed

Rollick NC, Ono Y, Kurji HM, Nelson AA, Boorman RS, Thornton GM, Lo IK. Long-term
outcomes of the Bankart and Latarjet repairs: a systematic review. Open Access J Sports Med.
2017 Apr 15;8:97-105. doi: 10.2147/OAJSM.S106983. eCollection 2017. PubMed

Question 43 of 100

A football player injures his knee when he is tackled and falls awkwardly. He does not note any discreet
“pop,” but pain prevents him from returning to the game. An effusion is noted the following day and an
MRI scan is ordered. Selected images are shown in Figures 1 through 3. Based on these images, physical
examination findings likely include
 Figure 1 Figure 2 Figure 3

A. positive Lachman test, normal posterior drawer, positive pivot shift.

B. positive Lachman test, positive posterior drawer, negative pivot shift.
C. normal Lachman test, positive posterior drawer, positive pivot shift.
D. normal Lachman test, positive posterior drawer, negative pivot shift.

Correct answer: D

 Discussion

The images provided reveal a posterior cruciate ligament (PCL) disruption with an intact anterior
cruciate ligament (ACL). Common diagnostic findings for a PCL tear include a positive posterior drawer
test, positive reverse pivot shift, positive quadriceps active test, and positive posterior sag. A positive
Lachman test, which would indicate a torn ACL, would not be expected to be positive. A false-positive
result for a Lachman test can arise with a torn PCL because of the overall increased anterior-posterior
translation; this must be avoided by careful attention to initial resting position and station of the knee.

 Recommended Readings

Lubowitz JH, Bernardini BJ, Reid JB 3rd. Current concepts review: comprehensive physical
examination for instability of the knee. Am J Sports Med. 2008 Mar;36(3):577-94. doi:
10.1177/0363546507312641. Epub 2008 Jan 24. PubMed

Wind WM Jr, Bergfeld JA, Parker RD. Evaluation and treatment of posterior cruciate ligament
injuries: revisited. Am J Sports Med. 2004 Oct-Nov;32(7):1765-75. Review. PubMed
Bronstein RD, Schaffer JC. Physical Examination of Knee Ligament Injuries. J Am Acad Orthop
Surg. 2017 Apr;25(4):280-287. doi: 10.5435/JAAOS-D-15-00463. Review. PubMed

Question 44 of 100

A 40-year-old man who is a manual laborer has had 3 years of worsening medial-sided left knee pain
that has inhibited his ability to work. He reports undergoing a left subtotal medial meniscectomy 10
years ago. He has been treated with nonsteroidal anti-inflammatory drugs and two different
corticosteroids, with the most recent injection given 1 month ago. Each injection provided him with a
few weeks of pain control. His medical history is unremarkable, and he has smoked 20 cigarettes per day
for the last 15 years. His BMI is 22. On examination, he has varus alignment of the involved leg and
medial joint line tenderness and no lateral or patellofemoral pain. His knee range of motion is 3° shy of
full extension to 130° of flexion. He has negative Lachman and posterior drawer test results. He
demonstrates no lateral thrust with ambulation.

What imaging study is most appropriate to determine treatment options for this patient?

A. Full-length weight-bearing radiographs of both legs

B. MRI scan of the left knee
C. CT scan of the left knee
D. Ultrasonography of the left leg

Correct answer: A

 Discussion

This patient has a classic presentation of postmeniscectomy medial compartment arthritis. The
appropriate diagnostic study is weight-bearing radiographs to confirm the diagnosis. An MRI scan will
reveal medial compartment arthritis but will not provide information about alignment. A CT scan would
be appropriate to detect an occult fracture; however, this condition is not suspected in this clinical
scenario. Ultrasonography can provide information about fluid collection around the knee or a deep vein
thrombosis; however, these conditions also are not suspected in this clinical scenario.

Because the patient has a correctable deformity (gaps 3 mm with valgus stress), and his symptoms are
localized to the involved compartment, a trial of a medial unloader brace is appropriate both
diagnostically and therapeutically. If unloading the medial compartment resolves the patient’s
symptoms, he would be an excellent candidate for an osteotomy. An MRI scan may be obtained to
evaluate ligamentous integrity or to evaluate degenerative involvement of the lateral and
patellofemoral compartment for presurgical planning of an osteotomy; however, the integrity of the
medial meniscus has no clinical importance in a patient with severe medial compartment arthritis. A
repeat corticosteroid injection is not indicated within 1 month of his last injection, and referral to pain
management is not appropriate with other options available to help this patient.

A VPHTO is the appropriate intervention considering the patient’s young age, high-functional
occupation, examination, radiographic findings, and response to medial unloader bracing. A revision
knee arthroscopy would be appropriate for a recurrent medial meniscus tear, but not appropriate in a
patient with severe medial compartment arthritis. The patient’s young age and high functional
requirements are contraindications to TKA. The presence of severe arthritis is a contraindication to
medial meniscus transplant.

The patient is a candidate for a VPHTO. The technical options include a medial opening-wedge or a
lateral closing-wedge osteotomy. Both techniques have advantages and disadvantages; however, a
medial opening-wedge osteotomy is contraindicated in a smoker because of concern for nonunion. As a
result, current smoking history is the only factor listed that would influence the technique used. The
history of prior arthroscopy has no relevance in the decision about which type of osteotomy is
appropriate. Normal BMI is between 18.5 and 24.9, so this patient’s BMI is considered normal and
would not affect the surgical technique (if this patient were obese, a lateral closing-wedge osteotomy
would be considered, but this is controversial). His age of 40 years is an indication for HTO but does not
influence technique.

 Recommended Readings

W-Dahl A, Toksvig-Larsen S. Cigarette smoking delays bone healing: a prospective study of 200
patients operated on by the hemicallotasis technique. Acta Orthop Scand. 2004 Jun;75(3):347-51.
PubMed

Amendola A. Knee osteotomy and meniscal transplantation: indications, technical

considerations, and results. Sports Med Arthrosc. 2007 Mar;15(1):32-8. PubMed

Sprenger TR, Doerzbacher JF. Tibial osteotomy for the treatment of varus gonarthrosis. Survival
and failure analysis to twenty-two years. J Bone Joint Surg Am. 2003 Mar;85-A(3):469-74.
Erratum in: J Bone Joint Surg Am. 2003 May 85-A(5):912. PubMed

Rossi R, Bonasia DE, Amendola A. The role of high tibial osteotomy in the varus knee. J Am
Acad Orthop Surg. 2011 Oct;19(10):590-9. Full text
Question 45 of 100

A 40-year-old man who is a manual laborer has had 3 years of worsening medial-sided left knee pain
that has inhibited his ability to work. He reports undergoing a left subtotal medial meniscectomy 10
years ago. He has been treated with nonsteroidal anti-inflammatory drugs and two different
corticosteroids, with the most recent injection given 1 month ago. Each injection provided him with a
few weeks of pain control. His medical history is unremarkable, and he has smoked 20 cigarettes per day
for the last 15 years. His BMI is 22. On examination, he has varus alignment of the involved leg and
medial joint line tenderness and no lateral or patellofemoral pain. His knee range of motion is 3° shy of
full extension to 130° of flexion. He has negative Lachman and posterior drawer test results. He
demonstrates no lateral thrust with ambulation.

What is the most appropriate next step in treatment?

A. Repeat corticosteroid injection

B. Trial of a medial unloader brace
C. MRI scan of the knee to evaluate for recurrent medial meniscus tear
D. Referral to pain management

Correct answer: B

 Discussion

This patient has a classic presentation of postmeniscectomy medial compartment arthritis. The
appropriate diagnostic study is weight-bearing radiographs to confirm the diagnosis. An MRI scan will
reveal medial compartment arthritis but will not provide information about alignment. A CT scan would
be appropriate to detect an occult fracture; however, this condition is not suspected in this clinical
scenario. Ultrasonography can provide information about fluid collection around the knee or a deep vein
thrombosis; however, these conditions also are not suspected in this clinical scenario.

Because the patient has a correctable deformity (gaps 3 mm with valgus stress), and his symptoms are
localized to the involved compartment, a trial of a medial unloader brace is appropriate both
diagnostically and therapeutically. If unloading the medial compartment resolves the patient’s
symptoms, he would be an excellent candidate for an osteotomy. An MRI scan may be obtained to
evaluate ligamentous integrity or to evaluate degenerative involvement of the lateral and
patellofemoral compartment for presurgical planning of an osteotomy; however, the integrity of the
medial meniscus has no clinical importance in a patient with severe medial compartment arthritis. A
repeat corticosteroid injection is not indicated within 1 month of his last injection, and referral to pain
management is not appropriate with other options available to help this patient.

A VPHTO is the appropriate intervention considering the patient’s young age, high-functional
occupation, examination, radiographic findings, and response to medial unloader bracing. A revision
knee arthroscopy would be appropriate for a recurrent medial meniscus tear, but not appropriate in a
patient with severe medial compartment arthritis. The patient’s young age and high functional
requirements are contraindications to TKA. The presence of severe arthritis is a contraindication to
medial meniscus transplant.

The patient is a candidate for a VPHTO. The technical options include a medial opening-wedge or a
lateral closing-wedge osteotomy. Both techniques have advantages and disadvantages; however, a
medial opening-wedge osteotomy is contraindicated in a smoker because of concern for nonunion. As a
result, current smoking history is the only factor listed that would influence the technique used. The
history of prior arthroscopy has no relevance in the decision about which type of osteotomy is
appropriate. Normal BMI is between 18.5 and 24.9, so this patient’s BMI is considered normal and
would not affect the surgical technique (if this patient were obese, a lateral closing-wedge osteotomy
would be considered, but this is controversial). His age of 40 years is an indication for HTO but does not
influence technique.

 Recommended Readings

W-Dahl A, Toksvig-Larsen S. Cigarette smoking delays bone healing: a prospective study of 200
patients operated on by the hemicallotasis technique. Acta Orthop Scand. 2004 Jun;75(3):347-51.
PubMed

Amendola A. Knee osteotomy and meniscal transplantation: indications, technical

considerations, and results. Sports Med Arthrosc. 2007 Mar;15(1):32-8. PubMed

Sprenger TR, Doerzbacher JF. Tibial osteotomy for the treatment of varus gonarthrosis. Survival
and failure analysis to twenty-two years. J Bone Joint Surg Am. 2003 Mar;85-A(3):469-74.
Erratum in: J Bone Joint Surg Am. 2003 May 85-A(5):912. PubMed

Rossi R, Bonasia DE, Amendola A. The role of high tibial osteotomy in the varus knee. J Am
Acad Orthop Surg. 2011 Oct;19(10):590-9. Full text

Question 46 of 100

A 40-year-old man who is a manual laborer has had 3 years of worsening medial-sided left knee pain
that has inhibited his ability to work. He reports undergoing a left subtotal medial meniscectomy 10
years ago. He has been treated with nonsteroidal anti-inflammatory drugs and two different
corticosteroids, with the most recent injection given 1 month ago. Each injection provided him with a
few weeks of pain control. His medical history is unremarkable, and he has smoked 20 cigarettes per day
for the last 15 years. His BMI is 22. On examination, he has varus alignment of the involved leg and
medial joint line tenderness and no lateral or patellofemoral pain. His knee range of motion is 3° shy of
full extension to 130° of flexion. He has negative Lachman and posterior drawer test results. He
demonstrates no lateral thrust with ambulation.

The patient is provided with a medial unloader brace that provides substantial pain relief, and he is able
to work while wearing the brace. After 4 months, he returns to work and reports that while the brace
enables him to work, it is uncomfortable. Consequently, his symptoms return when he is not wearing
the brace, and he is requesting a surgical intervention for his problem. What is the most appropriate
surgical treatment?

A. Valgus-producing high tibial osteotomy (VPHTO)

B. Repeat knee arthroscopy
C. Total knee arthroplasty (TKA)
D. Medial meniscus transplant

Correct answer: A

 Discussion

This patient has a classic presentation of postmeniscectomy medial compartment arthritis. The
appropriate diagnostic study is weight-bearing radiographs to confirm the diagnosis. An MRI scan will
reveal medial compartment arthritis but will not provide information about alignment. A CT scan would
be appropriate to detect an occult fracture; however, this condition is not suspected in this clinical
scenario. Ultrasonography can provide information about fluid collection around the knee or a deep vein
thrombosis; however, these conditions also are not suspected in this clinical scenario.

Because the patient has a correctable deformity (gaps 3 mm with valgus stress), and his symptoms are
localized to the involved compartment, a trial of a medial unloader brace is appropriate both
diagnostically and therapeutically. If unloading the medial compartment resolves the patient’s
symptoms, he would be an excellent candidate for an osteotomy. An MRI scan may be obtained to
evaluate ligamentous integrity or to evaluate degenerative involvement of the lateral and
patellofemoral compartment for presurgical planning of an osteotomy; however, the integrity of the
medial meniscus has no clinical importance in a patient with severe medial compartment arthritis. A
repeat corticosteroid injection is not indicated within 1 month of his last injection, and referral to pain
management is not appropriate with other options available to help this patient.
A VPHTO is the appropriate intervention considering the patient’s young age, high-functional
occupation, examination, radiographic findings, and response to medial unloader bracing. A revision
knee arthroscopy would be appropriate for a recurrent medial meniscus tear, but not appropriate in a
patient with severe medial compartment arthritis. The patient’s young age and high functional
requirements are contraindications to TKA. The presence of severe arthritis is a contraindication to
medial meniscus transplant.

The patient is a candidate for a VPHTO. The technical options include a medial opening-wedge or a
lateral closing-wedge osteotomy. Both techniques have advantages and disadvantages; however, a
medial opening-wedge osteotomy is contraindicated in a smoker because of concern for nonunion. As a
result, current smoking history is the only factor listed that would influence the technique used. The
history of prior arthroscopy has no relevance in the decision about which type of osteotomy is
appropriate. Normal BMI is between 18.5 and 24.9, so this patient’s BMI is considered normal and
would not affect the surgical technique (if this patient were obese, a lateral closing-wedge osteotomy
would be considered, but this is controversial). His age of 40 years is an indication for HTO but does not
influence technique.

 Recommended Readings

W-Dahl A, Toksvig-Larsen S. Cigarette smoking delays bone healing: a prospective study of 200
patients operated on by the hemicallotasis technique. Acta Orthop Scand. 2004 Jun;75(3):347-51.
PubMed

Amendola A. Knee osteotomy and meniscal transplantation: indications, technical

considerations, and results. Sports Med Arthrosc. 2007 Mar;15(1):32-8. PubMed

Sprenger TR, Doerzbacher JF. Tibial osteotomy for the treatment of varus gonarthrosis. Survival
and failure analysis to twenty-two years. J Bone Joint Surg Am. 2003 Mar;85-A(3):469-74.
Erratum in: J Bone Joint Surg Am. 2003 May 85-A(5):912. PubMed

Rossi R, Bonasia DE, Amendola A. The role of high tibial osteotomy in the varus knee. J Am
Acad Orthop Surg. 2011 Oct;19(10):590-9. Full text

Question 47 of 100

A 40-year-old man who is a manual laborer has had 3 years of worsening medial-sided left knee pain
that has inhibited his ability to work. He reports undergoing a left subtotal medial meniscectomy 10
years ago. He has been treated with nonsteroidal anti-inflammatory drugs and two different
corticosteroids, with the most recent injection given 1 month ago. Each injection provided him with a
few weeks of pain control. His medical history is unremarkable, and he has smoked 20 cigarettes per day
for the last 15 years. His BMI is 22. On examination, he has varus alignment of the involved leg and
medial joint line tenderness and no lateral or patellofemoral pain. His knee range of motion is 3° shy of
full extension to 130° of flexion. He has negative Lachman and posterior drawer test results. He
demonstrates no lateral thrust with ambulation.

The patient is offered a VPHTO. What aspect of his history will determine the most appropriate VPHTO
technique?

A. Prior arthroscopy
B. Current smoking history
C. BMI of 22
D. Age of 40

Correct answer: B

 Discussion

This patient has a classic presentation of postmeniscectomy medial compartment arthritis. The
appropriate diagnostic study is weight-bearing radiographs to confirm the diagnosis. An MRI scan will
reveal medial compartment arthritis but will not provide information about alignment. A CT scan would
be appropriate to detect an occult fracture; however, this condition is not suspected in this clinical
scenario. Ultrasonography can provide information about fluid collection around the knee or a deep vein
thrombosis; however, these conditions also are not suspected in this clinical scenario.

Because the patient has a correctable deformity (gaps 3 mm with valgus stress), and his symptoms are
localized to the involved compartment, a trial of a medial unloader brace is appropriate both
diagnostically and therapeutically. If unloading the medial compartment resolves the patient’s
symptoms, he would be an excellent candidate for an osteotomy. An MRI scan may be obtained to
evaluate ligamentous integrity or to evaluate degenerative involvement of the lateral and
patellofemoral compartment for presurgical planning of an osteotomy; however, the integrity of the
medial meniscus has no clinical importance in a patient with severe medial compartment arthritis. A
repeat corticosteroid injection is not indicated within 1 month of his last injection, and referral to pain
management is not appropriate with other options available to help this patient.

A VPHTO is the appropriate intervention considering the patient’s young age, high-functional
occupation, examination, radiographic findings, and response to medial unloader bracing. A revision
knee arthroscopy would be appropriate for a recurrent medial meniscus tear, but not appropriate in a
patient with severe medial compartment arthritis. The patient’s young age and high functional
requirements are contraindications to TKA. The presence of severe arthritis is a contraindication to
medial meniscus transplant.

The patient is a candidate for a VPHTO. The technical options include a medial opening-wedge or a
lateral closing-wedge osteotomy. Both techniques have advantages and disadvantages; however, a
medial opening-wedge osteotomy is contraindicated in a smoker because of concern for nonunion. As a
result, current smoking history is the only factor listed that would influence the technique used. The
history of prior arthroscopy has no relevance in the decision about which type of osteotomy is
appropriate. Normal BMI is between 18.5 and 24.9, so this patient’s BMI is considered normal and
would not affect the surgical technique (if this patient were obese, a lateral closing-wedge osteotomy
would be considered, but this is controversial). His age of 40 years is an indication for HTO but does not
influence technique.

 Recommended Readings

W-Dahl A, Toksvig-Larsen S. Cigarette smoking delays bone healing: a prospective study of 200
patients operated on by the hemicallotasis technique. Acta Orthop Scand. 2004 Jun;75(3):347-51.
PubMed

Amendola A. Knee osteotomy and meniscal transplantation: indications, technical

considerations, and results. Sports Med Arthrosc. 2007 Mar;15(1):32-8. PubMed

Sprenger TR, Doerzbacher JF. Tibial osteotomy for the treatment of varus gonarthrosis. Survival
and failure analysis to twenty-two years. J Bone Joint Surg Am. 2003 Mar;85-A(3):469-74.
Erratum in: J Bone Joint Surg Am. 2003 May 85-A(5):912. PubMed

Rossi R, Bonasia DE, Amendola A. The role of high tibial osteotomy in the varus knee. J Am
Acad Orthop Surg. 2011 Oct;19(10):590-9. Full text

Question 48 of 100

Figure 1 is the MRI scan of a patient with recurrent knee instability, which persists after a period of
nonsurgical treatment. Anatomic reconstruction of the torn ligament is recommended. What
radiographic finding is the most important independent predictor of recurrent instability following
surgery?
 Figure 1

A. Tibial tubercle to trochlear groove (TT-TG) distance

B. Patella alta
C. Tibial slope
D. Trochlear dysplasia

Correct answer: D

 Discussion

The MR image is consistent with an episode of patellar instability with concomitant bruising of the
medial patellar facet and lateral femoral condyle. The medial patellofemoral ligament appears torn and
attenuated. Kita and associates reported that severe trochlear dysplasia is the most important predictor
of residual patellofemoral instability after isolated medial patellofemoral ligament reconstruction. An
increased TT-TG affected outcomes of patients with type D trochlear dysplasia (Dejour classification).
Wagner and associates also found that high degrees of trochlear dysplasia correlate with poor clinical
outcome due to graft overload in dysplastic situations. Other studies by Nelitz and associates and
Matsushita and associates have also suggested that TT-TG distance did not reliably correlate with clinical
outcome. Tibial slope would not affect recurrent patellar instability.

 Recommended Readings
Kita K, Tanaka Y, Toritsuka Y, Amano H, Uchida R, Takao R, Horibe S. Factors Affecting the
Outcomes of Double-Bundle Medial Patellofemoral Ligament Reconstruction for Recurrent
Patellar Dislocations Evaluated by Multivariate Analysis. Am J Sports Med. 2015
Dec;43(12):2988-96. doi: 10.1177/0363546515606102. Epub 2015 Oct 4. PubMed

Matsushita T, Kuroda R, Oka S, Matsumoto T, Takayama K, Kurosaka M. Clinical outcomes of

medial patellofemoral ligament reconstruction in patients with an increased tibial tuberosity-
trochlear groove distance. Knee Surg Sports Traumatol Arthrosc. 2014 Oct;22(10):2438-44. doi:
10.1007/s00167-014-2919-3. Epub 2014 Mar 4. PubMed

Nelitz M, Theile M, Dornacher D, Wölfle J, Reichel H, Lippacher S. Analysis of failed surgery

for patellar instability in children with open growth plates. Knee Surg Sports Traumatol
Arthrosc. 2012 May;20(5):822-8. doi: 10.1007/s00167-011-1599-5. Epub 2011 Jul 6. PubMed

Wagner D, Pfalzer F, Hingelbaum S, Huth J, Mauch F, Bauer G. The influence of risk factors on
clinical outcomes following anatomical medial patellofemoral ligament (MPFL) reconstruction
using the gracilis tendon. Knee Surg Sports Traumatol Arthrosc. 2013 Feb;21(2):318-24. doi:
10.1007/s00167-012-2015-5. Epub 2012 Apr 27. PubMed

Question 49 of 100

Figure 1 is an arthroscopic view of the intercondylar notch of a right knee from an anterolateral portal.
What is the main function of the structure delineated by the black asterisks?

Figure 1

A. Resist anterior translation during knee flexion

B. Resist posterior translation during knee flexion
 C. Resist rotatory loads during knee flexion
D. Resist rotatory loads during knee extension

Correct answer: D

 Discussion

The structure shown is the posterolateral bundle of the anterior cruciate ligament (ACL). This bundle is
optimally positioned in the knee to resist rotatory forces during terminal knee extension. "Resist
anterior translation during knee flexion" best describes the anteromedial bundle. "Resist rotatory loads
during knee flexion" is unlikely because the posterolateral bundle is tightest during knee extension. The
posterior cruciate ligament, not the ACL, functions to resist posterior translation.

 Recommended Readings

Petersen W, Zantop T. Anatomy of the anterior cruciate ligament with regard to its two bundles.
Clin Orthop Relat Res. 2007 Jan;454:35-47. PubMed

Zantop T, Petersen W, Sekiya JK, Musahl V, Fu FH. Anterior cruciate ligament anatomy and
function relating to anatomical reconstruction. Knee Surg Sports Traumatol Arthrosc. 2006
Oct;14(10):982-92. Epub 2006 Aug 5. PubMed

Question 50 of 100

A 19-year old Division 1 offensive lineman sustains an ankle injury during a game. He has pain with
weight-bearing and is unable to return to the game. Figures 1 through 5 are his radiographs taken the
next day. What is the best next step?
Figure 1 Figure 2 Figure 3
 Figure 4 Figure 5

A. Immobilization
B. Syndesmotic fixation
C. Physical therapy
D. Obtain an MRI scan

Correct answer: B

 Discussion

The radiographs reveal medial clear space widening and an oblique proximal fibula fracture (best seen
on the lateral view overlapping the tibia). This is consistent with an unstable syndesmotic injury.
Operative repair of the syndesmosis with reduction and fixation is warranted. Immobilization is the best
option for a stable syndesmotic injury. Physical therapy and MRI are not warranted given the findings on
the radiographs.

 Recommended Readings

Rammelt S, Zwipp H, Grass R. Injuries to the distal tibiofibular syndesmosis: an evidence-based

approach to acute and chronic lesions. Foot Ankle Clin. 2008 Dec;13(4):611-33, vii-viii. doi:
10.1016/j.fcl.2008.08.001. PubMed

Hunt KJ, Phisitkul P, Pirolo J, Amendola A. High Ankle Sprains and Syndesmotic Injuries in
Athletes. J Am Acad Orthop Surg. 2015 Nov;23(11):661-73. doi: 10.5435/JAAOS-D-13-00135.
PubMed

Question 51 of 100

A 16-year-old boy falls while playing soccer. He reports that his knee buckled when he planted his leg to
kick a ball. He noticed an obvious deformity of his knee, which spontaneously resolved with a “clunk.”
He could not finish the game but was able to bear weight with a limp. He has had two similar episodes
but has never sought medical attention. An initial examination demonstrated an effusion, tenderness at
the proximal medial collateral region and medial patellofemoral retinaculum, decreased range of
motion, and patella apprehension. A lateral patellar glide performed at 30° of flexion was 3+. He was
otherwise ligamentously stable, and there were no other noteworthy findings.

What do Figures 1 and 2 reveal?

Figure 1 Figure 2

A. Medial femoral condyle physeal widening

B. An osseous or osteochondral loose fragment
C. Osgood-Schlatter disease
D. A patella nondisplaced fracture
Correct answer: B

 Discussion

This patient’s examination and history indicate recurrent patellar dislocations. Radiographs show an
osseous or osteochondral loose fragment. There is no evidence of an obvious nondisplaced fracture or
physeal changes. In the setting of suspected patella dislocation or subluxation with loose fragment seen
on radiograph, an MRI is indicated. Lateral release alone is seldom indicated in a knee that is normal
before injury. The examination and MRI do not indicate a need for medial collateral ligament repair.
Treatment should consist of arthroscopy or arthrotomy and attempted internal fixation of this fragment.
If fixation is not possible, the loose body can be removed. Normal TT-TG values, an increased lateral
patellar glide, and a history of recurrent patellar dislocations after trauma suggest MPFL incompetence
and the need for reconstruction.

 Recommended Readings

Iobst CA, Stanitski CL. Acute knee injuries. Clin Sports Med. 2000 Oct;19(4):621-35, vi.
PubMed

Fithian DC, Paxton EW, Stone ML, Silva P, Davis DK, Elias DA, White LM. Epidemiology and
natural history of acute patellar dislocation. Am J Sports Med. 2004 Jul-Aug;32(5):1114-21.
Epub 2004 May 18. PubMed

Schepsis, AA, Rogers, AJ. Medial patellofemoral ligament reconstruction: indications and
technique. Sports Med Arthrosc. 2012 Sep;20(3):162-70. PMID 22878657.

Question 52 of 100

A 16-year-old boy falls while playing soccer. He reports that his knee buckled when he planted his leg to
kick a ball. He noticed an obvious deformity of his knee, which spontaneously resolved with a “clunk.”
He could not finish the game but was able to bear weight with a limp. He has had two similar episodes
but has never sought medical attention. An initial examination demonstrated an effusion, tenderness at
the proximal medial collateral region and medial patellofemoral retinaculum, decreased range of
motion, and patella apprehension. A lateral patellar glide performed at 30° of flexion was 3+. He was
otherwise ligamentously stable, and there were no other noteworthy findings.
Figures 3 and 4 are this patient's proton density fat-saturated MR images. His tibial tubercle-trochlear
groove (TT-TG) distance is 12 mm, and he has normal limb-alignment film findings. Treatment at this
stage should include

Figure 1 Figure 2

A. hinged knee bracing, protected weight bearing, and physical therapy.

B. anteromedialization of the tibial tubercle.
C. internal fixation and medial patellofemoral ligament (MPFL) reconstruction.
D. arthroscopic lateral retinacular release.

Correct answer: C

 Discussion

This patient’s examination and history indicate recurrent patellar dislocations. Radiographs show an
osseous or osteochondral loose fragment. There is no evidence of an obvious nondisplaced fracture or
physeal changes. In the setting of suspected patella dislocation or subluxation with loose fragment seen
on radiograph, an MRI is indicated. Lateral release alone is seldom indicated in a knee that is normal
before injury. The examination and MRI do not indicate a need for medial collateral ligament repair.
Treatment should consist of arthroscopy or arthrotomy and attempted internal fixation of this fragment.
If fixation is not possible, the loose body can be removed. Normal TT-TG values, an increased lateral
patellar glide, and a history of recurrent patellar dislocations after trauma suggest MPFL incompetence
and the need for reconstruction.

 Recommended Readings

Iobst CA, Stanitski CL. Acute knee injuries. Clin Sports Med. 2000 Oct;19(4):621-35, vi.
PubMed

Fithian DC, Paxton EW, Stone ML, Silva P, Davis DK, Elias DA, White LM. Epidemiology and
natural history of acute patellar dislocation. Am J Sports Med. 2004 Jul-Aug;32(5):1114-21.
Epub 2004 May 18. PubMed

Schepsis, AA, Rogers, AJ. Medial patellofemoral ligament reconstruction: indications and
technique. Sports Med Arthrosc. 2012 Sep;20(3):162-70. PMID 22878657.

Question 53 of 100

Figure 1 is the axial cut MRI scan of a 35-year-old woman who has had posteriorly based right hip pain
for 3 months. Examination demonstrates full and symmetric range of motion between the right and left
hips, negative impingement test, but reproduction of her pain with passive extension of the right hip.
Which muscle is indicated by the arrow?

Figure 1

A. Piriformis
B. Obturator internus
C. Superior gemellus
 D. Quadratus femoris

Correct answer: D

 Discussion

This patient has ischiofemoral impingement, in which there is abnormal contact between the lesser
trochanter and the lateral border of the ischium. Patients typically present with posteriorly based hip
pain and do not respond to intra-articular diagnostic injections. Examination can demonstrate pain with
long strides, pain with palpation over the area, as well as reproduction of symptoms with the patient in
the contralateral decubitus position and taking the affected hip into passive extension (ischiofemoral
impingement test). MRI demonstrates a narrowed ischiofemoral space, as well as increased signal within
the quadratus femoris muscle. The diagnosis can be confirmed with a diagnostic injection into this area.
Treatment is typically nonsurgical, with surgical intervention consisting of resection of the lesser
trochanter reserved for refractory cases.

 Recommended Readings

Gómez-Hoyos J, Martin RL, Schröder R, Palmer IJ, Martin HD. Accuracy of 2 Clinical Tests for
Ischiofemoral Impingement in Patients With Posterior Hip Pain and Endoscopically Confirmed
Diagnosis. Arthroscopy. 2016 Jul;32(7):1279-84. doi: 10.1016/j.arthro.2016.01.024. Epub 2016
Mar 25. PubMed

Backer MW, Lee KS, Blankenbaker DG, Kijowski R, Keene JS. Correlation of ultrasound-
guided corticosteroid injection of the quadratus femoris with MRI findings of ischiofemoral
impingement. AJR Am J Roentgenol M. 2014 Sep;203(3):589-93. doi: 10.2214/AJR.13.12304.
Erratum in: AJR Am J Roentgenol. 2014 Nov;203(5):1156. PubMed

Hatem MA, Palmer IJ, Martin HD. Diagnosis and 2-year outcomes of endoscopic treatment for
ischiofemoral impingement. Arthroscopy. 2015 Feb;31(2):239-46. doi:
10.1016/j.arthro.2014.07.031. Epub 2014 Sep 30. PubMed

Question 54 of 100
A 17-year-old high school football player sustains a neck injury in a game. During the initial on-field
assessment, the team physician removes the player’s helmet, and the athlete is log-rolled to the supine
position while the physician manually stabilizes his cervical spine. An examination demonstrates
tenderness to palpation over the cervical spine and neurologic deficits in bilateral upper and lower
extremities. Shoulder pads prohibit proper placement of a hard cervical collar, and the athlete is
immobilized on a spine board and transported to the emergency department via ambulance.
Comprehensive evaluation in the emergency department reveals a bilateral facet dislocation of C5 on
C6. The on-field intervention most likely to cause a neurologic injury is

A. failure to place a hard cervical collar.

B. helmet removal prior to examination.
C. transfer to a spine board prior to transport.
D. log-rolling the athlete to the supine position.

Correct answer: B

 Discussion

Complete immobilization of the cervical spine is critical for athletes with a suspected cervical spine or
spinal cord injury. The spinal cord in the subaxial spine is especially sensitive to motion, and removal of
protective gear such as the helmet and shoulder pads presents an unacceptable risk for progressive
neurologic injury in the setting of a potentially unstable cervical spine injury. Removal of the face mask
alone is typically performed to improve access to an athlete's airway. Protective equipment often
prevents proper placement of a hard cervical collar, and the spine board offers a variety of options for
safe cervical spine immobilization of helmeted athletes without a hard cervical collar. The log-roll and
lift-and-slide techniques allow for the safe transfer of an athlete to a spine board while maintaining
appropriate manual stabilization of the cervical spine.

 Recommended Readings

Rihn JA, Anderson DT, Lamb K, Deluca PF, Bata A, Marchetto PA, Neves N,Vaccaro AR.
Cervical spine injuries in American football. Sports Med. 2009;39(9):697-708. doi:
10.2165/11315190-000000000-00000. PubMed

Mall NA, Buchowski J, Zebala L, Brophy RH, Wright RW, Matava MJ. Spine and axial skeleton
injuries in the National Football League. Am J Sports Med. 2012 Aug;40(8):1755-61. doi:
10.1177/0363546512448355. Epub 2012 May 30. Erratum in:Am J Sports Med. 2013
Apr;41(4):NP21. Brophy, Robert H [added]. PubMed
Boden BP, Tacchetti RL, Cantu RC, Knowles SB, Mueller FO. Catastrophic cervical spine
injuries in high school and college football players. Am J Sports Med. 2006 Aug;34(8):1223-32.
Epub 2006 Jun 30. PubMed

Question 55 of 100

Figures 1 and 2 are the radiographs of a 24-year-old male wrestler who underwent surgery for recurrent
shoulder dislocations using coracoid autograft. At his first postoperative visit, the patient complains of
decreased sensation on the lateral aspect of his forearm. The patient’s symptoms are most likely due to
injury of the

Figure 1 Figure 2

A. axillary nerve.
B. musculocutaneous nerve.
C. median nerve.
D. radial nerve.
Correct answer: B

 Discussion

The patient has undergone a Latarjet procedure as shown in the radiographs. After harvesting the
coracoid graft, care must be taken to not place too much tension on or dissect excessively near the
musculocutaneous nerve. The nerve is encountered 5 cm distal to the coracoid as it enters the conjoint
tendon. The lateral antebrachial cutaneous nerve is the terminal branch of the musculocutaneous nerve
and; therefore, injury can cause decreased sensation in the lateral forearm.

 Recommended Readings

Hovelius L, Körner L, Lundberg B, Akermark C, Herberts P, Wredmark T, Berg E. The coracoid

transfer for recurrent dislocation of the shoulder. Technical aspects of the Bristow-Latarjet
procedure. J Bone Joint Surg Am. 1983 Sep;65(7):926-34. PubMed

Griesser MJ, Harris JD, McCoy BW, Hussain WM, Jones MH, Bishop JY, Miniaci A.
Complications and re-operations after Bristow-Latarjet shoulder stabilization: a systematic
review. J Shoulder Elbow Surg. 2013 Feb;22(2):286-92. doi: 10.1016/j.jse.2012.09.009. PubMed

Question 56 of 100

A 19-year-old running back lands directly on his anterior knee after being tackled. He has mild anterior
knee pain, a trace effusion, a 2+ posterior drawer, a grade 1+ stable Lachman, no valgus laxity, and
negative dial tests at 30° and 90°. What is the best treatment strategy at this time?

A. Physical therapy with a focus on quadriceps strengthening

B. Physical therapy and delayed posterior cruciate ligament (PCL) reconstruction
C. PCL reconstruction
D. PCL and posterolateral corner reconstruction
Correct answer: A

 Discussion

This patient has likely sustained an isolated PCL injury. The examination is consistent with a grade II
injury to the PCL. In this scenario, the best initial option is nonsurgical treatment and return to play as
symptoms subside and strength improves. Physical therapy with a focus on quadriceps strengthening
and delayed PCL reconstruction is not the answer because this patient can likely be treated without
surgery. The absence of valgus laxity and negative dial testing findings suggest that an injury to the
posteromedial and posterolateral corners has not occurred. Initial nonsurgical treatment is indicated for
this patient. If he completes rehabilitation and experiences persistent disability with anterior and/or
medial knee discomfort or senses the knee is "loose," PCL reconstruction should be considered at that
time.

 Recommended Readings

Shelbourne KD, Davis TJ, Patel DV. The natural history of acute, isolated, nonoperatively
treated posterior cruciate ligament injuries. A prospective study. Am J Sports Med. 1999 May-
Jun;27(3):276-83. PubMed

McAllister DR, Petrigliano FA. Diagnosis and treatment of posterior cruciate ligament injuries.
Curr Sports Med Rep. 2007 Oct;6(5):293-9. PubMed

Question 57 of 100

Figures 1 and 2 are the radiographs of a 55-year-old man who has a 3-year history of right shoulder pain.
He has maximized nonoperative management and is interested in operative treatment. He had an open
Bankart repair 20 years ago and did well until a few years ago. What is most important to know when
deciding on the best surgical treatment for this patient?
 Figure 1 Figure 2

A. Range of motion
B. Infraspinatus strength
C. Activity level
D. Quality of the subscapularis

Correct answer: D

 Discussion

The radiographs show severe osteoarthritis of the shoulder. The best surgical option would be an
arthroplasty. The major determining factor for which type of arthroplasty to choose is the integrity of
the rotator cuff tendons. Although the radiographs do not reveal any obvious signs of rotator cuff
failure, the patient had had an open Bankart 20 years ago. The integrity of the subscapularis tendon
following a previous open shoulder procedure is crucial in deciding which type of arthroplasty to
consider. Range of motion and infraspinatus strength do not affect the decision-making process,
assuming the rotator cuff is intact. Activity level can be important when deciding whether to proceed
with an arthroplasty, but it is not as important as the rotator cuff integrity when choosing which
arthroplasty to use.
  Recommended Readings

Randelli P, Randelli F, Compagnoni R, Cabitza P, Ragone V, Pulici L, Banfi G. Revision reverse

shoulder arthroplasty in failed shoulder arthroplasties for rotator cuff deficiency. Joints. 2015 Jun
8;3(1):31-7. eCollection 2015 Jan-Mar. PubMed

Singh JA, Sperling JW, Cofield RH. Revision surgery following total shoulder arthroplasty:
analysis of 2588 shoulders over three decades (1976 to 2008). J Bone Joint Surg Br. 2011
Nov;93(11):1513-7. doi: 10.1302/0301-620X.93B11.26938. PubMed

Question 58 of 100

A 47-year-old man who is an avid tennis player and laborer has had one year of shoulder pain and
weakness. His pain occurs at night and radiates to the deltoid laterally. The patient denies any anterior
based pain. He reports no prior surgeries and has been managed with steroid injections and physical
therapy. On examination, he has full passive motion with significant weakness with external rotation.
His neurologic examination is unremarkable. MRI evaluation reveals a posterior-superior rotator cuff
tear with Goutallier grade 4 fatty infiltrate in the supraspinatus and infraspinatus with retraction beyond
the glenoid. He is concerned about the lack of rotation of his arm and reports that this disability creates
significant disability with his occupation as a mason. What is the best next step?

A. Shoulder scope and subacromial decompression

B. Tendon transfer
C. Total shoulder arthroplasty
D. Reverse total shoulder arthroplasty

Correct answer: B

 Discussion

In younger active patients, tendon transfer is considered a preferable treatment option. The patient has
failed a course of nonoperative management. Subacromial decompression may offer pain relief but may
not be advisable in a patient with rotator cuff deficient shoulder. A total shoulder arthroplasty requires
functionality of the supraspinatus and infraspinatus. A reverse total shoulder is an option to alleviate
pain and perhaps improve forward flexion height and strength; however, reverse arthroplasty would not
improve external rotation in this patient, and there is concern for longevity of the implant in younger
patient populations.

 Recommended Readings

Elhassan BT, Cox RM, Shukla DR, Lee J, Murthi AM, Tashjian RZ, Abboud JA. Management
of Failed Rotator Cuff Repair in Young Patients. J Am Acad Orthop Surg. 2017
Nov;25(11):e261-e271. Full text

Omid R, Lee B. Tendon transfers for irreparable rotator cuff tears. J Am Acad Orthop Surg. 2013
Aug;21(8):492-501. Full text

Question 59 of 100

A 24-year-old collegiate pitcher has had increasing pain over his medial elbow for 3 months. He has
point tenderness over his medial epicondyle and reproduction of his symptoms with a valgus stress test.
Which phase of the throwing cycle shown in Figure 1 will most likely reproduce his symptoms?

Reproduced with permission from Poss R (ed): Orthopaedic Knowledge Update 3. Rosemont, IL. American
Academy of Orthopaedic Surgeons, 1990, pp 293-302.

Figure 1

A. A
B. B
C. C
 D. D

Correct answer: C

 Discussion

This patient is experiencing soreness over his medial (ulnar) collateral ligament. Valgus overload is likely
to reproduce his symptoms and is most pronounced during the late cocking phase of the throwing cycle.
In windup, very little elbow torque is required. In early cocking, the arm is getting loaded, and maximum
valgus is not yet achieved at the elbow. In acceleration and deceleration, more force is generated at the
level of the shoulder joint.

 Recommended Readings

Safran MR. Ulnar collateral ligament injury in the overhead athlete: diagnosis and treatment.
Clin Sports Med. 2004 Oct;23(4):643-63, x. PubMed

Safran M, Ahmad CS, Elattrache NS. Ulnar collateral ligament of the elbow. Arthroscopy. 2005
Nov;21(11):1381-95. PubMed

Question 60 of 100

Figure 1 is the MR image of a 36-year-old athlete who is tackled from behind and falls forward onto his
left knee. He has pain, swelling, and stiffness. Examination includes a moderate effusion, positive
quadriceps active test, and normal Lachman test finding.

The injured structure is composed of an

 Figure 1

A. anterolateral bundle that is tight in flexion and a posteromedial bundle that is tight in extension.
B. anterolateral bundle that is tight in extension and a posteromedial bundle that is tight in flexion.
C. anteromedial bundle that is tight in flexion and a posterolateral bundle that is tight in extension.
D. anteromedial bundle that is tight in extension and a posterolateral bundle that is tight in flexion.

Correct answer: A

 Discussion

The clinical description and MR image point to an injury to the posterior cruciate ligament (PCL). This
ligament is thought to be primarily composed of anterolateral and posteromedial bundles, with the
former tightening in flexion and the latter in extension. Because of alterations in knee kinematics and
increased varus alignment in PCL insufficiency, contact stresses and cartilage loads increase in the
patellofemoral and medial compartments. Although good outcomes may be obtained with transtibial,
open inlay, and arthroscopic inlay techniques, one major difference is the creation of the “killer-turn”
during the transtibial approach. This sharp turn in the graft as it emerges from the tibia appears to lead
to more pronounced attenuation and thinning of the graft during cyclic loading.
The scenario describes a patient with chronic PCL and posterolateral corner (PLC) injury, as evidenced by
the varus thrust and abnormal Dial test finding. A valgus-producing osteotomy may be effective, and, in
fact, may be the only treatment necessary to address chronic PLC injury. Accordingly, an opening lateral
osteotomy would not be appropriate. Of the remaining responses, an osteotomy that increases tibial
slope would also address the PCL deficiency by reducing posterior tibial sag.

Vascular injury is an uncommon, but potentially devastating, complication associated with PCL surgery
and may occur regardless of the technique used. Numerous strategies have been described to reduce
the risk, including use of a posteromedial accessory incision to allow finger retraction of the popliteal
neurovascular bundle, oscillating drills to prevent excessive soft-tissue entanglement, and tapered
(rather than square) drill bits that may minimize cut-out of sharp edges as drilling reaches the posterior
tibial cortex. Knee extension lessens, rather than increases, the distance between the posterior tibia and
the neurovascular bundle and increases, not lessens, risk for vascular injury.

 Recommended Readings

Zawodny SR, Miller MD. Complications of posterior cruciate ligament surgery. Sports Med
Arthrosc. 2010 Dec;18(4):269-74. doi: 10.1097/JSA.0b013e3181f2f4c2. PubMed

Arthur A, LaPrade RF, Agel J. Proximal tibial opening wedge osteotomy as the initial treatment
for chronic posterolateral corner deficiency in the varus knee: a prospective clinical study. Am J
Sports Med. 2007 Nov;35(11):1844-50. Epub 2007 Aug 27. PubMed

Giffin JR, Stabile KJ, Zantop T, Vogrin TM, Woo SL, Harner CD. Importance of tibial slope for
stability of the posterior cruciate ligament deficient knee. Am J Sports Med. 2007
Sep;35(9):1443-9. Epub 2007 Jul 19. PubMed

Matava MJ, Ellis E, Gruber B. Surgical treatment of posterior cruciate ligament tears: an
evolving technique. J Am Acad Orthop Surg. 2009 Jul;17(7):435-46. Full text

Voos JE, Mauro CS, Wente T, Warren RF, Wickiewicz TL. Posterior cruciate ligament:
anatomy, biomechanics, and outcomes. Am J Sports Med. 2012 Jan;40(1):222-31. doi:
10.1177/0363546511416316. Epub 2011 Jul 29. PubMed

Question 61 of 100

Figure 1 is the MR image of a 36-year-old athlete who is tackled from behind and falls forward onto his
left knee. He has pain, swelling, and stiffness. Examination includes a moderate effusion, positive
quadriceps active test, and normal Lachman test finding.
Left untreated, injury to this structure most likely will lead to degenerative changes in

Figure 1

A. medial and lateral compartments.

B. medial and patellofemoral compartments.
C. lateral and patellofemoral compartments.
D. the patellofemoral compartment only.

Correct answer: B

 Discussion

The clinical description and MR image point to an injury to the posterior cruciate ligament (PCL). This
ligament is thought to be primarily composed of anterolateral and posteromedial bundles, with the
former tightening in flexion and the latter in extension. Because of alterations in knee kinematics and
increased varus alignment in PCL insufficiency, contact stresses and cartilage loads increase in the
patellofemoral and medial compartments. Although good outcomes may be obtained with transtibial,
open inlay, and arthroscopic inlay techniques, one major difference is the creation of the “killer-turn”
during the transtibial approach. This sharp turn in the graft as it emerges from the tibia appears to lead
to more pronounced attenuation and thinning of the graft during cyclic loading.

The scenario describes a patient with chronic PCL and posterolateral corner (PLC) injury, as evidenced by
the varus thrust and abnormal Dial test finding. A valgus-producing osteotomy may be effective, and, in
fact, may be the only treatment necessary to address chronic PLC injury. Accordingly, an opening lateral
osteotomy would not be appropriate. Of the remaining responses, an osteotomy that increases tibial
slope would also address the PCL deficiency by reducing posterior tibial sag.

Vascular injury is an uncommon, but potentially devastating, complication associated with PCL surgery
and may occur regardless of the technique used. Numerous strategies have been described to reduce
the risk, including use of a posteromedial accessory incision to allow finger retraction of the popliteal
neurovascular bundle, oscillating drills to prevent excessive soft-tissue entanglement, and tapered
(rather than square) drill bits that may minimize cut-out of sharp edges as drilling reaches the posterior
tibial cortex. Knee extension lessens, rather than increases, the distance between the posterior tibia and
the neurovascular bundle and increases, not lessens, risk for vascular injury.

 Recommended Readings

Zawodny SR, Miller MD. Complications of posterior cruciate ligament surgery. Sports Med
Arthrosc. 2010 Dec;18(4):269-74. doi: 10.1097/JSA.0b013e3181f2f4c2. PubMed

Arthur A, LaPrade RF, Agel J. Proximal tibial opening wedge osteotomy as the initial treatment
for chronic posterolateral corner deficiency in the varus knee: a prospective clinical study. Am J
Sports Med. 2007 Nov;35(11):1844-50. Epub 2007 Aug 27. PubMed

Giffin JR, Stabile KJ, Zantop T, Vogrin TM, Woo SL, Harner CD. Importance of tibial slope for
stability of the posterior cruciate ligament deficient knee. Am J Sports Med. 2007
Sep;35(9):1443-9. Epub 2007 Jul 19. PubMed

Matava MJ, Ellis E, Gruber B. Surgical treatment of posterior cruciate ligament tears: an
evolving technique. J Am Acad Orthop Surg. 2009 Jul;17(7):435-46. Full text

Voos JE, Mauro CS, Wente T, Warren RF, Wickiewicz TL. Posterior cruciate ligament:
anatomy, biomechanics, and outcomes. Am J Sports Med. 2012 Jan;40(1):222-31. doi:
10.1177/0363546511416316. Epub 2011 Jul 29. Review. PubMed

Question 62 of 100
Figure 1 is the MR image of a 36-year-old athlete who is tackled from behind and falls forward onto his
left knee. He has pain, swelling, and stiffness. Examination includes a moderate effusion, positive
quadriceps active test, and normal Lachman test finding.

If the patient chooses surgical reconstruction, he should be advised that, when compared with a
transtibial technique, the tibial inlay technique has been shown to provide

Figure 1

A. stronger initial graft fixation.

B. more anatomic positioning of tibial fixation.
C. more natural knee kinematics during deep flexion.
D. more graft protection during cyclic loading.

Correct answer: D

 Discussion

The clinical description and MR image point to an injury to the posterior cruciate ligament (PCL). This
ligament is thought to be primarily composed of anterolateral and posteromedial bundles, with the
former tightening in flexion and the latter in extension. Because of alterations in knee kinematics and
increased varus alignment in PCL insufficiency, contact stresses and cartilage loads increase in the
patellofemoral and medial compartments. Although good outcomes may be obtained with transtibial,
open inlay, and arthroscopic inlay techniques, one major difference is the creation of the “killer-turn”
during the transtibial approach. This sharp turn in the graft as it emerges from the tibia appears to lead
to more pronounced attenuation and thinning of the graft during cyclic loading.

The scenario describes a patient with chronic PCL and posterolateral corner (PLC) injury, as evidenced by
the varus thrust and abnormal Dial test finding. A valgus-producing osteotomy may be effective, and, in
fact, may be the only treatment necessary to address chronic PLC injury. Accordingly, an opening lateral
osteotomy would not be appropriate. Of the remaining responses, an osteotomy that increases tibial
slope would also address the PCL deficiency by reducing posterior tibial sag.

Vascular injury is an uncommon, but potentially devastating, complication associated with PCL surgery
and may occur regardless of the technique used. Numerous strategies have been described to reduce
the risk, including use of a posteromedial accessory incision to allow finger retraction of the popliteal
neurovascular bundle, oscillating drills to prevent excessive soft-tissue entanglement, and tapered
(rather than square) drill bits that may minimize cut-out of sharp edges as drilling reaches the posterior
tibial cortex. Knee extension lessens, rather than increases, the distance between the posterior tibia and
the neurovascular bundle and increases, not lessens, risk for vascular injury.

 Recommended Readings

Zawodny SR, Miller MD. Complications of posterior cruciate ligament surgery. Sports Med
Arthrosc. 2010 Dec;18(4):269-74. doi: 10.1097/JSA.0b013e3181f2f4c2. PubMed

Arthur A, LaPrade RF, Agel J. Proximal tibial opening wedge osteotomy as the initial treatment
for chronic posterolateral corner deficiency in the varus knee: a prospective clinical study. Am J
Sports Med. 2007 Nov;35(11):1844-50. Epub 2007 Aug 27. PubMed

Giffin JR, Stabile KJ, Zantop T, Vogrin TM, Woo SL, Harner CD. Importance of tibial slope for
stability of the posterior cruciate ligament deficient knee. Am J Sports Med. 2007
Sep;35(9):1443-9. Epub 2007 Jul 19. PubMed

Matava MJ, Ellis E, Gruber B. Surgical treatment of posterior cruciate ligament tears: an
evolving technique. J Am Acad Orthop Surg. 2009 Jul;17(7):435-46. Full text

Voos JE, Mauro CS, Wente T, Warren RF, Wickiewicz TL. Posterior cruciate ligament:
anatomy, biomechanics, and outcomes. Am J Sports Med. 2012 Jan;40(1):222-31. doi:
10.1177/0363546511416316. Epub 2011 Jul 29. PubMed
Question 63 of 100

Figure 1 is the MR image of a 36-year-old athlete who is tackled from behind and falls forward onto his
left knee. He has pain, swelling, and stiffness. Examination includes a moderate effusion, positive
quadriceps active test, and normal Lachman test finding.

This patient elects nonsurgical treatment and later experiences persistent instability. Examination
reveals an asymmetric Dial test finding and a varus thrust during ambulation. Which osteotomy and
correction appropriately addresses this chronic instability pattern?

Figure 1

A. Distal femoral/opening lateral wedge osteotomy

B. Distal femoral/closing lateral wedge osteotomy
C. High tibial osteotomy; opening medial wedge with increased tibial slope
D. High tibial osteotomy; closing lateral wedge with decreased tibial slope

Correct answer: C
  Discussion

The clinical description and MR image point to an injury to the posterior cruciate ligament (PCL). This
ligament is thought to be primarily composed of anterolateral and posteromedial bundles, with the
former tightening in flexion and the latter in extension. Because of alterations in knee kinematics and
increased varus alignment in PCL insufficiency, contact stresses and cartilage loads increase in the
patellofemoral and medial compartments. Although good outcomes may be obtained with transtibial,
open inlay, and arthroscopic inlay techniques, one major difference is the creation of the “killer-turn”
during the transtibial approach. This sharp turn in the graft as it emerges from the tibia appears to lead
to more pronounced attenuation and thinning of the graft during cyclic loading.

The scenario describes a patient with chronic PCL and posterolateral corner (PLC) injury, as evidenced by
the varus thrust and abnormal Dial test finding. A valgus-producing osteotomy may be effective, and, in
fact, may be the only treatment necessary to address chronic PLC injury. Accordingly, an opening lateral
osteotomy would not be appropriate. Of the remaining responses, an osteotomy that increases tibial
slope would also address the PCL deficiency by reducing posterior tibial sag.

Vascular injury is an uncommon, but potentially devastating, complication associated with PCL surgery
and may occur regardless of the technique used. Numerous strategies have been described to reduce
the risk, including use of a posteromedial accessory incision to allow finger retraction of the popliteal
neurovascular bundle, oscillating drills to prevent excessive soft-tissue entanglement, and tapered
(rather than square) drill bits that may minimize cut-out of sharp edges as drilling reaches the posterior
tibial cortex. Knee extension lessens, rather than increases, the distance between the posterior tibia and
the neurovascular bundle and increases, not lessens, risk for vascular injury.

 Recommended Readings

Zawodny SR, Miller MD. Complications of posterior cruciate ligament surgery. Sports Med
Arthrosc. 2010 Dec;18(4):269-74. doi: 10.1097/JSA.0b013e3181f2f4c2. PubMed

Arthur A, LaPrade RF, Agel J. Proximal tibial opening wedge osteotomy as the initial treatment
for chronic posterolateral corner deficiency in the varus knee: a prospective clinical study. Am J
Sports Med. 2007 Nov;35(11):1844-50. Epub 2007 Aug 27. PubMed

Giffin JR, Stabile KJ, Zantop T, Vogrin TM, Woo SL, Harner CD. Importance of tibial slope for
stability of the posterior cruciate ligament deficient knee. Am J Sports Med. 2007
Sep;35(9):1443-9. Epub 2007 Jul 19. PubMed

Matava MJ, Ellis E, Gruber B. Surgical treatment of posterior cruciate ligament tears: an
evolving technique. J Am Acad Orthop Surg. 2009 Jul;17(7):435-46. Full text
Voos JE, Mauro CS, Wente T, Warren RF, Wickiewicz TL. Posterior cruciate ligament:
anatomy, biomechanics, and outcomes. Am J Sports Med. 2012 Jan;40(1):222-31. doi:
10.1177/0363546511416316. Epub 2011 Jul 29. PubMed

Question 64 of 100

Figure 1 is the MR image of a 36-year-old athlete who is tackled from behind and falls forward onto his
left knee. He has pain, swelling, and stiffness. Examination includes a moderate effusion, positive
quadriceps active test, and normal Lachman test finding.

Risk for vascular injury during transtibial drilling for reconstruction of this injury is increased by

Figure 1

A. accessory incisions.
B. use of tapered drill bits.
C. use of oscillating drills.
D. greater knee extension.
Correct answer: D

 Discussion

The clinical description and MR image point to an injury to the posterior cruciate ligament (PCL). This
ligament is thought to be primarily composed of anterolateral and posteromedial bundles, with the
former tightening in flexion and the latter in extension. Because of alterations in knee kinematics and
increased varus alignment in PCL insufficiency, contact stresses and cartilage loads increase in the
patellofemoral and medial compartments. Although good outcomes may be obtained with transtibial,
open inlay, and arthroscopic inlay techniques, one major difference is the creation of the “killer-turn”
during the transtibial approach. This sharp turn in the graft as it emerges from the tibia appears to lead
to more pronounced attenuation and thinning of the graft during cyclic loading.

The scenario describes a patient with chronic PCL and posterolateral corner (PLC) injury, as evidenced by
the varus thrust and abnormal Dial test finding. A valgus-producing osteotomy may be effective, and, in
fact, may be the only treatment necessary to address chronic PLC injury. Accordingly, an opening lateral
osteotomy would not be appropriate. Of the remaining responses, an osteotomy that increases tibial
slope would also address the PCL deficiency by reducing posterior tibial sag.

Vascular injury is an uncommon, but potentially devastating, complication associated with PCL surgery
and may occur regardless of the technique used. Numerous strategies have been described to reduce
the risk, including use of a posteromedial accessory incision to allow finger retraction of the popliteal
neurovascular bundle, oscillating drills to prevent excessive soft-tissue entanglement, and tapered
(rather than square) drill bits that may minimize cut-out of sharp edges as drilling reaches the posterior
tibial cortex. Knee extension lessens, rather than increases, the distance between the posterior tibia and
the neurovascular bundle and increases, not lessens, risk for vascular injury.

 Recommended Readings

Zawodny SR, Miller MD. Complications of posterior cruciate ligament surgery. Sports Med
Arthrosc. 2010 Dec;18(4):269-74. doi: 10.1097/JSA.0b013e3181f2f4c2. PubMed

Arthur A, LaPrade RF, Agel J. Proximal tibial opening wedge osteotomy as the initial treatment
for chronic posterolateral corner deficiency in the varus knee: a prospective clinical study. Am J
Sports Med. 2007 Nov;35(11):1844-50. Epub 2007 Aug 27. PubMed

Giffin JR, Stabile KJ, Zantop T, Vogrin TM, Woo SL, Harner CD. Importance of tibial slope for
stability of the posterior cruciate ligament deficient knee. Am J Sports Med. 2007
Sep;35(9):1443-9. Epub 2007 Jul 19. PubMed
Matava MJ, Ellis E, Gruber B. Surgical treatment of posterior cruciate ligament tears: an
evolving technique. J Am Acad Orthop Surg. 2009 Jul;17(7):435-46. Full text

Voos JE, Mauro CS, Wente T, Warren RF, Wickiewicz TL. Posterior cruciate ligament:
anatomy, biomechanics, and outcomes. Am J Sports Med. 2012 Jan;40(1):222-31. doi:
10.1177/0363546511416316. Epub 2011 Jul 29. PubMed

Question 65 of 100

A 15-year-old male ice hockey player is hit in the chest by a puck and immediately falls to the ground
unconscious. What has been shown to predict survival in the treatment of this condition?

A. Use of chest protectors

B. Time to initiation of chest compressions
C. Lower velocity of the puck at impact
D. Time to defibrillation

Correct answer: D

 Discussion

The hockey player is suffering from commotio cordis, in which a cardiac arrhythmia occurs after a
sudden blunt impact to the chest. Treatment of commotio cordis is defibrillation. As the time to
defibrillation increases, the likelihood of survival decreases. In animal models, chest protectors have not
shown efficacy against ventricular fibrillation. The velocity of the projectile (most commonly baseball,
hockey puck or lacrosse ball) has also not been shown to alter survival.

 Recommended Readings

Maron BJ, Poliac LC, Kaplan JA, Mueller FO. Blunt impact to the chest leading to sudden death
from cardiac arrest during sports activities. N Engl J Med. 1995 Aug 10;333(6):337-42. PubMed

Weinstock J, Maron BJ, Song C, Mane PP, Estes NA 3rd, Link MS. Failure of commercially
available chest wall protectors to prevent sudden cardiac death induced by chest wall blows in an
experimental model of commotio cordis. Pediatrics. 2006 Apr;117(4):e656-62. Epub 2006 Mar
1. PubMed

Question 66 of 100

Figures 1 through 6 reveal the radiographs and MR images of a 30-year-old man who has a 1-year
history of atraumatic medial-sided left knee pain refractory to nonsurgical measures. What is the most
appropriate treatment?

Figure 1 Figure 2 Figure 3

 Figure 4 Figure 5 Figure 6

A. Distal femoral varus osteotomy

B. Autologous chondrocyte implantation (ACI)
C. Fresh osteochondral allograft (OCA) transplantation
D. Arthroscopic microfracture

Correct answer: C

 Discussion

The images illustrate a large unstable osteochondral lesion of the medial femoral condyle. Radiographs
and MR images clearly show deep subchondral bone involvement. The appropriate choice of surgery is
OCA transplantation, which is indicated for primary treatment of large cartilage lesions, osteochondral
lesions, and salvage procedure from failed prior cartilage surgery. Correction of mechanical axis
malalignment, ligamentous insufficiency, and meniscal deficiency should also be addressed. ACI alone or
an arthroscopic microfracture procedure would not address the bone defect, leaving an uneven articular
surface. Although an osteotomy may be a viable choice, a distal femoral varus osteotomy would
increase the contact pressure in the medial compartment and worsen the situation.

The histologic anatomy of articular cartilage is well described. The superficial layer or lamina splendens
contains a small amount of proteoglycan with collagen fibrils arranged parallel to the articular surface.
In contrast, the deep zone contains the largest-diameter collagen fibrils, oriented perpendicular to the
joint surface, and the highest concentration of proteoglycans.

 Recommended Readings

Browne JE, Branch TP. Surgical alternatives for treatment of articular cartilage lesions. J Am
Acad Orthop Surg. 2000 May-Jun;8(3):180-9. Review. Full text

Sherman SL, Garrity J, Bauer K, Cook J, Stannard J, Bugbee W. Fresh osteochondral allograft
transplantation for the knee: current concepts. J Am Acad Orthop Surg. 2014 Feb;22(2):121-33.
doi: 10.5435/JAAOS-22-02-121. Review. Erratumin: J Am Acad Orthop Surg. 2014
Mar;22(3):199. Full text
Question 67 of 100

A hockey player had a puck hit his foot. Radiographs taken immediately after the game were negative.
He still has persistent pain 5 days after the injury and difficulty weight bearing. What is the best next
step?

A. Repeat radiographs
B. Full clearance to return to play
C. Bone scan
D. MRI scan

Correct answer: D

 Discussion

Ice hockey injuries demand a thorough assessment because they have the potential to be significant. In
hockey players, bone injuries in the foot and ankle can be missed or improperly diagnosed through
routine radiographic imaging. MRI can display bone injuries that are not found radiographically; this is
because some fractures and contusions involve the medial ankle and midfoot bones.

 Recommended Readings

Baker JC, Hoover EG, Hillen TJ, Smith MV, Wright RW, Rubin DA. Subradiographic Foot and
Ankle Fractures and Bone Contusions Detected by MRI in Elite Ice Hockey Players. Am J Sports
Med. 2016 May;44(5):1317-23. doi: 10.1177/0363546515626181. Epub 2016 Feb 17. PubMed

Polites SF, Sebastian AS, Habermann EB, Iqbal CW, Stuart MJ, Ishitani MB. Youth ice hockey
injuries over 16 years at a pediatric trauma center. Pediatrics. 2014 Jun;133(6):e1601-7. doi:
10.1542/peds.2013-3628. PubMed

Question 68 of 100
A 19-year-old male collegiate rower has a 3-month history of right shoulder pain. There was no inciting
trauma prior to the onset of his pain. He also complains of weakness, particularly in abduction and
overhead activity. Examination reveals no range-of-motion deficits. Strength testing of the right
shoulder demonstrates 4/5 motor strength in forward elevation and abduction. His Beighton
hypermobility score is 3/9. Figure 1 shows his scapular position during a wall pushup maneuver. An EMG
would likely reveal damage to what nerve?

Figure 1

A. Long thoracic nerve

B. Cranial nerve XI (spinal accessory nerve)
C. Suprascapular nerve
D. Axillary nerve

Correct answer: A

 Discussion

Figure 1 reveals medial scapular winging secondary to weakness of the serratus anterior, which is
innervated by the long thoracic nerve. Damage to the long thoracic nerve can occur via repetitive
stretching, compression, or iatrogenic injury during a surgical procedure. Lateral thoracic winging is
caused by weakness of the trapezius, which is innervated by cranial nerve XI (spinal accessory nerve).
The direction of scapular winging is judged by the upper medial border of the scapula. Observation of a
period of at least 6 months with serratus anterior strengthening while the nerve recovers is the
mainstay of treatment for medial scapular winging.

 Recommended Readings
Nawa S. Scapular Winging Secondary to Apparent Long Thoracic Nerve Palsy in a Young
Female Swimmer. J Brachial Plex Peripher Nerve Inj. 2015 Nov 6;10(1):e57-e61. eCollection
2015 Dec. PubMed

Gooding BW, Geoghegan JM, Wallace WA, Manning PA. Scapular Winging. Shoulder Elbow.
2014 Jan;6(1):4-11. doi: 10.1111/sae.12033. Epub 2013 Jul 15. PubMed

Question 69 of 100

Figure 1 is the MR image of a 14-year-old football player who injured his right knee during a game. He
describes feeling a "pop" and then needing help walking off the field. His knee is visibly swollen.

Knee range of motion is between 0° and 70°. What is the most appropriate treatment option?

Figure 1

A. Open reduction and internal fixation of the lateral condyle

B. Microfracture of the chondral defect
C. Immediate anterior cruciate ligament (ACL) reconstruction
D. Delayed ACL reconstruction

Correct answer: D
  Discussion

The MR image shows bone bruises (“kissing contusions”) consistent with an ACL tear. During the ACL
subluxation event, the posterolateral tibial plateau subluxes anteriorly, making contact with the mid
portion of the lateral femoral condyle and resulting in this characteristic bone bruise pattern on MRI.
Randomized clinical trials comparing early accelerated versus nonaccelerated rehabilitation programs
have demonstrated no significant differences in long-term results with regard to function, reinjury, and
successful return to play. These studies did not address timing of return to play with an early
accelerated rehabilitation program. At 2 and 3 years postsurgically, there are no differences in laxity,
number of graft failures, or KOOS scores.

 Recommended Readings

Beynnon BD, Johnson RJ, Naud S, Fleming BC, Abate JA, Brattbakk B, Nichols CE.
Accelerated versus nonaccelerated rehabilitation after anterior cruciate ligament reconstruction: a
prospective, randomized, double-blind investigation evaluating knee joint laxity using roentgen
stereophotogrammetric analysis. Am J Sports Med. 2011 Dec;39(12):2536-48. Epub 2011 Sep
27. PubMed

Bales CP, Guettler JH, Moorman CT 3rd. Anterior cruciate ligament injuries in children with
open physes: evolving strategies of treatment. Am J Sports Med. 2004 Dec;32(8):1978-85.
PubMed

Question 70 of 100

Figure 1 is the MR image of a 14-year-old football player who injured his right knee during a game. He
describes feeling a "pop" and then needing help walking off the field. His knee is visibly swollen.

The patient undergoes surgery to repair/reconstruct the damaged structure and has no postsurgical
complications and begins physical therapy rehabilitation. The boy and his parents stress they want to
“get the therapy over with as fast as possible" to expedite his return to sports, and the surgeon and
rehabilitation team consider their request. Compared with nonaccelerated rehabilitation, patients who
follow an early accelerated rehabilitation protocol experience
 Figure 1

A. increased laxity.
B. increased risk for graft failure.
C. no differences in long-term results.
D. lower Knee Injury and Osteoarthritis Outcome Score (KOOS).

Correct answer: C

 Discussion

The MR image shows bone bruises (“kissing contusions”) consistent with an ACL tear. During the ACL
subluxation event, the posterolateral tibial plateau subluxes anteriorly, making contact with the mid
portion of the lateral femoral condyle and resulting in this characteristic bone bruise pattern on MRI.
Randomized clinical trials comparing early accelerated versus nonaccelerated rehabilitation programs
have demonstrated no significant differences in long-term results with regard to function, reinjury, and
successful return to play. These studies did not address timing of return to play with an early
accelerated rehabilitation program. At 2 and 3 years postsurgically, there are no differences in laxity,
number of graft failures, or KOOS scores.

 Recommended Readings
Beynnon BD, Johnson RJ, Naud S, Fleming BC, Abate JA, Brattbakk B, Nichols CE.
Accelerated versus nonaccelerated rehabilitation after anterior cruciate ligament reconstruction: a
prospective, randomized, double-blind investigation evaluating knee joint laxity using roentgen
stereophotogrammetric analysis. Am J Sports Med. 2011 Dec;39(12):2536-48. Epub 2011 Sep
27. PubMed

Bales CP, Guettler JH, Moorman CT 3rd. Anterior cruciate ligament injuries in children with
open physes: evolving strategies of treatment. Am J Sports Med. 2004 Dec;32(8):1978-85.
PubMed

Question 71 of 100

Figure 1 is the MRI scan of a 19-year-old man who has an acute anterior shoulder dislocation. The bony
fragment occupies 10% of the glenoid articular surface. What is the most appropriate treatment?

Figure 1

A. Open structural iliac crest graft

B. Open reduction and internal fixation
C. Arthroscopic coracoid transfer
D. Arthroscopic repair incorporating the bone lesion

Correct answer: D
  Discussion

The MRI scan shows a bony Bankart lesion involving <20% of the glenoid joint surface. A recent series
reported high success rates after arthroscopic treatment when the defect is incorporated into the
repair. Anterior bony deficiencies occupying >25% to >30% of the glenoid joint surface treated with soft-
tissue repair only are associated with high recurrence rates. In these patients, an open or arthroscopic
coracoid transfer or structural iliac crest graft should be considered. Open reduction and internal
fixation has been reported for treatment of large acute glenoid rim fractures but is not recommended
for recurrent anterior shoulder instability in the setting of a 10% glenoid rim fracture.

 Recommended Readings

Getz CL, Buzzell JE, Krishnan SG. Shoulder instability and rotator cuff tears. In: Flynn JM, ed.
Orthopaedic Knowledge Update 10. Rosemont, IL: American Academy of Orthopaedic
Surgeons; 2011;299-314.

Sugaya H, Moriishi J, Kanisawa I, Tsuchiya A. Arthroscopic osseous Bankart repair for chronic
recurrent traumatic anterior glenohumeral instability. J Bone Joint Surg Am. 2005
Aug;87(8):1752-60. PubMed

Question 72 of 100

A 14-year-old gymnast misses her dismount off of the uneven bars, hits the mat face first, and loses
consciousness for about 15 seconds. She is dazed and confused for several minutes. She does not
complain of pain; numbness; or weakness, and she is moving all extremities without deficit. The athlete
and coach want to go back to competition that day. How should they be advised?

A. Concussion precludes same-day return to play.

B. Order an urgent MRI scan; if findings are normal, she can return to competition.
C. Order neurocognitive testing; if findings are normal, she can return to competition.
D. If she is symptom-free after a 15-minute exertional test, she may return to competition.

Correct answer: A
  Discussion

The National Collegiate Athletic Association's (NCAA) 2011 revised health and safety guidelines
regarding concussion management recommend no return to play on the same day of an injury. In
particular, athletes sustaining a concussion should not return to play the same day as their injury. Before
resuming exercise, athletes must be asymptomatic or returned to baseline symptoms at rest and have
no symptoms with cognitive effort. They must be off of medications that could mask or alter concussion
symptoms. Neurocognitive testing can be a helpful tool in determining brain function even after all
symptoms of concussion have resolved. With a comparison baseline test, this evaluation, in conjunction
with a physician's examination, may reduce risk for second impact syndrome. The athlete's clinical
neurologic examination findings (cognitive, cranial nerve, balance testing) must return to baseline
before resuming exercise. Research has shown that among youth athletes, it may take longer for tested
functions to return to baseline (compared with the recovery rate in adult athletes). Brain MRI scan has
no role in evaluating athletes for return to play in this situation.

 Recommended Readings

Herring SA, Cantu RC, Guskiewicz KM, Putukian M, Kibler WB, Bergfeld JA, Boyajian-
O'Neill LA, Franks RR, Indelicato PA. Concussion (mild traumatic brain injury) and the team
physician: a consensus statement--2011 update. Med Sci Sports Exerc. 2011 Dec;43(12):2412-
22. PubMed

McCrory P, Johnston K, Meeuwisse W, Aubry M, Cantu R, Dvorak J, Graf-Baumann T, Kelly J,

Lovell M, Schamasch P. Summary and agreement statement of the 2nd International Conference
on Concussion in Sport, Prague 2004. Br J Sports Med. 2005 Apr;39(4):196-204. PubMed

Question 73 of 100

Figures 1 through 3 are the weight-bearing radiograph and MRI scans of a 27-year-old man who twisted
his knee coming down awkwardly from a lay-up during a basketball game. He felt a sharp stabbing pain
in the posterior aspect of his knee at the time of the injury. Physical examination reveals a trace
effusion, full range of motion but pain with hyperflexion >90° degrees and tenderness over the affected
joint line. What is the most appropriate treatment at this time?
 Figure 1 Figure 2 Figure 3

A. Lateral meniscus repair

B. Corticosteroid injection and physical therapy
C. Medial meniscus repair
D. Unloader brace

Correct answer: C

 Discussion

The MRI scan shows a posterior horn medial meniscus root avulsion with bony edema at the tibial root
insertion. The radiograph shows no significant degenerative changes. If left untreated, posterior
meniscal root tears lead to progressive degenerative changes as a result of the altered tibiofemoral
contact pressures and areas. Nonsurgical treatment including injections, physical therapy, and unloader
braces are more appropriate in the older patient with pre-existing advanced degenerative changes.

 Recommended Readings

Steadman JR, Matheny LM, Singleton SB, Johnson NS, Rodkey WG, Crespo B, Briggs KK.
Meniscus suture repair: minimum 10-year outcomes in patients younger than 40 years compared
with patients 40 and older. Am J Sports Med. 2015 Sep;43(9):2222-7. doi:
10.1177/0363546515591260. Epub 2015 Jul 17. PubMed

LaPrade RF, Matheny LM, Moulton SG, James EW, Dean CS. Posterior Meniscal Root Repairs:
Outcomes of an Anatomic Transtibial Pull-Out Technique. Am J Sports Med. 2017
Mar;45(4):884-891. doi: 10.1177/0363546516673996. Epub 2016 Dec 5. PubMed

Furumatsu T, Kodama Y, Kamatsuki Y, Hino T, Okazaki Y, Ozaki T. Meniscal Extrusion

Progresses Shortly after the Medial Meniscus Posterior Root Tear. Knee Surg Relat Res. 2017
Dec 1;29(4):295-301. doi: 10.5792/ksrr.17.027. PubMed

Question 74 of 100

A 26-year-old weightlifter has increasing pain in his left shoulder for 4 months. Nonsurgical treatment
consisting of anti-inflammatory medication, corticosteroid injections, and rest fails to alleviate his
symptoms. He undergoes an arthroscopic distal clavicle resection with excision of the distal 8 mm of
clavicle (Mumford procedure). Three months after surgery, he reports mild pain and popping by his
clavicle. His clavicle demonstrates mild posterior instability on examination without any obvious
deformity on his radiographs. What structures were compromised during his excision?

A. Anterior and superior acromioclavicular joint ligaments

B. Posterior and superior acromioclavicular joint ligaments
C. Conoid ligament
D. Trapezoid ligament

Correct answer: B

 Discussion

The posterior and superior acromioclavicular ligaments provide the most restraint to posterior
translation of the acromioclavicular joint and must be preserved during a Mumford procedure. Anterior
and superior acromioclavicular joint ligaments are the opposite of the preferred response and prevent
anterior translation of the clavicle. Injuries to the conoid and trapezoid ligaments are more pronounced
with grade III or higher acromioclavicular separations, with superior migration of the clavicle relative to
the acromion.
  Recommended Readings

Strauss EJ, Barker JU, McGill K, Verma NN. The evaluation and management of failed distal
clavicle excision. Sports Med Arthrosc. 2010 Sep;18(3):213-9. PubMed

Nuber GW, Bowen MK. Arthroscopic treatment of acromioclavicular joint injuries and results.
Clin Sports Med. 2003 Apr;22(2):301-17. PubMed

Question 75 of 100

Augmentation of a Broström repair with the mobilized lateral portion of the extensor retinaculum
(Gould modification) is expected to produce

A. higher risk for iatrogenic nerve injury.

B. decreased ankle range of motion 6 weeks after surgery.
C. no significant biomechanical difference in initial ankle stability.
D. a significantly lower incidence of osteoarthritis on long-term follow-up.

Correct answer: C

 Discussion

Multiple biomechanical studies have investigated the contribution of the Gould modification with the
Broström anatomic repair for chronic ankle instability. No studies to date have demonstrated a
statistically significant difference in initial ankle stability with inclusion of the Gould modification or
augmentation of the repair with a mobilized lateral portion of the extensor retinaculum. No clear
association exists between the Broström-Gould repair technique and risk for nerve injury, postsurgical
range of motion, or incidence of osteoarthritis on long-term follow-up.

 Recommended Readings

Wainright WB, Spritzer CE, Lee JY, Easley ME, DeOrio JK, Nunley JA, DeFrate LE. The effect
of modified Broström-Gould repair for lateral ankle instability on in vivo tibiotalar kinematics.
Am J Sports Med. 2012 Sep;40(9):2099-104. doi:10.1177/0363546512454840. Epub 2012 Aug
10. PubMed
Behrens SB, Drakos M, Lee BJ, Paller D, Hoffman E, Koruprolu S, DiGiovanni CW.
Biomechanical analysis of Brostrom versus Brostrom-Gould lateral ankle instability repairs.
Foot Ankle Int. 2013 Apr;34(4):587-92. doi:10.1177/1071100713477622. Epub 2013 Feb 7.
PubMed

Question 76 of 100

A 12-year-old boy has a head-on head collision while playing soccer. He had no loss of consciousness but
has persistent headaches for 2 weeks. The patient is now back to school and has no headaches. What is
the best next step?

A. Return to full soccer activity

B. Start light aerobic activity
C. Obtain baseline neuropsychological testing
D. MRI scan of the brain

Correct answer: B

 Discussion

Mild traumatic brain injury is common in the adolescent child. Neuropsychological examination is widely
used but, in this case, the patient is asymptomatic and has no baseline testing. There is a limited role for
MRI in the recovery process of concussions. Furthermore, higher levels of physical/cognitive activity
should be avoided due to their potential to increase total recovery time. In this scenario, a graduated
return to activity is most appropriate thus, the next appropriate step is to start light aerobic activity.

 Recommended Readings

Brown NJ, Mannix RC, O'Brien MJ, Gostine D, Collins MW, Meehan WP 3rd. Effect of
cognitive activity level on duration of post-concussion symptoms. Pediatrics. 2014
Feb;133(2):e299-304. doi: 10.1542/peds.2013-2125. Epub 2014 Jan 6. PubMed

Majerske CW, Mihalik JP, Ren D, Collins MW, Reddy CC, Lovell MR, Wagner AK.
Concussion in sports: postconcussive activity levels, symptoms, and neurocognitive
performance. J Athl Train. 2008 May-Jun;43(3):265-74. doi: 10.4085/1062-6050-43.3.265.
PubMed

Ruff RM. A friendly critique of neuropsychology: facing the challenges of our future. Arch Clin
Neuropsychol. 2003 Dec;18(8):847-64. PubMed

Question 77 of 100

Figure 1 is the MR image of a 43-year-old man who has left shoulder pain and weakness after a fall. An
examination reveals active forward elevation at 120° and positive Yergason and lift-off test examination
findings. Arthroscopy reveals that the articular surfaces of the glenohumeral joint have a normal
appearance without significant degenerative changes. What is the most appropriate treatment at this
time?

Figure 1

A. Rotator cuff repair and biceps tenodesis

B. Rotator cuff repair and loose body removal
C. Latissimus dorsi transfer
D. Bankart repair

Correct answer: A
  Discussion

The MR image shows medial subluxation of the biceps tendon, which can be confused with an articular
loose body. In the clinical scenario of biceps instability/subluxation, the rationale regarding tenodesis is
to address the painful dislocation and subluxation of the biceps tendon from the bicipital groove. Biceps
tendon subluxation is most frequently associated with subscapularis tendon pathology, which is
indicated by the MRI and by a positive lift-off test.

The MR image does not show a loose body or Bankart lesion. Patients with irreparable rotator cuff tears
with a severe external rotation deficit and a deficient teres minor may experience a better functional
result with latissimus dorsi transfer.

 Recommended Readings

Creech MJ, Yeung M, Denkers M, Simunovic N, Athwal GS, Ayeni OR. Surgical indications for
long head biceps tenodesis: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2014
Nov 23. [Epub ahead of print] PMID 25416963.

Boileau P, Baqué F, Valerio L, Ahrens P, Chuinard C, Trojani C. Isolated arthroscopic biceps

tenotomy or tenodesis improves symptoms in patients with massive irreparable rotator cuff tears.
J Bone Joint Surg Am. 2007 Apr;89(4):747-57. PubMed

Getz CL, Buzzell JE, Krishnan SG. Shoulder instability and rotator cuff tears. In: Flynn JM, ed.
Orthopaedic Knowledge Update 10. Rosemont, IL: American Academy of Orthopaedic
Surgeons; 2011;299-314.

Question 78 of 100

What factor highly correlates with poor outcomes after surgery for femoroacetabular impingement?

A. Age <20
B. Tonnis grade 2
C. Prominence of the femoral head in cam impingement
D. The patient is a professional athlete
Correct answer: B

 Discussion

A systematic review of case studies looking at the results of surgical treatment for femoroacetabular
impingement shows good results for most patients, with the exception of those with preoperative
radiographs showing osteoarthritis or Outerbridge grade III or grade IV cartilage damage noted
intraoperatively. Both Byrd and Jones and Philippon and associates have shown good surgical results for
this condition among professional athletes. Likewise, Fabricant and associates demonstrated good
surgical results among adolescent patients with an average age of 17.6 years.

 Recommended Readings

Ng VY, Arora N, Best TM, Pan X, Ellis TJ. Efficacy of surgery for femoroacetabular
impingement: a systematic review. Am J Sports Med. 2010 Nov;38(11):2337-45. Epub 2010
May 20. PubMed

Philippon M, Schenker M, Briggs K, Kuppersmith D. Femoroacetabular impingement in 45

professional athletes: associated pathologies and return to sport following arthroscopic
decompression. Knee Surg Sports Traumatol Arthrosc. 2007 Jul;15(7):908-14. Epub 2007 May
4. PubMed

Byrd JW, Jones KS. Arthroscopic management of femoroacetabular impingement in athletes. Am

J Sports Med. 2011 Jul;39 Suppl:7S-13S. PubMed

Fabricant PD, Heyworth BE, Kelly BT. Hip arthroscopy improves symptoms associated with
FAI in selected adolescent athletes. Clin Orthop Relat Res. 2012 Jan;470(1):261-9. Epub 2011
Aug 11. PubMed

Question 79 of 100

Figures 1 and 2 are the T2-weighted MR images of a 54-year-old woman with medial knee pain and
catching of 6 months’ duration. Which treatment option is most likely to be associated with a favorable
outcome?
 Figure 1 Figure 2

A. Physical therapy
B. Meniscal repair
C. Menisectomy
D. Reconstruction

Correct answer: B

 Discussion

MR images reveal a posterior horn root tear of the medial meniscus. LaPrade and associates found that
outcomes after posterior meniscal root repair significantly improved postoperatively and patient
satisfaction was high, regardless of age or meniscal laterality. Patients aged <50 years had outcomes
similar to those of patients ≥50 years, as did patients who underwent medial versus lateral root repair.
In patients undergoing pullout fixation for posterior medial meniscus root tear, Chung and associates (in
“Pullout Fixation of Posterior Medial Meniscus Root Tears”) found that patients with decreased
meniscus extrusion at postoperative 1 year have more favorable clinical scores and radiographic findings
at midterm follow-up than those with increased extrusion at 1 year. Krych and associates found that
nonoperative treatment of medial meniscus posterior horn root tears is associated with poor clinical
outcome, worsening arthritis, and a relatively high rate of arthroplasty at 5-year follow-up.
Reconstruction would have no role in the setting of a reparable meniscal root tear.
  Recommended Readings

Krych AJ, Reardon PJ, Johnson NR, Mohan R, Peter L, Levy BA, Stuart MJ. Non-operative
management of medial meniscus posterior horn root tears is associated with worsening arthritis
and poor clinical outcome at 5-year follow-up. Knee Surg Sports Traumatol Arthrosc. 2017
Feb;25(2):383-389. doi: 10.1007/s00167-016-4359-8. Epub 2016 Oct 19. PubMed

Chung KS, Ha JK, Yeom CH, Ra HJ, Jang HS, Choi SH, Kim JG. Comparison of Clinical and
Radiologic Results Between Partial Meniscectomy and Refixation of Medial Meniscus Posterior
Root Tears: A Minimum 5-Year Follow-up. Arthroscopy. 2015 Oct;31(10):1941-50. doi:
10.1016/j.arthro.2015.03.035. Epub 2015 Jun 18. PubMed

Chung KS, Ha JK, Ra HJ, Nam GW, Kim JG. Pullout Fixation of Posterior Medial Meniscus
Root Tears: Correlation Between Meniscus Extrusion and Midterm Clinical Results. Am J Sports
Med. 2017 Jan;45(1):42-49. doi: 10.1177/0363546516662445. Epub 2016 Oct 1. PubMed

LaPrade RF, Matheny LM, Moulton SG, James EW, Dean CS. Posterior Meniscal Root Repairs:
Outcomes of an Anatomic Transtibial Pull-Out Technique. Am J Sports Med. 2017
Mar;45(4):884-891. doi: 10.1177/0363546516673996. Epub 2016 Dec 5. PubMed

Question 80 of 100

Figures 1 through 4 are selected sagittal MR images of an otherwise healthy 20-year-old collegiate
football running back who was tackled during a game and has immediate onset of right knee pain. Video
analysis of the injury shows that his flexed knee impacted the field. He is not able to return to play. On
examination in the training room the following morning, he has a moderate effusion, no patellar
instability, minimal joint line tenderness, and is stable to varus and valgus stress at 30° of knee flexion. A
dial test is also negative. He has increased laxity in the anterior to posterior direction. What is the most
appropriate next step in treatment?
 Figure 1 Figure 2

Figure 3 Figure 4

A. Rehabilitation initially focused on closed chain quadriceps strengthening

B. Rehabilitation initially focused on hamstring strengthening
C. Anterior cruciate ligament (ACL) reconstruction using autograft tissue
D. Posterior cruciate ligament (PCL) reconstruction using autograft tissue

Correct answer: A

 Discussion

This athlete sustained an isolated PCL injury. The mechanism of injury is typical for a PCL injury. When a
PCL injury is identified, one must rule out other ligamentous injuries to the knee. The patient has a
stable examination to varus and valgus and a negative dial test, so the lateral collateral, medial
collateral, and posterolateral corner (respectively) are intact. It is common to have increased anterior to
posterior translation in isolated PCL injuries, even with an intact ACL, as the tibia will rest posterior to
the medial femoral condyle.

Treatment of isolated PCL injuries is typically nonoperative, with an initial focus on quadriceps
strengthening. Hamstring strengthening and rehabilitation is added at a later time, as this places
increased stress on the healing PCL. The images reveal an isolated PCL injury with intact menisci and
ACL, ruling out ACL reconstruction using autograft tissue and PCL reconstruction using autograft tissue.
  Recommended Readings

Parolie JM, Bergfeld JA. Long-term results of nonoperative treatment of isolated posterior
cruciate ligament injuries in the athlete. Am J Sports Med. 1986 Jan-Feb;14(1):35-8. PubMed

Agolley D, Gabr A, Benjamin-Laing H, Haddad FS. Successful return to sports in athletes

following non-operative management of acute isolated posterior cruciate ligament injuries:
medium-term follow-up. Bone Joint J. 2017 Jun;99-B(6):774-778. doi: 10.1302/0301-
620X.99B6.37953. PubMed

Question 81 of 100

Figure 1 is the radiograph of a 21-year-old college lacrosse player who has a 2-year history of
progressive left groin pain that is exacerbated by activity. Pain is preventing him from participating with
his team. Examination reveals a fit man without tenderness to palpation around the hip. No clicking or
popping occurs with hip range of motion. Strength of all muscles about the hip is normal, but there is
some mild pain with resisted hip flexion and hip adduction. While lying supine, progressive hip flexion
with internal rotation and adduction reproduces his groin pain.

What is the most likely cause of this patient's pain?

Figure 1
 A. Femoroacetabular impingement (FAI)
B. Osteoarthritis of the sacroiliac joint
C. Intra-articular loose body
D. Trochanteric bursitis

Correct answer: A

 Discussion

This clinical scenario describes a patient with FAI attributable to pincer (acetabular) deformity. This form
of FAI, which involves prominence of the anterosuperior acetabular lip, may be more common among
women. Decreased range of motion and pain occur secondary to the abutment of the femoral head
against the acetabular labrum and rim. Hip flexion, combined with adduction and internal rotation,
recreates this contact and causes pain, but CAM or pincer etiology remains unknown.

The differential diagnosis of hip pain in a young athlete includes femoral neck stress reaction/fracture,
sacroiliac arthritis, intra-articular loose body, trochanteric bursitis, osteitis pubis, and hernia. No
information presented in this scenario suggests any of these causes. Diagnosis of FAI is best performed
via MR imaging, with an arthrogram increasing the sensitivity and specificity for labral pathology.
Ultrasonography may be useful in the diagnosis of dysplasia or for dynamic assessment of a snapping
hip, but ultrasonography is not commonly used to diagnose labral pathology.

Although concomitant chondral lesions of the femoral head are uncommon, the forced leverage of the
anterosuperior femoral neck upon the anterior acetabulum may result in a “contra-coup” chondral
injury on the posteroinferior acetabulum. This is the most common location of chondral lesions in this
scenario. Without bony resection to prevent further impingement, this patient will continue to
experience symptoms. Because there is no evidence of femoral neck prominence (CAM lesion), there is
no indication for osteoplasty of the femoral neck; resection of the pincer lesion is necessary. This will
often require take-down of the labrum in this location. If possible, iatrogenic or traumatic labral tears
should subsequently be repaired after pincer debridement because the labrum has important functions
for hip stability and maintenance of the suction seal of the joint.

 Recommended Readings

Schoenecker PL, Clohisy JC, Millis MB, Wenger DR. Surgical management of the problematic
hip in adolescent and young adult patients. J Am Acad Orthop Surg. 2011 May;19(5):275-86.
Full text
Safran MR. The acetabular labrum: anatomic and functional characteristics and rationale for
surgical intervention. J Am Acad Orthop Surg. 2010 Jun;18(6):338-45. Full text

Parvizi J, Leunig M, Ganz R. Femoroacetabular impingement. J Am Acad Orthop Surg. 2007

Sep;15(9):561-70. Full text

Matsuda DK, Carlisle JC, Arthurs SC, Wierks CH, Philippon MJ. Comparative systematic
review of the open dislocation, mini-open, and arthroscopic surgeries for femoroacetabular
impingement. Arthroscopy. 2011 Feb;27(2):252-69. PubMed

Leunig M, Podeszwa D, Beck M, Werlen S, Ganz R. Magnetic resonance arthrography of labral

disorders in hips with dysplasia and impingement. Clin Orthop Relat Res. 2004 Jan;(418):74-80.
PubMed

Konan S, Rayan F, Meermans G, Witt J, Haddad FS. Validation of the classification system for
acetabular chondral lesions identified at arthroscopy in patients with femoroacetabular
impingement. J Bone Joint Surg Br. 2011 Mar;93(3):332-6. PubMed

Byrd JW, Jones KS. Primary repair of the acetabular labrum: outcomes with 2 years' follow-up.
Arthroscopy. 2014 May;30(5):588-92. doi: 10.1016/j.arthro.2014.02.007. PubMed

Bloomfield MR, Erickson JA, McCarthy JC, Mont MA, Mulkey P, Peters CL, Pivec R, Austin
MS. Hip pain in the young, active patient: surgical strategies. Instr Course Lect. 2014;63:159-76.
PubMed

Question 82 of 100

Figure 1 is the radiograph of a 21-year-old college lacrosse player who has a 2-year history of
progressive left groin pain that is exacerbated by activity. Pain is preventing him from participating with
his team. Examination reveals a fit man without tenderness to palpation around the hip. No clicking or
popping occurs with hip range of motion. Strength of all muscles about the hip is normal, but there is
some mild pain with resisted hip flexion and hip adduction. While lying supine, progressive hip flexion
with internal rotation and adduction reproduces his groin pain.

The patient participates in physical therapy for 8 weeks with his team's trainer but notes little
improvement. What is the most appropriate next diagnostic step to determine the cause of his pain?
 Figure 1

A. Diagnostic arthroscopy of the hip

B. Hip bone scan
C. Hip MRI arthrogram
D. Hip ultrasonography

Correct answer: C

 Discussion

This clinical scenario describes a patient with FAI attributable to pincer (acetabular) deformity. This form
of FAI, which involves prominence of the anterosuperior acetabular lip, may be more common among
women. Decreased range of motion and pain occur secondary to the abutment of the femoral head
against the acetabular labrum and rim. Hip flexion, combined with adduction and internal rotation,
recreates this contact and causes pain, but CAM or pincer etiology remains unknown.

The differential diagnosis of hip pain in a young athlete includes femoral neck stress reaction/fracture,
sacroiliac arthritis, intra-articular loose body, trochanteric bursitis, osteitis pubis, and hernia. No
information presented in this scenario suggests any of these causes. Diagnosis of FAI is best performed
via MR imaging, with an arthrogram increasing the sensitivity and specificity for labral pathology.
Ultrasonography may be useful in the diagnosis of dysplasia or for dynamic assessment of a snapping
hip, but ultrasonography is not commonly used to diagnose labral pathology.

Although concomitant chondral lesions of the femoral head are uncommon, the forced leverage of the
anterosuperior femoral neck upon the anterior acetabulum may result in a “contra-coup” chondral
injury on the posteroinferior acetabulum. This is the most common location of chondral lesions in this
scenario. Without bony resection to prevent further impingement, this patient will continue to
experience symptoms. Because there is no evidence of femoral neck prominence (CAM lesion), there is
no indication for osteoplasty of the femoral neck; resection of the pincer lesion is necessary. This will
often require take-down of the labrum in this location. If possible, iatrogenic or traumatic labral tears
should subsequently be repaired after pincer debridement because the labrum has important functions
for hip stability and maintenance of the suction seal of the joint.

 Recommended Readings

Schoenecker PL, Clohisy JC, Millis MB, Wenger DR. Surgical management of the problematic
hip in adolescent and young adult patients. J Am Acad Orthop Surg. 2011 May;19(5):275-86.
Full text

Safran MR. The acetabular labrum: anatomic and functional characteristics and rationale for
surgical intervention. J Am Acad Orthop Surg. 2010 Jun;18(6):338-45. Full text

Parvizi J, Leunig M, Ganz R. Femoroacetabular impingement. J Am Acad Orthop Surg. 2007

Sep;15(9):561-70. Full text

Matsuda DK, Carlisle JC, Arthurs SC, Wierks CH, Philippon MJ. Comparative systematic
review of the open dislocation, mini-open, and arthroscopic surgeries for femoroacetabular
impingement. Arthroscopy. 2011 Feb;27(2):252-69. PubMed

Leunig M, Podeszwa D, Beck M, Werlen S, Ganz R. Magnetic resonance arthrography of labral

disorders in hips with dysplasia and impingement. Clin Orthop Relat Res. 2004 Jan;(418):74-80.
PubMed

Konan S, Rayan F, Meermans G, Witt J, Haddad FS. Validation of the classification system for
acetabular chondral lesions identified at arthroscopy in patients with femoroacetabular
impingement. J Bone Joint Surg Br. 2011 Mar;93(3):332-6. PubMed

Byrd JW, Jones KS. Primary repair of the acetabular labrum: outcomes with 2 years' follow-up.
Arthroscopy. 2014 May;30(5):588-92. doi: 10.1016/j.arthro.2014.02.007. PubMed
Bloomfield MR, Erickson JA, McCarthy JC, Mont MA, Mulkey P, Peters CL, Pivec R, Austin
MS. Hip pain in the young, active patient: surgical strategies. Instr Course Lect. 2014;63:159-76.
PubMed

Question 83 of 100

Figure 1 is the radiograph of a 21-year-old college lacrosse player who has a 2-year history of
progressive left groin pain that is exacerbated by activity. Pain is preventing him from participating with
his team. Examination reveals a fit man without tenderness to palpation around the hip. No clicking or
popping occurs with hip range of motion. Strength of all muscles about the hip is normal, but there is
some mild pain with resisted hip flexion and hip adduction. While lying supine, progressive hip flexion
with internal rotation and adduction reproduces his groin pain.

Further workup confirms an anterosuperior tear of the acetabular labrum and prominence of the
acetabulum. What is the most likely location of a chondral injury associated with these findings?

Figure 1

A. Posterosuperior acetabulum
B. Posteroinferior acetabulum
C. Femoral head above the fovea
 D. Femoral head below the fovea

Correct answer: B

 Discussion

This clinical scenario describes a patient with FAI attributable to pincer (acetabular) deformity. This form
of FAI, which involves prominence of the anterosuperior acetabular lip, may be more common among
women. Decreased range of motion and pain occur secondary to the abutment of the femoral head
against the acetabular labrum and rim. Hip flexion, combined with adduction and internal rotation,
recreates this contact and causes pain, but CAM or pincer etiology remains unknown.

The differential diagnosis of hip pain in a young athlete includes femoral neck stress reaction/fracture,
sacroiliac arthritis, intra-articular loose body, trochanteric bursitis, osteitis pubis, and hernia. No
information presented in this scenario suggests any of these causes. Diagnosis of FAI is best performed
via MR imaging, with an arthrogram increasing the sensitivity and specificity for labral pathology.
Ultrasonography may be useful in the diagnosis of dysplasia or for dynamic assessment of a snapping
hip, but ultrasonography is not commonly used to diagnose labral pathology.

Although concomitant chondral lesions of the femoral head are uncommon, the forced leverage of the
anterosuperior femoral neck upon the anterior acetabulum may result in a “contra-coup” chondral
injury on the posteroinferior acetabulum. This is the most common location of chondral lesions in this
scenario. Without bony resection to prevent further impingement, this patient will continue to
experience symptoms. Because there is no evidence of femoral neck prominence (CAM lesion), there is
no indication for osteoplasty of the femoral neck; resection of the pincer lesion is necessary. This will
often require take-down of the labrum in this location. If possible, iatrogenic or traumatic labral tears
should subsequently be repaired after pincer debridement because the labrum has important functions
for hip stability and maintenance of the suction seal of the joint.

 Recommended Readings

Schoenecker PL, Clohisy JC, Millis MB, Wenger DR. Surgical management of the problematic
hip in adolescent and young adult patients. J Am Acad Orthop Surg. 2011 May;19(5):275-86.
Full text

Safran MR. The acetabular labrum: anatomic and functional characteristics and rationale for
surgical intervention. J Am Acad Orthop Surg. 2010 Jun;18(6):338-45. Full text
Parvizi J, Leunig M, Ganz R. Femoroacetabular impingement. J Am Acad Orthop Surg. 2007
Sep;15(9):561-70. Full text

Matsuda DK, Carlisle JC, Arthurs SC, Wierks CH, Philippon MJ. Comparative systematic
review of the open dislocation, mini-open, and arthroscopic surgeries for femoroacetabular
impingement. Arthroscopy. 2011 Feb;27(2):252-69. PubMed

Leunig M, Podeszwa D, Beck M, Werlen S, Ganz R. Magnetic resonance arthrography of labral

disorders in hips with dysplasia and impingement. Clin Orthop Relat Res. 2004 Jan;(418):74-80.
PubMed

Konan S, Rayan F, Meermans G, Witt J, Haddad FS. Validation of the classification system for
acetabular chondral lesions identified at arthroscopy in patients with femoroacetabular
impingement. J Bone Joint Surg Br. 2011 Mar;93(3):332-6. PubMed

Byrd JW, Jones KS. Primary repair of the acetabular labrum: outcomes with 2 years' follow-up.
Arthroscopy. 2014 May;30(5):588-92. doi: 10.1016/j.arthro.2014.02.007. PubMed

Bloomfield MR, Erickson JA, McCarthy JC, Mont MA, Mulkey P, Peters CL, Pivec R, Austin
MS. Hip pain in the young, active patient: surgical strategies. Instr Course Lect. 2014;63:159-76.
PubMed

Question 84 of 100

Figure 1 is the radiograph of a 21-year-old college lacrosse player who has a 2-year history of
progressive left groin pain that is exacerbated by activity. Pain is preventing him from participating with
his team. Examination reveals a fit man without tenderness to palpation around the hip. No clicking or
popping occurs with hip range of motion. Strength of all muscles about the hip is normal, but there is
some mild pain with resisted hip flexion and hip adduction. While lying supine, progressive hip flexion
with internal rotation and adduction reproduces his groin pain.

The patient experiences little improvement with activity modification and more physical therapy. An
intra-articular corticosteroid injection provides excellent relief, but relief only lasts for 1 month. The
player requests further treatment for his hip and is counseled regarding surgical intervention. Hip
arthroscopy is performed. Intraoperatively, a capsulolabral separation is observed with an underlying
pincer lesion. No articular cartilage injury is seen. Which treatment is most appropriate considering
these findings?
 Figure 1

A. Debridement of the labral tear plus bony resection of the pincer lesion
B. Debridement of the labral tear and no bony resection of the pincer lesion
C. Femoral neck osteoplasty plus labral repair using suture anchor
D. Resection of the bony pincer lesion plus labral repair using suture anchor

Correct answer: D

 Discussion

This clinical scenario describes a patient with FAI attributable to pincer (acetabular) deformity. This form
of FAI, which involves prominence of the anterosuperior acetabular lip, may be more common among
women. Decreased range of motion and pain occur secondary to the abutment of the femoral head
against the acetabular labrum and rim. Hip flexion, combined with adduction and internal rotation,
recreates this contact and causes pain, but CAM or pincer etiology remains unknown.

The differential diagnosis of hip pain in a young athlete includes femoral neck stress reaction/fracture,
sacroiliac arthritis, intra-articular loose body, trochanteric bursitis, osteitis pubis, and hernia. No
information presented in this scenario suggests any of these causes. Diagnosis of FAI is best performed
via MR imaging, with an arthrogram increasing the sensitivity and specificity for labral pathology.
Ultrasonography may be useful in the diagnosis of dysplasia or for dynamic assessment of a snapping
hip, but ultrasonography is not commonly used to diagnose labral pathology.

Although concomitant chondral lesions of the femoral head are uncommon, the forced leverage of the
anterosuperior femoral neck upon the anterior acetabulum may result in a “contra-coup” chondral
injury on the posteroinferior acetabulum. This is the most common location of chondral lesions in this
scenario. Without bony resection to prevent further impingement, this patient will continue to
experience symptoms. Because there is no evidence of femoral neck prominence (CAM lesion), there is
no indication for osteoplasty of the femoral neck; resection of the pincer lesion is necessary. This will
often require take-down of the labrum in this location. If possible, iatrogenic or traumatic labral tears
should subsequently be repaired after pincer debridement because the labrum has important functions
for hip stability and maintenance of the suction seal of the joint.

 Recommended Readings

Schoenecker PL, Clohisy JC, Millis MB, Wenger DR. Surgical management of the problematic
hip in adolescent and young adult patients. J Am Acad Orthop Surg. 2011 May;19(5):275-86.
Full text

Safran MR. The acetabular labrum: anatomic and functional characteristics and rationale for
surgical intervention. J Am Acad Orthop Surg. 2010 Jun;18(6):338-45. Full text

Parvizi J, Leunig M, Ganz R. Femoroacetabular impingement. J Am Acad Orthop Surg. 2007

Sep;15(9):561-70. Full text

Matsuda DK, Carlisle JC, Arthurs SC, Wierks CH, Philippon MJ. Comparative systematic
review of the open dislocation, mini-open, and arthroscopic surgeries for femoroacetabular
impingement. Arthroscopy. 2011 Feb;27(2):252-69. PubMed

Leunig M, Podeszwa D, Beck M, Werlen S, Ganz R. Magnetic resonance arthrography of labral

disorders in hips with dysplasia and impingement. Clin Orthop Relat Res. 2004 Jan;(418):74-80.
PubMed

Konan S, Rayan F, Meermans G, Witt J, Haddad FS. Validation of the classification system for
acetabular chondral lesions identified at arthroscopy in patients with femoroacetabular
impingement. J Bone Joint Surg Br. 2011 Mar;93(3):332-6. PubMed

Byrd JW, Jones KS. Primary repair of the acetabular labrum: outcomes with 2 years' follow-up.
Arthroscopy. 2014 May;30(5):588-92. doi: 10.1016/j.arthro.2014.02.007. PubMed
Bloomfield MR, Erickson JA, McCarthy JC, Mont MA, Mulkey P, Peters CL, Pivec R, Austin
MS. Hip pain in the young, active patient: surgical strategies. Instr Course Lect. 2014;63:159-76.
PubMed

Question 85 of 100

Figure 1 is the MRI scan of a 35-year-old female soccer player who injured her knee during a game.
Given the findings of the scan, physical examination is most likely to reveal

Figure 1

A. grade 2 pivot shift.

B. positive Thessaly test.
C. positive quadriceps active test.
D. positive dial test at 30°.

Correct answer: A

 Discussion
The MRI scan clearly reveals bone bruises in the mid lateral femoral condyle and posterior tibial plateau.
These MRI findings are commonly associated with acute anterior cruciate ligament injuries. Therefore,
the preferred answer would be a positive pivot shift examination. A positive posterior drawer and
positive quad active test are associated with posterior cruciate ligament injuries. A positive dial test
would be suggestive of a posterolateral instability of the knee.

 Recommended Readings

Patel SA, Hageman J, Quatman CE, Wordeman SC, Hewett TE. Prevalence and location of bone
bruises associated with anterior cruciate ligament injury and implications for mechanism of
injury: a systematic review. Sports Med. 2014 Feb;44(2):281-93. doi: 10.1007/s40279-013-0116-
z. PubMed

Song GY, Zhang H, Wang QQ, Zhang J, Li Y, Feng H. Bone Contusions After Acute
Noncontact Anterior Cruciate Ligament Injury Are Associated With Knee Joint Laxity,
Concomitant Meniscal Lesions, and Anterolateral Ligament Abnormality. Arthroscopy. 2016
Nov;32(11):2331-2341. doi: 10.1016/j.arthro.2016.03.015. Epub 2016 May 11. PubMed

Question 86 of 100

A 28-year-old woman undergoes a closing-wedge high tibial osteotomy (HTO) for medial compartment
overload after medial meniscectomy. Postsurgically, she reports improvement in her medial pain and
resumes normal activities. About 9 months after her surgery, however, she reports burning pain in the
front of her knee with running. Her examination reveals no joint line tenderness, mild pain with patellar
compression, and limited patellar glides. What is the most likely cause of her symptoms?

A. Patella infera (baja)

B. Patella alta
C. Recurrence of medial joint overload
D. Nonunion of the osteotomy

Correct answer: A

 Discussion
After HTO, particularly in patients who have been immobilized after a closing-wedge osteotomy, patella
baja is a common finding. This can precipitate anterior knee pain or patellofemoral pain syndrome.
Recurrence of medial joint overload is incorrect because the patient has no medial joint complaints.
Nonunion is less likely with a closing-wedge osteotomy and likely will not result in anterior knee pain.

 Recommended Readings

Scuderi GR, Windsor RE, Insall JN. Observations on patellar height after proximal tibial
osteotomy. J Bone Joint Surg Am. 1989 Feb;71(2):245-8. PubMed

Aglietti P, Buzzi R, Vena LM, Baldini A, Mondaini A. High tibial valgus osteotomy for medial
gonarthrosis: a 10- to 21-year study. J Knee Surg. 2003 Jan;16(1):21-6. PubMed

Question 87 of 100

Figures 1 and 2 are the MR arthrogram images of a 20-year-old right-hand dominant collegiate
basketball player who sustained an initial shoulder dislocation 1 year ago. In the month prior to
presentation, he dislocated his shoulder two more times. Each time it occurred when going up for a
rebound and an opponent grabbed the ball from behind him, hyperextending his shoulder. Physical
examination demonstrates full range of motion, absence of atrophy, a positive apprehension sign and
relocation test, and a positive Kim test. What is the best next step?
 Figure 1 Figure 2

A. Anterior labral repair

B. Anterior labral repair and remplissage
C. Posterior labral repair and rotator interval closure
D. Anterior and posterior labral repair

Correct answer: D

 Discussion

The mechanism of injury/dislocation is most consistent with anterior glenohumeral joint instability. The
axial cuts of the MR arthrogram reveals an anteroinferior labral tear, as well as a posterior labral tear. A
Hill-Sachs lesion is also consistent with anterior glenohumeral joint instability. At the time of
examination under anesthesia, this patient exhibited 2+ anterior and 2+ posterior glenohumeral joint
instability. Patients with pan-labral tears and 270° tears can be challenging to diagnose, because
patients can report anterior or posterior shoulder instability alone. The physical examination and
advanced imaging in these patients are crucial in directing appropriate treatment.

 Recommended Readings

Mazzocca AD, Cote MP, Solovyova O, Rizvi SH, Mostofi A, Arciero RA. Traumatic shoulder
instability involving anterior, inferior, and posterior labral injury: a prospective clinical
evaluation of arthroscopic repair of 270° labral tears. Am J Sports Med. 2011 Aug;39(8):1687-
96. doi: 10.1177/0363546511405449. Epub 2011 May 12. PubMed

Van Blarcum GS, Svoboda SJ. Glenohumeral Instability Related to Special Conditions: SLAP
Tears, Pan-labral Tears, and Multidirectional Instability. Sports Med Arthrosc Rev. 2017
Sep;25(3):e12-e17. doi: 10.1097/JSA.0000000000000153. PubMed

Tjoumakaris FP, Bradley JP. The rationale for an arthroscopic approach to shoulder stabilization.
Arthroscopy. 2011 Oct;27(10):1422-33. doi: 10.1016/j.arthro.2011.06.006. Epub 2011 Aug 26.
PubMed
Question 88 of 100

Figure 1 is the MRI scan of a 15-year-old boy who has had knee pain with running for 5 months.
Radiographs show an osteochondritis dissecans (OCD) lesion of the medial femoral condyle. What is the
most appropriate treatment?

Figure 1

A. Arthroscopic or open reduction and internal fixation

B. Arthroscopic loose body removal
C. Activity restriction for up to 9 months
D. Subchondral drilling

Correct answer: A

 Discussion

OCD is an acquired lesion of the subchondral bone. Patients with OCD initially report nonspecific pain
and variable amounts of swelling. Initial radiographs help identify the lesion and establish the status of
the physes. An MRI scan is useful for assessing the potential for the lesion to heal with nonsurgical
treatment. Nonsurgical treatment is appropriate for small, stable lesions in patients with open physes
and focuses on activity restriction for 3 to 9 months. Surgical treatment is necessary for unstable or
detached lesions. Stable lesions with intact articular cartilage can be treated with subchondral drilling to
stimulate vascular ingrowth, with radiographic healing at an average of 4.4 months. Fixation is indicated
for unstable or hinged lesions, and stabilization of the fragment can be achieved using a variety of
implants through an arthroscopic or open approach. The fragment should be salvaged and the normal
articular surface restored whenever possible.

 Recommended Readings

Shea K, Ganley TJ. Injuries and conditions of the pediatric and adolescent athlete. In: Flynn JM,
ed. Orthopaedic Knowledge Update 10. Rosemont, IL: American Academy of Orthopaedic
Surgeons; 2011:783-796.

Magnussen RA, Carey JL, Spindler KP. Does operative fixation of an osteochondritis dissecans
loose body result in healing and long-term maintenance of knee function? Am J Sports Med.
2009 Apr;37(4):754-9. Epub 2009 Feb 9. PubMed

Question 89 of 100

A 17-year-old high school football linebacker sustains an injury while making a tackle. His initial
symptoms are right shoulder pain, bilateral biceps weakness, and right arm numbness. The symptoms
only last a few minutes, and he continues to play in the game. He tells his parents after the game, and
they bring him to your office for evaluation the next day. He no longer has any symptoms, and his
examination findings and cervical spine radiographs are normal. What is the best next step?

A. Allow him to continue playing football

B. Order an EMG
C. Observe and if symptoms are negative for one week, then a return to football
D. Order a cervical MRI scan

Correct answer: D

 Discussion
The football player had bilateral weakness indicating that the injury was more significant than a stinger.
Stingers present with unilateral symptoms, and if they resolve, an athlete can return to sports. However,
bilateral symptoms indicate cervical spine pathology, such as spinal stenosis, and warrant an MRI scan of
the cervical spine. Despite the patient being able to continue playing in the game and having symptom
resolution, a cervical MRI scan should be performed prior to return to sports.

 Recommended Readings

Meyer SA, Schulte KR, Callaghan JJ, Albright JP, Powell JW, Crowley ET, el-Khoury GY.
Cervical spinal stenosis and stingers in collegiate football players. Am J Sports Med. 1994 Mar-
Apr;22(2):158-66. PubMed

Schroeder GD, Vaccaro AR. Cervical Spine Injuries in the Athlete. J Am Acad Orthop Surg.
2016 Sep;24(9):e122-33. doi: 10.5435/JAAOS-D-15-00716. PubMed

Question 90 of 100

Figures 1 and 2 are the AP and lateral radiographs of a 32-year-old man 10 years after anterior cruciate
ligament (ACL) reconstruction. The patient now has worsening medial knee pain and a failed ACL with
instability. What is the best surgical option?
 Figure 1 Figure 2

A. Revision ACL with bone-patellar tendon-bone (BTB) allograft and meniscal transplant
B. Distal femoral osteotomy
C. Pure sagittal osteotomy
D. Closing wedge and slope neutralizing high-tibial osteotomy

Correct answer: D

 Discussion
Lateral closing wedge (LCW) and medial opening wedge (MOW) high-tibial osteotomies (HTOs) can both
correct varus knee alignment and stabilize the ACL–deficient knee. Increasingly, HTO is being proposed
as a singular or concomitant procedure with ACL reconstruction for restoring knee stability and as a
more reliable slope correction. LCW HTO demonstrates more reliable slope correction than does MOW
HTO. Revision ACL with BTB allograft and meniscal transplant will not help early arthritis in varus
alignment. Distal femoral osteotomy is usually considered for valgus knee. Pure sagittal osteotomy
would not help the patient’s medial knee pain, arthritis, and malalignment.

 Recommended Readings

Boden BP, Breit I, Sheehan FT. Tibiofemoral alignment: contributing factors to noncontact
anterior cruciate ligament injury. J Bone Joint Surg Am. 2009 Oct;91(10):2381-9. doi:
10.2106/JBJS.H.01721. PubMed

Ranawat AS, Nwachukwu BU, Pearle AD, Zuiderbaan HA, Weeks KD, Khamaisy S.
Comparison of Lateral Closing-Wedge Versus Medial Opening-Wedge High Tibial Osteotomy
on Knee Joint Alignment and Kinematics in the ACL-Deficient Knee. Am J Sports Med. 2016
Dec;44(12):3103-3110. Epub 2016 Aug 5. PubMed

Brandon ML, Haynes PT, Bonamo JR, Flynn MI, Barrett GR, Sherman MF. The association
between posterior-inferior tibial slope and anterior cruciate ligament insufficiency. Arthroscopy.
2006 Aug;22(8):894-9. PubMed

Question 91 of 100

Figure 1 is the T2 coronal MRI scan of a 52-year-old woman with a 6-month history of shoulder pain. She
does not recall a history of trauma. Physical therapy is recommended. What is the most significant
predictor of failure of nonoperative treatment?
 Figure 1

A. Tear size
B. Pain scale score
C. Strength deficit
D. Patient expectations

Correct answer: D

 Discussion

The MRI reveals a large full thickness supraspinatus tear. A large, prospective study showed that physical
therapy can be effective in the treatment of atraumatic full-thickness rotator cuff tears. Patient
expectations regarding the role of rehabilitation were the strongest predictor of surgery. Other factors
associated with surgery were higher activity level and not smoking. Anatomic features of the rotator cuff
tear and the severity of patient’s reported pain did not predict failure of nonoperative treatment.
Patients who have low expectations regarding the effectiveness of physical therapy are more likely to
fail nonoperative treatment.

 Recommended Readings
Dunn WR, Kuhn JE, Sanders R, An Q, Baumgarten KM, Bishop JY, Brophy RH, Carey JL,
Holloway GB, Jones GL, Ma CB, Marx RG, McCarty EC, Poddar SK, Smith MV, Spencer EE,
Vidal AF, Wolf BR, Wright RW. Symptoms of pain do not correlate with rotator cuff tear
severity: a cross-sectional study of 393 patients with a symptomatic atraumatic full-thickness
rotator cuff tear. J Bone Joint Surg Am. 2014 May 21;96(10):793-800. doi:
10.2106/JBJS.L.01304. PubMed

Dunn WR, Kuhn JE, Sanders R, An Q, Baumgarten KM, Bishop JY, Brophy RH, Carey JL,
Harrell F, Holloway BG, Jones GL, Ma CB, Marx RG, McCarty EC, Poddar SK, Smith MV,
Spencer EE, Vidal AF, Wolf BR, Wright RW; MOON Shoulder Group. 2013 Neer Award:
predictors of failure of nonoperative treatment of chronic, symptomatic, full-thickness rotator
cuff tears. J Shoulder Elbow Surg. 2016 Aug;25(8):1303-11. doi: 10.1016/j.jse.2016.04.030.
PubMed

Question 92 of 100

Figures 1 through 5 are the MR images of a 12-year-old boy with left lateral-sided knee pain following a
football injury. He has a several-year history of recurrent knee pain that improves with rest. An
examination reveals a moderate effusion. Range of motion is 0° to 90° and is limited by pain in deep
flexion. He has tenderness to palpation along the lateral joint line, and no instability is noted.

What is the underlying cause of the pathology noted in the figures?

Figure 1 Figure 2 Figure 3

 Figure 4 Figure 5

A. Genetic mutation
B. Recurrent trauma
C. Shallow intercondylar notch
D. Congenital abnormality

Correct answer: D

 Discussion

The MR images show a tear through a discoid lateral meniscus. A discoid meniscus is caused by a failure
of apoptosis during development in utero and is considered a congenital abnormality. Discoid menisci
are prone to tearing and can be caused by minimal trauma. There is no known genetic cause for this
condition. Radiographic findings that may be present in the setting of a discoid meniscus include lateral
joint space widening, squaring of the lateral femoral condyle, and cupping of the lateral tibial plateau.
Contralateral discoid menisci are noted in 20% of patients. There are no other known associated
conditions. Treatment of a symptomatic discoid meniscus should include partial meniscectomy and
saucerization or repair.

 Recommended Readings

Kramer DE, Micheli LJ. Meniscal tears and discoid meniscus in children: diagnosis and
treatment. J Am Acad Orthop Surg. 2009 Nov;17(11):698-707. Full text
Good CR, Green DW, Griffith MH, Valen AW, Widmann RF, Rodeo SA. Arthroscopic
treatment of symptomatic discoid meniscus in children: classification, technique,and results.
Arthroscopy. 2007 Feb;23(2):157-63. PubMed

Question 93 of 100

Figures 1 through 5 are the MR images of a 12-year-old boy with left lateral-sided knee pain following a
football injury. He has a several-year history of recurrent knee pain that improves with rest. An
examination reveals a moderate effusion. Range of motion is 0° to 90° and is limited by pain in deep
flexion. He has tenderness to palpation along the lateral joint line, and no instability is noted.

Based on the pathology noted, which finding may be found on plain knee radiographs?

Figure 1 Figure 2 Figure 3

Figure 4 Figure 5

A. Shallow trochlear groove

 B. Squaring of the lateral femoral condyle
C. Deepening of the sulcus terminalis
D. Medial joint space narrowing

Correct answer: B

 Discussion

The MR images show a tear through a discoid lateral meniscus. A discoid meniscus is caused by a failure
of apoptosis during development in utero and is considered a congenital abnormality. Discoid menisci
are prone to tearing and can be caused by minimal trauma. There is no known genetic cause for this
condition. Radiographic findings that may be present in the setting of a discoid meniscus include lateral
joint space widening, squaring of the lateral femoral condyle, and cupping of the lateral tibial plateau.
Contralateral discoid menisci are noted in 20% of patients. There are no other known associated
conditions. Treatment of a symptomatic discoid meniscus should include partial meniscectomy and
saucerization or repair.

 Recommended Readings

Kramer DE, Micheli LJ. Meniscal tears and discoid meniscus in children: diagnosis and
treatment. J Am Acad Orthop Surg. 2009 Nov;17(11):698-707. Full text

Good CR, Green DW, Griffith MH, Valen AW, Widmann RF, Rodeo SA. Arthroscopic
treatment of symptomatic discoid meniscus in children: classification, technique,and results.
Arthroscopy. 2007 Feb;23(2):157-63. PubMed

Question 94 of 100

Figures 1 through 5 are the MR images of a 12-year-old boy with left lateral-sided knee pain following a
football injury. He has a several-year history of recurrent knee pain that improves with rest. An
examination reveals a moderate effusion. Range of motion is 0° to 90° and is limited by pain in deep
flexion. He has tenderness to palpation along the lateral joint line, and no instability is noted.

What other finding may be noted in patients with this diagnosis?

 Figure 1 Figure 2 Figure 3

Figure 4 Figure 5

A. Symmetric knee pathology

B. Excessive joint laxity
C. Recurrent patella instability
D. Extra-articular manifestations

Correct answer: A

 Discussion

The MR images show a tear through a discoid lateral meniscus. A discoid meniscus is caused by a failure
of apoptosis during development in utero and is considered a congenital abnormality. Discoid menisci
are prone to tearing and can be caused by minimal trauma. There is no known genetic cause for this
condition. Radiographic findings that may be present in the setting of a discoid meniscus include lateral
joint space widening, squaring of the lateral femoral condyle, and cupping of the lateral tibial plateau.
Contralateral discoid menisci are noted in 20% of patients. There are no other known associated
conditions. Treatment of a symptomatic discoid meniscus should include partial meniscectomy and
saucerization or repair.

 Recommended Readings

Kramer DE, Micheli LJ. Meniscal tears and discoid meniscus in children: diagnosis and
treatment. J Am Acad Orthop Surg. 2009 Nov;17(11):698-707. Full text

Good CR, Green DW, Griffith MH, Valen AW, Widmann RF, Rodeo SA. Arthroscopic
treatment of symptomatic discoid meniscus in children: classification, technique,and results.
Arthroscopy. 2007 Feb;23(2):157-63. PubMed

Question 95 of 100

Figures 1 through 5 are the MR images of a 12-year-old boy with left lateral-sided knee pain following a
football injury. He has a several-year history of recurrent knee pain that improves with rest. An
examination reveals a moderate effusion. Range of motion is 0° to 90° and is limited by pain in deep
flexion. He has tenderness to palpation along the lateral joint line, and no instability is noted.

Treatment should include

Figure 1 Figure 2 Figure 3

 Figure 4 Figure 5

A. anterior cruciate ligament reconstruction with lateral meniscus repair.

B. partial lateral meniscectomy with saucerization.
C. lateral meniscus transplant.
D. protected weight bearing with referral for genetic testing.

Correct answer: B

 Discussion

The MR images show a tear through a discoid lateral meniscus. A discoid meniscus is caused by a failure
of apoptosis during development in utero and is considered a congenital abnormality. Discoid menisci
are prone to tearing and can be caused by minimal trauma. There is no known genetic cause for this
condition. Radiographic findings that may be present in the setting of a discoid meniscus include lateral
joint space widening, squaring of the lateral femoral condyle, and cupping of the lateral tibial plateau.
Contralateral discoid menisci are noted in 20% of patients. There are no other known associated
conditions. Treatment of a symptomatic discoid meniscus should include partial meniscectomy and
saucerization or repair.

 Recommended Readings

Kramer DE, Micheli LJ. Meniscal tears and discoid meniscus in children: diagnosis and
treatment. J Am Acad Orthop Surg. 2009 Nov;17(11):698-707. Full text
Good CR, Green DW, Griffith MH, Valen AW, Widmann RF, Rodeo SA. Arthroscopic
treatment of symptomatic discoid meniscus in children: classification, technique,and results.
Arthroscopy. 2007 Feb;23(2):157-63. PubMed

Question 96 of 100

Figures 1 and 2 are the right shoulder MRI scans of a 22-year-old right-handed professional male
volleyball player with 4 months of right shoulder pain. The pain began insidiously and is exacerbated by
overhead activities and hitting during games. He has maintained a daily program of shoulder stretching
and strengthening exercises but has experienced a steady decline in function to the point of not being
able to participate in volleyball. Examination reveals some mild atrophy at the posterior shoulder, full
forward elevation, mild weakness of external rotation on the right shoulder, negative empty-can testing,
positive O’Brien’s and negative apprehension. Surgical intervention would aim to resolve pathology
related to which nerve?

Figure 1 Figure 2

A. Lower subscapular nerve

B. Suprascapular nerve at the spinoglenoid notch
C. Suprascapular nerve at the suprascapular notch
D. Axillary nerve
Correct answer: B

 Discussion

This athlete has a symptomatic posterior-superior labral tear, spinoglenoid notch cysts, and subsequent
suprascapular nerve compression, as evidenced by the atrophy of the infraspinatus muscle on sagittal T1
MRI. The cyst is located at the spinoglenoid notch and is compressing the suprascapular nerve after it
has innervated the supraspinatus but before innervation of the infraspinatus; hence, the atrophy of
infraspinatus on examination and imaging. Compression of the suprascapular nerve at the suprascapular
notch would lead to weakness and atrophy of both the supraspinatus and infraspinatus. The lower
subscapular nerve innervates the teres major, as well as, with the upper subscapular nerve, the
subscapularis. The teres minor is innervated by the axillary nerve.

 Recommended Readings

Kim SJ, Choi YR, Jung M, Park JY, Chun YM. Outcomes of Arthroscopic Decompression of
Spinoglenoid Cysts Through a Subacromial Approach. Arthroscopy. 2017 Jan;33(1):62-67. doi:
10.1016/j.arthro.2016.05.034. Epub 2016 Jul 27. PubMed

Schroder CP, Skare O, Stiris M, Gjengedal E, Uppheim G, Brox JI. Treatment of labral tears
with associated spinoglenoid cysts without cyst decompression. J Bone Joint Surg Am. 2008
Mar;90(3):523-30. doi: 10.2106/JBJS.F.01534. PubMed

Shon MS, Jung SW, Kim JW, Yoo JC. Arthroscopic all-intra-articular decompression and labral
repair of paralabral cyst in the shoulder. J Shoulder Elbow Surg. 2015 Jan;24(1):e7-e14. doi:
10.1016/j.jse.2014.05.017. Epub 2014 Aug 28. PubMed

Question 97 of 100

During anatomic medial patellofemoral ligament (MPFL) reconstruction, the surgeon notes that the graft
is becoming too tight with greater knee flexion. What is the most likely cause?

A. Femoral attachment placed too distal

B. Femoral attachment placed too proximal
C. Patellar attachment placed too distal
D. Patellar attachment placed too proximal
Correct answer: B

 Discussion

If the graft becomes tighter with knee flexion, the femoral attachment is too proximal. This error is
referred to as “high and tight,” meaning that a high or proximal femoral attachment produces a graft
that is too tight with knee flexion. If graft tension increases with increasing knee flexion, the result is loss
of knee flexion or graft failure, increased contact forces resulting in patella femoral chondrosis, and
possibly medial subluxation.

 Recommended Readings

Stephen JM, Kaider D, Lumpaopong P, Deehan DJ, Amis AA. The effect of femoral tunnel
position and graft tension on patellar contact mechanics and kinematics after medial
patellofemoral ligament reconstruction. Am J Sports Med. 2014 Feb;42(2):364-72. doi:
10.1177/0363546513509230. Epub 2013 Nov 25. Erratum in: Am J Sports Med. 2016
Mar;44(3):NP11. PubMed

Burrus MT, Werner BC, Cancienne JM, Diduch DR. Correct Positioning of the Medial
Patellofemoral Ligament: Troubleshooting in the Operating Room. Am J Orthop (Belle Mead
NJ). 2017 Mar/Apr;46(2):76-81. PubMed

Question 98 of 100

Figure 1 is the radiograph of a 50-year old woman with lateral-sided left knee pain. She noticed the pain
over the last few months and has had no new injury. She had a microfracture performed of her lateral
femoral condyle 5 years ago. What is the likely cause of the finding noted on her radiograph?
 Figure 1

A. Uncontained cartilage lesion

B. Removal of the subchondral plate
C. Removal of the calcified cartilage layer
D. Failure to remove the calcified cartilage layer

Correct answer: B

 Discussion

The radiograph reveals bony overgrowth of the microfracture site on the lateral femoral condyle. This
occurs from violation of the subchondral plate during aggressive removal of the calcified cartilage layer
during the microfracture. It is important during a microfracture to attempt to have a contained lesion
and remove the calcified cartilage layer down to the subchondral plate, but avoid aggressively
penetrating the plate.
  Recommended Readings

Kaul G, Cucchiarini M, Remberger K, Kohn D, Madry H. Failed cartilage repair for early
osteoarthritis defects: a biochemical, histological and immunohistochemical analysis of the
repair tissue after treatment with marrow-stimulation techniques. Knee Surg Sports Traumatol
Arthrosc. 2012 Nov;20(11):2315-24. doi: 10.1007/s00167-011-1853-x. Epub 2012 Jan 6.
PubMed

Mithoefer K, Venugopal V, Manaqibwala M. Incidence, Degree, and Clinical Effect of

Subchondral Bone Overgrowth After Microfracture in the Knee. Am J Sports Med. 2016
Aug;44(8):2057-63. doi: 10.1177/0363546516645514. Epub 2016 May 17. PubMed

Question 99 of 100

A 29-year-old recreational basketball player has developed pain to the distal aspect of her patella that
occurs during warm-ups and returns toward the end of the game. She reports no history of trauma,
effusions, instability, and no mechanical symptoms. On examination, she is point tender at the inferior
pole of the patella, lacks patella apprehension, and has a Q-angle of 15°. She has no ligamentous laxity.
Radiographs are unremarkable. What is the best next step?

A. Therapy with an emphasis on eccentric exercises

B. Steroid injection
C. Platelet-rich plasma
D. Extracorporeal shock therapy

Correct answer: A

 Discussion

Patellar tendinopathy is a relatively common condition in athletes for which repetitive jumping is the
norm, especially volleyball and basketball athletes. The prevalence has been reported to be up to 32% in
professional basketball players. Initial management is nonoperative in nature with eccentric exercises
providing the most reliable clinical results. The other selections have not demonstrated consistent long-
term results.
  Recommended Readings

Kongsgaard M, Kovanen V, Aagaard P, Doessing S, Hansen P, Laursen AH, Kaldau NC, Kjaer
M, Magnusson SP. Corticosteroid injections, eccentric decline squat training and heavy slow
resistance training in patellar tendinopathy. Scand J Med Sci Sports. 2009 Dec;19(6):790-802.
doi: 10.1111/j.1600-0838.2009.00949.x. Epub 2009 May 28. PubMed

Figueroa D, Figueroa F, Calvo R. Patellar Tendinopathy: Diagnosis and Treatment. J Am Acad

Orthop Surg. 2016 Dec;24(12):e184-e192. Review. PubMed

Question 100 of 100

Figure 1 is the radiograph of an 11-year-old baseball pitcher who has had right shoulder pain for the past
3 months. He has full range of motion and normal strength in both external rotation and abduction,
although all tests cause him discomfort over the lateral and anterior shoulder. What is the most likely
basis for his injury?

Figure 1

A. Increased external rotation with an associated decrease in internal rotation

B. Excessive pitch counts
C. Use of breaking pitches such as sliders and curve balls
D. Congenital humeral cyst

Correct answer: B
  Discussion

The radiograph reveals a widened lateral physis at the proximal humerus, consistent with a physeal
stress fracture or “Little Leaguer’s shoulder.” Numerous studies have established that children and
adolescents are particularly prone to such overuse injuries. With regard to baseball participation, a
major contributor is over-pitching, i.e., excessive numbers of pitches, excessive innings pitched, and
insufficient rest days. Altered range of rotational motion, a gradual adaptation to the increased stresses
of throwing, can predispose to long-term injury, especially internal impingement and labral pathology. A
unicameral or aneurysmal bone cyst can often occur in the proximal humerus, but has a distinct
radiographic appearance and would predispose to fracture. There is evidence that breaking pitches
place increased stresses on the elbow and shoulder, but it remains controversial whether such throws
should be avoided at certain ages.

 Recommended Readings

Taylor DC, Krasinski KL. Adolescent shoulder injuries: consensus and controversies. J Bone
Joint Surg Am. 2009 Feb;91(2):462-73. PubMed

Heyworth BE, Kramer DE, Martin DJ, Micheli LJ, Kocher MS, Bae DS. Trends in the
Presentation, Management, and Outcomes of Little League Shoulder. Am J Sports Med. 2016
Jun;44(6):1431-8. doi: 10.1177/0363546516632744. Epub 2016 Mar 16. PubMed

Chen FS, Diaz VA, Loebenberg M, Rosen JE. Shoulder and elbow injuries in the skeletally
immature athlete. J Am Acad Orthop Surg. 2005 May-Jun;13(3):172-85. Full text