Sports Medicine Scored and Recorded Self-
Assessment Examination 2019
,Question 1 of 99
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?
A. Time to healing
B. Retear rate
C. Functional outcome scores
D. Postsurgical pain scores
PREFERRED RESPONSE: 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.
Question 2 of 99
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?
A. Recurrent instability
B. Degenerative joint disease
, C. Shoulder stiffness
D. Axillary nerve injury
PREFERRED RESPONSE: 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.
Question 3 of 99
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?
A. Open structural iliac crest graft
B. Open reduction and internal fixation
C. Arthroscopic coracoid transfer
D. Arthroscopic repair incorporating the bone lesion
PREFERRED RESPONSE: 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.
Question 4 of 99
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
PREFERRED RESPONSE: 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.
Question 5 of 99
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
PREFERRED RESPONSE: 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.
Question 6 of 99
Assessment Examination 2019
,Question 1 of 99
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?
A. Time to healing
B. Retear rate
C. Functional outcome scores
D. Postsurgical pain scores
PREFERRED RESPONSE: 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.
Question 2 of 99
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?
A. Recurrent instability
B. Degenerative joint disease
, C. Shoulder stiffness
D. Axillary nerve injury
PREFERRED RESPONSE: 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.
Question 3 of 99
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?
A. Open structural iliac crest graft
B. Open reduction and internal fixation
C. Arthroscopic coracoid transfer
D. Arthroscopic repair incorporating the bone lesion
PREFERRED RESPONSE: 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.
Question 4 of 99
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
PREFERRED RESPONSE: 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.
Question 5 of 99
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
PREFERRED RESPONSE: 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.
Question 6 of 99
