2013 Sports Medicine Self-Assessment Examination by Dr.Dhahirortho
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1
, 2013 Sports Medicine Self-Assessment Examination by Dr.Dhahirortho
Question 1Figure 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?
1. Open structural iliac crest graft
2. Open reduction and internal fixation
3. Arthroscopic coracoid transfer
4. Arthroscopic repair incorporating the bone lesion
DISCUSSION --The MRI scan shows a bony Bankart lesion
involving less than 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 more than 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. PREFERRED RESPONSE: 4
Question 2--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 degrees and 90 degrees. What is the
best treatment strategy at this time?
1. Physical therapy with a focus on quadriceps strengthening
2. Physical therapy and delayed posterior cruciate ligament (PCL) reconstruction
3. PCL reconstruction
4. PCL and posterolateral corner reconstruction
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. PREFERRED RESPONSE: 1
Question 3-Figure 3 is the clinical photograph of a 20-year-old college soccer player who has a
7-day history of worsening left ankle pain and swelling after being slide-tackled in a game.
Radiograph findings of his ankle and foot are normal. He complains of malaise. His history
includes a severe ankle sprain 3 months ago. The sprain caused him to miss half the season,
but he was able to play in the last 2 games. What is the most appropriate treatment?
116
1. Incision and drainage
3
, 2013 Sports Medicine Self-Assessment Examination by Dr.Dhahirortho
2. Ice the ankle but don't let him play.
3. Topical antibiotics for 7 days with an occlusive dressing
4. Debridement in the training room followed by 5 days of oral antibiotics
DISCUSSION--The clinical photograph shows a skin infection with an
appearance consistent with methicillin-resistant Staphylococcus aureus.
This infection should be clinically incised and allowed to drain and a
course of antibiotics should follow. If this infection is not promptly treated with debridement, it likely will
worsen and potentially spread to other teammates. Antibiotics are secondary to surgical debridement
but are a necessary adjunct. Although this patient has a history of severe sprain, his malaise and skin
appearance do not correlate with a ligament injury or fracture. Debridement in the training room is not
appropriate and would likely not fully decompress the fluid collection. PREFERRED RESPONSE: 1
RESPONSES FOR QUESTIONS 4 AND 5
1. Semimembranosis tendonitis
2. Patellar tendonitis
3. Iliotibial band friction syndrome
4. Quadriceps tendonitis
Please select the most likely diagnosis listed above for each clinical situation.
Question 4-A 23-year-old otherwise healthy 6-ft, 4-in basketball player complains of pain in his
knees. An examination reveals localized tenderness to palpation over the inferior pole of the
patella. The patient notes a significant exacerbation of his pain when the examiner takes the
knee from flexion to extension.
PREFERRED RESPONSE: 2
Question 5-A 22-year-old 6-ft, 2-in Olympic cyclist has had knee pain for 2 months.
Examination reveals localized tenderness to palpation over the lateral femoral epicondyle
most notably at 30 degrees of flexion.
PREFERRED RESPONSE: 3
DISCUSSION FOR QUESTIONS 4 AND 5
Patellar tendonitis is common in jumping sports such as basketball and volleyball. The pain is
localized to the inferior border of the patella and is exacerbated by extension of the knee. Treatment
for the vast majority of patients is nonsurgical and includes nonsteroidal anti-inflammatory drugs,
physical therapy,and orthoses (patella tendon strap). Iliotibial band friction most commonly occurs in
cyclists and runners (especially those who run up hills) and is a result of abrasion between the iliotibial
band and the lateral femoral condyle. Localized tenderness with the knee flexed at 30 degrees is
common. The Ober test may be helpful in making the diagnosis. Semimembranosis tendonitis most
commonly occurs in male athletes during their fourth decade of life. The diagnosis is usually made
with an MRI scan or nuclear imaging. Quadriceps tendonitis is similar to patellar tendonitis but is
much less common. The pain may be associated with clicking and is localized to the superior border
of the patella.
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, 2013 Sports Medicine Self-Assessment Examination by Dr.Dhahirortho
Question 6-A 26-year-old weightlifter had increasing pain in his left shoulder for 4 months.
Nonsurgical treatment consisting of anti-inflammatory medication, corticosteroid injections,
and rest failed to alleviate his symptoms. He underwent an arthroscopic distal clavicle
resection with excision of the distal 8 mm of clavicle (Mumford procedure). Three months after
surgery, he reported popping by his clavicle and mild pain. His clavicle demonstrated mild
posterior instability on examination without any obvious deformity on his radiographs. What
structures were compromised during his excision?
1. Anterior and superior acromioclavicular joint ligaments
2. Posterior and superior acromioclavicular joint ligaments
3. Conoid ligament
4. Trapezoid ligament
DISCUSSIO-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. PREFERRED RESPONSE: 2
CLINICAL SITUATION FOR QUESTIONS 7 THROUGH 9
Question 7-A 19-year-old female field hockey player has a right ankle injury that occurred last
night during a game.The patient is on crutches and states 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
revealed discoloration similar to a hematoma and significant swelling around the lateral ankle
area. Pain was elicited during palpation of the anterior talofibular ligament. What examination
test should be performed to aid in this diagnosis?
1. Thompson test
2. External rotation stress test
3. Anterior drawer test
4. Squeeze test
PREFERRED RESPONSE: 3
Question 8-Radiographs of the player’s right ankle confirm there are no fractures. With a
lateral talar tilt test result of 19 degrees, which additional structure is most likely damaged?
1. Deltoid ligament
2. Calcaneofibular ligament
3. Anterior tibiofibular ligament
4. Posterior tibiofibular ligament
PREFERRED RESPONSE: 2
Question 9-What is the most appropriate course of action for this patient’s condition?
1. Early mobilization and a guided proprioceptive and strengthening rehabilitation program
2. Extended immobilization in a cast
3. Surgical intervention
4. Weight bearing as tolerated in an ankle brace for 6 weeks
PREFERRED RESPONSE: 1 118
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114
1
, 2013 Sports Medicine Self-Assessment Examination by Dr.Dhahirortho
Question 1Figure 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?
1. Open structural iliac crest graft
2. Open reduction and internal fixation
3. Arthroscopic coracoid transfer
4. Arthroscopic repair incorporating the bone lesion
DISCUSSION --The MRI scan shows a bony Bankart lesion
involving less than 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 more than 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. PREFERRED RESPONSE: 4
Question 2--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 degrees and 90 degrees. What is the
best treatment strategy at this time?
1. Physical therapy with a focus on quadriceps strengthening
2. Physical therapy and delayed posterior cruciate ligament (PCL) reconstruction
3. PCL reconstruction
4. PCL and posterolateral corner reconstruction
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. PREFERRED RESPONSE: 1
Question 3-Figure 3 is the clinical photograph of a 20-year-old college soccer player who has a
7-day history of worsening left ankle pain and swelling after being slide-tackled in a game.
Radiograph findings of his ankle and foot are normal. He complains of malaise. His history
includes a severe ankle sprain 3 months ago. The sprain caused him to miss half the season,
but he was able to play in the last 2 games. What is the most appropriate treatment?
116
1. Incision and drainage
3
, 2013 Sports Medicine Self-Assessment Examination by Dr.Dhahirortho
2. Ice the ankle but don't let him play.
3. Topical antibiotics for 7 days with an occlusive dressing
4. Debridement in the training room followed by 5 days of oral antibiotics
DISCUSSION--The clinical photograph shows a skin infection with an
appearance consistent with methicillin-resistant Staphylococcus aureus.
This infection should be clinically incised and allowed to drain and a
course of antibiotics should follow. If this infection is not promptly treated with debridement, it likely will
worsen and potentially spread to other teammates. Antibiotics are secondary to surgical debridement
but are a necessary adjunct. Although this patient has a history of severe sprain, his malaise and skin
appearance do not correlate with a ligament injury or fracture. Debridement in the training room is not
appropriate and would likely not fully decompress the fluid collection. PREFERRED RESPONSE: 1
RESPONSES FOR QUESTIONS 4 AND 5
1. Semimembranosis tendonitis
2. Patellar tendonitis
3. Iliotibial band friction syndrome
4. Quadriceps tendonitis
Please select the most likely diagnosis listed above for each clinical situation.
Question 4-A 23-year-old otherwise healthy 6-ft, 4-in basketball player complains of pain in his
knees. An examination reveals localized tenderness to palpation over the inferior pole of the
patella. The patient notes a significant exacerbation of his pain when the examiner takes the
knee from flexion to extension.
PREFERRED RESPONSE: 2
Question 5-A 22-year-old 6-ft, 2-in Olympic cyclist has had knee pain for 2 months.
Examination reveals localized tenderness to palpation over the lateral femoral epicondyle
most notably at 30 degrees of flexion.
PREFERRED RESPONSE: 3
DISCUSSION FOR QUESTIONS 4 AND 5
Patellar tendonitis is common in jumping sports such as basketball and volleyball. The pain is
localized to the inferior border of the patella and is exacerbated by extension of the knee. Treatment
for the vast majority of patients is nonsurgical and includes nonsteroidal anti-inflammatory drugs,
physical therapy,and orthoses (patella tendon strap). Iliotibial band friction most commonly occurs in
cyclists and runners (especially those who run up hills) and is a result of abrasion between the iliotibial
band and the lateral femoral condyle. Localized tenderness with the knee flexed at 30 degrees is
common. The Ober test may be helpful in making the diagnosis. Semimembranosis tendonitis most
commonly occurs in male athletes during their fourth decade of life. The diagnosis is usually made
with an MRI scan or nuclear imaging. Quadriceps tendonitis is similar to patellar tendonitis but is
much less common. The pain may be associated with clicking and is localized to the superior border
of the patella.
117
4
, 2013 Sports Medicine Self-Assessment Examination by Dr.Dhahirortho
Question 6-A 26-year-old weightlifter had increasing pain in his left shoulder for 4 months.
Nonsurgical treatment consisting of anti-inflammatory medication, corticosteroid injections,
and rest failed to alleviate his symptoms. He underwent an arthroscopic distal clavicle
resection with excision of the distal 8 mm of clavicle (Mumford procedure). Three months after
surgery, he reported popping by his clavicle and mild pain. His clavicle demonstrated mild
posterior instability on examination without any obvious deformity on his radiographs. What
structures were compromised during his excision?
1. Anterior and superior acromioclavicular joint ligaments
2. Posterior and superior acromioclavicular joint ligaments
3. Conoid ligament
4. Trapezoid ligament
DISCUSSIO-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. PREFERRED RESPONSE: 2
CLINICAL SITUATION FOR QUESTIONS 7 THROUGH 9
Question 7-A 19-year-old female field hockey player has a right ankle injury that occurred last
night during a game.The patient is on crutches and states 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
revealed discoloration similar to a hematoma and significant swelling around the lateral ankle
area. Pain was elicited during palpation of the anterior talofibular ligament. What examination
test should be performed to aid in this diagnosis?
1. Thompson test
2. External rotation stress test
3. Anterior drawer test
4. Squeeze test
PREFERRED RESPONSE: 3
Question 8-Radiographs of the player’s right ankle confirm there are no fractures. With a
lateral talar tilt test result of 19 degrees, which additional structure is most likely damaged?
1. Deltoid ligament
2. Calcaneofibular ligament
3. Anterior tibiofibular ligament
4. Posterior tibiofibular ligament
PREFERRED RESPONSE: 2
Question 9-What is the most appropriate course of action for this patient’s condition?
1. Early mobilization and a guided proprioceptive and strengthening rehabilitation program
2. Extended immobilization in a cast
3. Surgical intervention
4. Weight bearing as tolerated in an ankle brace for 6 weeks
PREFERRED RESPONSE: 1 118
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