Sports OITE - 2012 2013 2014

Sports
University of Pennsylvania Department of Orthopaedic Surgery

2012-09 (Sports)
• Arthroscopic remplissage of the shoulder is

most indicated for patients with?

• 1. irreparable subscapularis tear.
• 2. irreparable supraspinatus tendon tear.
• 3. large (>25%) glenoid rim deficiency.
• 4. large (>25%) humeral head deficiency.
• 5. glenohumeral internal rotation deficit.
2012-09 (Sports)
• Arthroscopic remplissage of the shoulder is

most indicated for patients with?

• 1. irreparable subscapularis tear.
• 2. irreparable supraspinatus tendon tear.
• 3. large (>25%) glenoid rim deficiency.
• 4. large (>25%) humeral head
deficiency.
• 5. glenohumeral internal rotation deficit.
2012-09 (Sports)
• Remplissage is a procedure performed for shoulder

instability where the posterior capsule and infraspinatous
tendon are sutured into a large Hill-Sachs lesion on the
humeral head. The criteria for a large Hill-Sachs is
involvement of 25% of the humeral head or an ‘engaging’
Hill-Sachs lesion. The paper cited reports good results with
combined arthroscopic Bankart and remplissage in patients
with anterior instability.
2012-36 (Sports)
Figures 36a and 36b are the clinical photographs of a 35-year-old man seen 3
months after repair of an acute Achilles tendon rupture. He has no constitutional
symptoms and is unable to perform a single heelrise test. The most appropriate
treatment is?

1. swab culture of the sinus tract and appropriate oral antibiotics for 6 weeks
followed by Achilles reconstruction.
2. excision of the distal Achilles tendon with flexor hallucis longus tendon transfer to
the calcaneus followed by culture-specific intravenous antibiotics for 12 weeks.
3. debridement of the Achilles tendon followed by culture-specific intravenous
antibiotics for 6 weeks.
4. debridement of the Achilles tendon with free-flap application and culture-specific
intravenous antibiotics for 6 weeks.
5. debridement of the Achilles tendon with turndown procedure and culture-specific
intravenous antibiotics for 12 weeks.
3. Debridement of the Achilles tendon followed by culture-specific intravenous
antibiotics for 6 weeks. This patient clearly has a post-surgical infection after
Achilles tendon repair. Treatment principles include removal of all infected material
and treatment with IV antibiotics. Reconstruction can be performed at a later date
but first goal is to clear the infection. The patient may need a free flap in the future
and may need augmentation with FHL or a gastoc turn down but all of these options
are AFTER the infection has been cleared and treated with antibiotics. Swab and
oral antibiotics is not an apprpriate treatment in this deep infection.
2012-41 (Sports)
What is the occurrence ratio of noncontact anterior cruciate ligament (ACL) injuries
among men and women (men:women)?

1. 1:1 ACL injuries occur more commonly in women by a ratio of 9:1, are frequently
contact injuries, and are related primarily to the cyclical effects of sex hormones on
ligament tensile strength.
2. 4.5:1 ACL injuries occur more commonly in men by ratio of 1.5:1, are frequently
contact injuries, and may be related to neuromuscular characteristics of jumping and
landing.
3. 1:4.5. ACL injuries occur more commonly in women by a ratio of 4.5:1 and are
frequently noncontact injuries; a genotype within the COL5A1 gene is associated with
reduced risk for ACL ruptures in women.
4. 2:1 ACL injuries occur more commonly in men by a ratio of 2.5:1 and are frequently
noncontact injuries; a genotype within the COL5A1 gene is associated with increased
risk for ACL ruptures in men.
5. 1:2. ACL injuries occur more commonly in women by a ratio of 2:1, are frequently
noncontact injuries, and may be related to neuromuscular characteristics of jumping
and landing.
3. 1:4.5. ACL injuries occur more commonly in women by a ratio of 4.5:1 and
are frequently noncontact injuries; a genotype within the COL5A1 gene is
associated with reduced risk for ACL ruptures in women.
Females are at increased risk of ACL injuries when compared to males with a
male:female injury ration of 1:4.5. In females these injuries are more often
noncontact injuries. Other factors that help explain the increased incidence in women
include neuromuscular forces and control, landing biomechanics, smaller femoral
notches, genetic factors related to collagen production, smaller ligaments, hormone
levels, and valgus leg alignment.Posthumus et al. found that the CC genotype of the
COL5A1 BstUI RFLP was underrepresented in female participants with ACL
ruptures. This is the first study to show that there is a specific genetic risk factor
associated with risk of ACL ruptures in female athletes. Female subjects preparing
for landing with decreased hip and knee flexion at landing, increased quadriceps
activation, and decreased hamstring activation, which may result in increased ACL
loading and risk for noncontact ACL injury.
2012-72 (Sports)
• 72. The femoral origin of the medial patellofemoral

ligament is located between what two anatomic
• landmarks?
•
• 1. Medial epicondyle and adductor tubercle
• 2. Medial epicondyle and gastrocnemius tubercle
• 3. Adductor tubercle and gastrocnemius tubercle
• 4. Adductor tubercle and medial collateral ligament
• 5. Medial epicondyle and semimembranosus tibial insertion
Sports
• 72. The femoral origin of the medial patellofemoral

ligament is located between what two anatomic
• landmarks?
• 1. Medial epicondyle and adductor tubercle
• 2. Medial epicondyle and gastrocnemius tubercle
• 3. Adductor tubercle and gastrocnemius tubercle
• 4. Adductor tubercle and medial collateral ligament
• 5. Medial epicondyle and semimembranosus tibial insertion
• The femoral insertion of the MPFL lies between the adductor tubercle and
the medial epicondyle as shown in the picture.
2012-86 (Sports)
A 20-year-old collegiate pitcher has a 6-week history of pain

and stiffness when throwing, which has caused a decrease in
maximal velocity and the inability to pitch competitively.
Examination reveals tenderness over the medial collateral ligament. An
MRI scan shows increased signal in the anterior band of the ulnar
collateral ligament without a full-thickness tear. What is the most
appropriate treatment?
• 1. Immobilization of the elbow

• 2. Continue throwing as tolerated
• 3. Arthroscopic evaluation and debridement
• 4. Medial collateral ligament reconstruction
• 5. Flexor pronator strengthening and gradual return to sports

Sports Medicine
Question 86
A 20-year-old collegiate pitcher has a 6-week history of pain

and stiffness when throwing, which has caused a decrease in
maximal velocity and the inability to pitch competitively.
Examination reveals tenderness over the medial collateral ligament. An
MRI scan shows increased signal in the anterior band of the ulnar
collateral ligament without a full-thickness tear. What is the most
appropriate treatment?
• 1. Immobilization of the elbow

• 2. Continue throwing as tolerated
• 3. Arthroscopic evaluation and debridement
• 4. Medial collateral ligament reconstruction
• 5. Flexor pronator strengthening and gradual return to sports

Explanation
• This patient had an insidious onset of pain

over the medial collateral ligament of the the
elbow. MRI did not demonstrate a full
thickness tear. The mainstay of treatment
for MCL insufficiency of the elbow is a period
of rest followed by Rehabilitation. Rettig et al.
reported on their outcomes of non-operative
treatment of these injuries. Nonoperative
treatment, which included a minimum of 3
months’ rest with rehabilitation exercises,
allowed 42% of the athletes to return to their
original level of competition.

2012-94 (Sports)
• Figure 94 is a sagittal knee MRI scan of an

injured 25-year-old man. What is the most
likely diagnosis?
• 1. Osteochondritis dissecans
• 2. Lateral patella dislocation
• 3. Discoid lateral meniscus tear
• 4. Anterior cruciate ligament tear
• 5. Bucket-handle lateral meniscus tear
Question 94
Question 94
• Figure 94 is a sagittal knee MRI scan of an

injured 25-year-old man. What is the most
likely diagnosis?
• 1. Osteochondritis dissecans
• 2. Lateral patella dislocation
• 3. Discoid lateral meniscus tear
• 4. Anterior cruciate ligament tear
• 5. Bucket-handle lateral meniscus tear
Question 94
• The sagittal MRI image shown in this question shows the most common pattern
of bone bruising that occurs in ACL tears, which is seen on the posterolateral
tibia and middle 1/3 of the lateral femoral condyle.
–
• Bone bruise patterns in ACL injuries correlate with the direction of the abnormal
anterior translation and abutment of the posterolateral tibia against the middle
1/3 of the lateral femur during the injury.
• Viskontas et al., in a prospective cohort study, looked at the correlation
between the mechanism of ACL injury and presence of bone bruise patterns in
100 patients. They found that bone bruising was more frequent, deeper, and
more intense in non-contact ACL injuries (P < .001).
• Yoon et al. reviewed 81 patients with bone contusions and associated meniscal
and medial collateral ligament (MCL) injuries in patients with anterior cruciate
ligament ruptures. They found patients with more severe bone contusions
tended to have more concomitant injuries of the menisci and the MCL.
2012-99 (Sports)
• A 14-year-old girl reports a 6-week history of diffuse pain in both knees
after attending cheerleading camp. There was no obvious traumatic event.
She denies any symptoms of locking or significant swelling, but states her
knees ‘give-way’ and ‘click’ occasionally. She has no other joint problems
and denies any history of similar symptoms. Examination is unremarkable
with the exception of global discomfort to palpation of both knees.
radiographs also are unremarkable. What is the most appropriate next
treatment step?
• 1. MRI scan of both knees

• 2. Corticosteroid injection into both knees
• 3. Bone scan with pinhole views of both knees
• 4. Bloodwork to rule-out a rheumatologic condition
• 5. Physical therapy regimen to both lower extremities
Question 99
• A 14-year-old girl reports a 6-week history of diffuse pain in both knees
after attending cheerleading camp. There was no obvious traumatic event.
She denies any symptoms of locking or significant swelling, but states her
knees ‘give-way’ and ‘click’ occasionally. She has no other joint problems
and denies any history of similar symptoms. Examination is unremarkable
with the exception of global discomfort to palpation of both knees.
radiographs also are unremarkable. What is the most appropriate next
treatment step?
• 1. MRI scan of both knees

• 2. Corticosteroid injection into both knees
• 3. Bone scan with pinhole views of both knees
• 4. Bloodwork to rule-out a rheumatologic condition
• 5. Physical therapy regimen to both lower extremities
Question 99
• The patient's clinical presentation is most consistent with an overuse
syndrome, most likely patellofemoral in nature, and is most appropriately
initially treated with a physical therapy regimen emphasizing quadriceps
(including VMO) as well as hip and core strengthening in a non-painful
fashion.
• Patellofemoral pain is the most common condition affecting adolescents and

is thought to have several different etiologies including biologic, mechanical,
and emotional causes.
• Dalton’s review of adolescent athlete injuries reports that overuse or

repetitive trauma injuries comprise approximately 50% of all pediatric sport-
related injuries.
• Outerbridge and Micheli present a Level 5 review discussing that adolescents

are susceptible to overuse injuries just as adults are, but also are at risk for
injuries due to their immature skeleton at the epiphyseal plate and
apophysis.
2012-113 (Sports)
The femoral insertion of the superficial medial collateral ligament is represented
by which letter on Figure 113?

1. A
2. B
3. C
4. D
5. E
Question 113

1. A
2. B
3. C
4. D
5. E

Question 113

1. A
2. B
3. C
4. D
5. E

RECOMMENDED READINGS:
•Wijdicks CA, Griffith CJ, LaPrade RF, Johansen S, Sunderland A, Arendt EA,
Engebretsen L. Radiographic identification of the primary medial knee
structures. J Bone Joint Surg Am. 2009 Mar 1;91(3):521-9. PubMed PMID:
19255211.
•Wijdicks CA, Griffith CJ, Johansen S, Engebretsen L, LaPrade RF. Injuries to
the medial collateral ligament and associated medial structures of the knee. J
Bone Joint Surg Am. 2010 May;92(5):1266-80. Review. PubMed PMID:
20439679.

Question 113

1. A
2. B
3. C
4. D
5. E

EXPLANATION:
This figure is from the Wijdicks et al. JBJS 2009 article demonstrating a method for identification of the
medial knee structures on plain radiography. The superficial MCL femoral insertion (sMCL) is located
in the distal-anterior quadrant (#3) as shown.

2012-168 (Sports)
A 21-year-old Division I collegiate football player sustained the injury

shown in Figures 168a through 168c. Which of the following
interventions is the optimal treatment for return to play?

1. Injection of platelet-rich plasma
2. Surgical treatment with cannulated screw fixation
3. Open reduction and internal fixation with modular locking plate
4. Short-leg casting for 6 weeks followed by conversion to a walker
boot and return to play
5. Short-leg casting for 6 weeks followed by conversion to a total-
contact insert with a carbon
fiber footplate
168
168
A 21-year-old Division I collegiate football player sustained the injury

shown in Figures 168a through 168c. Which of the following
interventions is the optimal treatment for return to play?

1. Injection of platelet-rich plasma
2. Surgical treatment with cannulated screw fixation
3. Open reduction and internal fixation with modular locking plate
4. Short-leg casting for 6 weeks followed by conversion to a walker
boot and return to play
5. Short-leg casting for 6 weeks followed by conversion to a total-
contact insert with a carbon
fiber footplate
168 - Explanation
• Intramedullary screw fixation is a reliable way to fix Jones

fractures, with excellent healing results and an average return to
full competition of 8.5 weeks.
• Full-weight bearing is initiated one week post-op.
• Consider this option in patients who desire quick return to full

activities or will have difficulty with a non-weight bearing cast.
2012-192 (Sports)
Excessive resection of a posterior olecranon

osteophyte in an overhead-throwing athlete with
medial ulnar collateral insufficiency may result in?

1. loss of flexion.
2. loss of extension.
3. varus instability.
4. valgus instability.
5. excessive lateral ulnar collateral ligament strain.
Question 192
Excessive resection of a posterior olecranon
osteophyte in an overhead-throwing athlete with
medial ulnar collateral insufficiency may result in?

1. loss of flexion.
2. loss of extension.
3. varus instability.
4. valgus instability.
5. excessive lateral ulnar collateral ligament strain.
• The anterior bundle of the MCL is the primary stabilizer of the elbow to valgus stress. The
other less important components of the MCL are the posterior and transverse bundles.
• The flexor pronator mass is an important dynamic stabilizer to the medial elbow.
• The radial head and olecranon are also important static stabilizers to valgus stability of the
elbow.
• Range of strain to failure of the MCL is roughly 10-30%.
• Repetitive overhead throwers are at risk for valgus extension overload syndrome.
• This results from posteromedial olecranon osteophyte formation and MCL injury.
• It has been common practice to resect this osteophyte as well as some posteromedial
olecranon.
• Sequential resection of the posteromedial olecranon increasing by 3mm at a time
consistently increases strain across the MCL.
• This suggests that the static stabilizing function of the anterior bundle of the MCL is
augmented considerably by other static and dynamic structures during such throwing
activities and injury to these other structures places the MCL at risk of rupture.
• In summary Resection of the posteromedial bone of the olecranon beyond the osteophytic
margin potentially places the anterior bundle of the medial collateral ligament in jeopardy of
rupture. The current recommendation in patients with valgus extension overload syndrome
and symptomatic posteromedial osteophytosis is to resect the osteophytes only
• In the setting of fracture/tumor/infection up to 75% of the olecranon can be resected with
out catastrophic failure in the face of varus and valgus stress. Above this percentage of
resection there is danger of resecting the ulnar attachments of the MCL and LUCL.
• With 75% resection of the olecranon there remains 70% of normal varus/valgus stability of
the elbow.
• With respect to excision and
triceps advancement, when
considering the percentage of
olecranon that can safely be removed,
measurement only includes the articulating
aspect of the olecranon and not the tip.
2012-198 (Sports)
A 30-year-old distance runner has a 6-week history of

midsubstance Achilles tendon pain and swelling. After an
initial period of immobilization, a course of rehabilitation was
recommended. The most appropriate rehabilitation regimen
includes?

1. an eccentric exercise program.
2. a concentric exercise program.
3. passive range of motion exercises alone.
4. a combination of concentric and passive rehabilitation.
5. manual manipulation without progressive strengthening.
Question 198
A 30-year-old distance runner has a 6-week history of
midsubstance Achilles tendon pain and swelling. After an
initial period of immobilization, a course of rehabilitation
was recommended. The most appropriate rehabilitation
regimen includes?

1. an eccentric exercise program.
2. a concentric exercise program.
3. passive range of motion exercises alone.
4. a combination of concentric and passive rehabilitation.
5. manual manipulation without progressive
strengthening.
• Tendinosis is defined as gradual onset of pain in the Achilles tendon
and structural changes on ultrasonography or MRI.
• The histologic characteristics of Achilles tendinosis are an area with
a high concentration of glycosaminoglycans and irregular fiber
structure and arrangement, but no inflammatory cell infiltrates.
• There is no chemical inflammation involved in the chronic stage of
this condition
• Treatment of painful mid-portion chronic Achilles tendinosis with
eccentric calf muscle training results in decreased tendon thickness
and a normalized tendon structure in the area with tendinosis.
• These findings are confirmed with both ultrasonographic and MR
imaging modalities.
• These results continue to persist in up to 3.8 yrs of follow up.
• Decreased tendon thickness may be due to reduced
neovascularization in the area with tendinosis, induced by the
eccentric training
• In general, for chronic tendon conditions, eccentric rehab is the way
to go.
2012-231 (Sports)
The clinical diagnosis of an injury to the posterior

branch of the axillary nerve is best determined with
assessment of sensation over the?

1. lateral deltoid and the Jobe test.
2. lateral deltoid and the Hornblower’s test.
3. anterior deltoid and the lift-off test.
4. anterior deltoid and the abdominal compression
test.
5. posterior deltoid and the active compression test.

Question 231
The clinical diagnosis of an injury to the posterior

branch of the axillary nerve is best determined with
assessment of sensation over the?

1. lateral deltoid and the Jobe test.
2. lateral deltoid and the Hornblower’s test.
3. anterior deltoid and the lift-off test.
4. anterior deltoid and the abdominal compression
test.
5. posterior deltoid and the active compression test.

According to the anatomic study by Ball et al., the posterior
branch of the axillary nerve has an intimate association with the
inferior aspects of the glenoid and shoulder joint capsule, which
may place it at particular risk during capsular plication or thermal
shrinkage procedures. The superior-lateral brachial cutaneous
nerve (which is responsible for sensation over the lateral deltoid)
and the nerve to the teres minor (which is evaluated with
Hornblower’s test) always arise from the posterior branch of the
axillary nerve. The correct answer is therefore (2) lateral deltoid
and the Hornblower’s test.
RECOMMENDED READINGS:
Ball CM, Steger T, Galatz LM, Yamaguchi K. The posterior branch
of the axillary nerve: an anatomic study. J Bone Joint Surg Am.
2003 Aug;85-A(8):1497-501. PubMed PMID: 12925629.
Uno A, Bain GI, Mehta JA. Arthroscopic relationship of the axillary
nerve to the shoulder joint capsule: an anatomic study. J Shoulder
Elbow Surg. 1999 May-Jun;8(3):226-30. PubMed PMID:
10389077.
Price MR, Tillett ED, Acland RD, Nettleton GS. Determining the
relationship of the axillary nerve to the shoulder joint capsule
from an arthroscopic perspective. J Bone Joint Surg Am. 2004
Oct;86-A(10):2135-42. PubMed PMID: 15466721.

2012-249 (Sports)
Figures 249a and 249b are the plain radiographs of a 14-year-old

healthy, active boy who sustained an anterior cruciate ligament
injury while playing football. Which of the following reconstruction
techniques is associated with the highest likelihood of growth
disturbance?
1. Iliotibial band tenodesis with over-the-top femoral fixation

2. Tibialis anterior allograft reconstruction with cross-pin fixation
3. Bone-patellar tendon-bone autograft with interference screw
fixation
4. Hamstring reconstruction with over-the-top staple fixation
5. Hamstring reconstruction with suspensory femoral and tibial post-
and-washer fixation
Images
Answer
• Question 249
Figures 249a and 249b are the plain radiographs of a 14-year-old
healthy, active boy who sustained an anterior cruciate ligament
injury while playing football. Which of the following reconstruction
techniques is associated with the highest likelihood of growth
disturbance?
1. Iliotibial band tenodesis with over-the-top femoral fixation

2. Tibialis anterior allograft reconstruction with cross-pin fixation
3. Bone-patellar tendon-bone autograft with interference
screw fixation
4. Hamstring reconstruction with over-the-top staple fixation
5. Hamstring reconstruction with suspensory femoral and tibial post-
and-washer fixation
Explanation
In a meta-analysis by Frosch et al. bone-patellar tendon-bone graft (compared to hamstring), all
epiphyseal-sparing techniques (compared to transphyseal) were associated with a HIGHER risk of leg-
length discrepancy. Another more recent review by Frank et al. describes risk factors for growth
disturbance to be: fixation hardware across the physis, large tunnels (>12mm), lateral extra-articular
tenodesis, disection in proximity to the perichondral ring of LaCroix, and suturing near the tibial tubercle.
Iliotibial band tenodesis with over-the-top femoral fixation, tibialis anterior allograft reconstruction with
cross-pin fixation, hamstring reconstruction with over-the-top staple fixation, and hamstring
reconstruction with suspensory femoral and tibial post-and-washer fixation all use techniques where at
least one physis is violated, therefore providing a LOWER risk of leg-length discrepancy compared to all-
epiphyseal techniques and bone-patellar tendon-bone grafts.
•RECOMMENDED READINGS:
Kocher MS, Smith JT, Zoric BJ, Lee B, Micheli LJ. Transphyseal anterior cruciate ligament reconstruction
in skeletally immature pubescent adolescents. J Bone Joint Surg Am. 2007 Dec;89(12):2632-9. PubMed
PMID: 18056495.
Frosch KH, Stengel D, Brodhun T, Stietencron I, Holsten D, Jung C, Reister D, Voigt C, Niemeyer P,
Maier M, Hertel P, Jagodzinski M, Lill H. Outcomes and risks of operative treatment of rupture of the
anterior cruciate ligament in children and adolescents. Arthroscopy. 2010 Nov;26(11):1539-50. Review.
PubMed PMID: 21035009.
2012-257 (Sports)
The primary function of the posterior oblique ligament of the knee is to

resist?
1. internal tibial rotation in full extension.

2. external tibial rotation in full extension.
3. external tibial rotation at 90 degrees of flexion.
4. anterior tibial translation in full extension.
5. posterior tibial translation at 90 degrees of knee flexion.

Question 257 – Preferred Response
The primary function of the posterior oblique ligament of the knee is to

resist?
1. internal tibial rotation in full extension.

2. external tibial rotation in full extension.
3. external tibial rotation at 90 degrees of flexion.
4. anterior tibial translation in full extension.
5. posterior tibial translation at 90 degrees of knee flexion.

Question 257 - Explanation
In the study cited below and performed by Griffith et

al . They tested 24 non-paired Fresh frozen
cadaveric knees buckle transducers were applied to
superficial medial collateral and posterior oblique
ligaments. With regard to this question the greatest
loads were felt by the posterior oblique ligament
when the knee was placed in internal rotation, these
forces were maximized near full extension. See
image for POL = Posterior Oblique ligament, this
function is also relatively intuitive in consideration of
its position.
Recommended reading:
Griffith CJ, Wijdicks CA, LaPrade RF, Armitage BM, Johansen S,
Engebretsen L. Force measurements on the posterior oblique
ligament and superficial medial collateral ligament proximal and distal
divisions to applied loads. Am J Sports Med. 2009 Jan;37(1):140-8.
Epub 2008 Aug 25. PubMed PMID: 18725650.
Tibor LM, Marchant MH Jr, Taylor DC, Hardaker WT Jr, Garrett WE
Jr, Sekiya JK. Management of
medial-sided knee injuries, part 2: posteromedial corner. Am J Sports
Med. 2011 Jun;39(6):1332-40. Epub 2010 Dec 20. Review. PubMed
PMID: 21173192.

Sports Question 23
During preparticipation physicals for college football, an athlete

tests positive for the sickle-cell trait. With regards to clearance
to play, his team physician should?
1) Counsel the athlete about his personal risk for bone infarcts
2) Recommend a prophylactic splenectomy prior to
participation
3) Bar the athlete from participating in NCAA sanctioned
events
4) Assure the athlete that he can participate in football without
concerns
5) Ensure that the athlete is given adequate recovery time and
remains hydrated.
Sports Question 23
During preparticipation physicals for college football, an athlete

tests positive for the sickle-cell trait. With regards to clearance
to play, his team physician should?
1) Counsel the athlete about his personal risk for bone infarcts
2) Recommend a prophylactic splenectomy prior to
participation
3) Bar the athlete from participating in NCAA sanctioned
events
4) Assure the athlete that he can participate in football without
concerns
5) Ensure that the athlete is given adequate recovery time and
remains hydrated.
Sports Question 23
• Otherwise unexplained, exertion related death is

higher in those with sickle cell trait than the
general population and an emphasis on
hydration, recovery, and modification of activity
in extreme conditions is recommended.
• Kark J, Posey DM, Schumacher HR, Ruehle CJ.
Sickle-Cell Trait As A Risk Factor For Sudden
Death in Physical Training. N Engl J Med.
1987;317(13):781-7.
Sports
39
Figure 39 is the anteroposterior radiograph of a marathon runner

who has left groin pain that prevents her from running. She recently
got back into her usual running routine after an ankle injury
prevented her from running for several months. She now has pain
with any weight bearing. What is the most appropriate treatment
option?
1. Hip resurfacing arthroplasty
2. Hip arthroscopy with removal of the cam lesion
3. Internal fixation of the femoral neck with multiple screws
4. Trial of nonsurgical treatment with no weight bearing on
the left leg
5. Vitamin D level assessment and supplementation with
50000 units weekly
39
Figure 39 is the anteroposterior radiograph of a marathon runner

who has left groin pain that prevents her from running. She recently
got back into her usual running routine after an ankle injury
prevented her from running for several months. She now has pain
with any weight bearing. What is the most appropriate treatment
option?
1. Hip resurfacing arthroplasty
2. Hip arthroscopy with removal of the cam lesion
3. Internal fixation of the femoral neck with multiple
screws
4. Trial of nonsurgical treatment with no weight bearing on
the left leg
5. Vitamin D level assessment and supplementation with
50000 units weekly
What does she have?
•Femoral neck stress fx
Do you always have to
operate?
•No-when on compression
side and fatigue line <50%
FNW can perform trial of NWB
Where is hers?
•Compression side, but
extensive with loss of inferior
neck scalloping
Surgically fix tension sided femoral neck stress fractures and compression side fx when
fatigue line >50%!
Shin AY, Gillingham BL. Fatigue fractures of the femoral neck in athletes. J Am Acad Orthop Surg. 1997 Nov;5(6):293-302. PubMed PMID: 10795065.
Hajek MR, Noble HB. Stress fractures of the femoral neck in joggers: case reports and review of the literature. Am J Sports Med. 1982 Mar-Apr;10(2):112-6. PubMed
PMID: 7081524.
Sports
42
Denervation most typically associated with the finding seen in Figure

42 results in which characteristic finding?
1. Internal rotation weakness
2. External rotation weakness in adduction
3. External rotation weakness in abduction
4. No noticeable weakness of shoulder
5. Forward flexion and weakness (more than 90 degrees)
This is one frame of an imbedded video
Sports
42
Denervation most typically associated with the finding seen in Figure

42 results in which characteristic finding?
1. Internal rotation weakness
2. External rotation weakness in adduction
3. External rotation weakness in abduction
4. No noticeable weakness of shoulder
5. Forward flexion and weakness (more than 90 degrees)
• Whats the pathology?
– Spinoglenoid notch ganglion cyst
• What nerve runs in the
spinoglenoid notch?
– Suprascapular nerve
• What does it innervate?
– Supraspinatous and
infraspinatous m.
• Spinoglenoid cysts cause isolated
deinnervation of infraspinatous
• Bring it all home-what is the function of infraspinatous?
– External rotation in adduction
Spinoglenoid notch cysts causes atrophy of infraspinatous and loss of external

rotation in adduction.
Piatt BE, Hawkins RJ, Fritz RC, Ho CP, Wolf E, Schickendantz M. Clinical evaluation and treatment of spinoglenoid notch ganglion cysts. J Shoulder Elbow Surg. 2002 Nov-
Dec;11(6):600-4. PubMed PMID:12469086.
Westerheide KJ, Dopirak RM, Karzel RP, Snyder SJ. Suprascapular nerve palsy secondary to spinoglenoid cysts: results of arthroscopic treatment. Arthroscopy. 2006
Jul;22(7):721-7. PubMed PMID: 16843807.
Piasecki DP, Romeo AA, Bach BR Jr, Nicholson GP. Suprascapular neuropathy. J Am Acad Orthop Surg. 2009 Nov;17(11):665-76. Review. PubMed PMID: 19880677.
SPORTS MEDICINE 51
A 36-year-old man who was playing recreational basketball felt a pop
in the back of his leg and is now unable to walk. Rest, ice, and
elevation have been ineffective at restoring his leg. Examination
reveals pain over the posterior calf, some ecchymosis, and weak
plantar flexion strength. A Thompson test result is positive. Compared
with nonsurgical treatment, surgical treatment is more likely to
• 1. carry a lower risk for equinus contracture.

• 2. restore strength (closer to usual levels).
• 3. reduce risk for rerupture.
• 4. allow for quicker ambulation and recovery.
• 5. result in better outcomes on blind
randomized studies.
51
A 36-year-old man who was playing recreational basketball felt a pop
in the back of his leg and is now unable to walk. Rest, ice, and
elevation have been ineffective at restoring his leg. Examination
reveals pain over the posterior calf, some ecchymosis, and weak
plantar flexion strength. A Thompson test result is positive. Compared
with nonsurgical treatment, surgical treatment is more likely to
• 1. carry a lower risk for equinus contracture.

• 2. restore strength (closer to usual levels).
• 3. reduce risk for rerupture.
• 4. allow for quicker ambulation and recovery.
• 5. result in better outcomes on blind
randomized studies.
51
• The benefit of operative management of achilles tendon
rupture is a reduction in the rate of re-rupture, though an
increased risk of wound complication exists.
• Willits et al, JBJS 2010: RCT comparing operative treatment + accelerated

functional rehab v. accelerated functional rehab alone showed no
statistically significant decrease in rerupture in operative group (2 of 72 v.
3 of 72); affected limbs in both groups achieved 80% plantarflexion and
100% dorsiflexion compared to unaffected limb at 2yrs; no difference in
strength or tendon thickness
• Keating et al, JBJS 2011: RCT comparing operative + ___ v. non-operative
in cast immobilization showed a non-statistically significant reduction in
achliles tendon re-rupture (5% v. 10%, p=0.68). There was a statistically
significant improvement in plantarflexion in operative group at 3 months,
which was equivocal at 1 yr followup. Similarly, peak torque differences for
plantarflexion and dorsiflexion, strength and SMFA scores were equivalent
between groups.
Sports
Question 83
A 20-year-old collegiate rower has pain along the left side of his chest just
anterior to the midaxillary line. The pain began approximately 4 weeks after he
started preseason training. The pain occurs almost immediately after he begins
rowing and goes away when he stops. He has not noticed the pain while
running. Which study will most likely reveal the diagnosis?
1. Echocardiogram
2. Electrocardiogram
3. 3-phase bone scan
4. Rib series radiographs
5. Posteroanterior chest radiograph

Question 83
A 20-year-old collegiate rower has pain along the left side of his chest just
anterior to the midaxillary line. The pain began approximately 4 weeks after he
started preseason training. The pain occurs almost immediately after he begins
rowing and goes away when he stops. He has not noticed the pain while
running. Which study will most likely reveal the diagnosis?
1. Echocardiogram
2. Electrocardiogram
3. 3-phase bone scan
4. Rib series radiographs
5. Posteroanterior chest radiograph

Question 83 Explained
• McDonnell LK, Hume PA, Nolte V. Rib stress fractures among

rowers: definition, epidemiology, mechanisms, risk factors and
effectiveness of injury prevention strategies. Sports Med. 2011
Nov 1;41(11):883-901.
– A rib stress fracture is an incomplete fracture occurring from an imbalance
between the rate of bone resorption and the rate of bone formation. RSF occurs
in 8.1–16.4% of elite rowers
– If the strain rate, or magnitude/frequency of mechanical loading exceeds the
ability of the bone to adapt, an accumulation of microdamage occurs leading to
stress fracture.
– Most occur in anterolateral aspects of middle ribs
– Symptoms: lateral chest pain, worse with activity, pain with deep breathing and
shoulder ROM
– DDX: Serratus anterior strain, intercostal strain, Ewing’s sarcoma
– Dx: XR, bone scan, MRI
– Injury management involves 1-2 weeks of rest and analgesics followed by slow
return to rowing with low-impact intensity.
– Bone scan is more sensitive than XR and can precede positive XR findings by 2
weeks. This modality should be used for diagnosis of rib stress fractures.
Sports
99: A 42-year-old man has a chondral defect of the medial femoral condyle that is
approximately 1 cm in diameter. He has a very athletic lifestyle, wishes to remain
active, and is now seeking a third opinion. He has seen 2 orthopaedic surgeons;
the first surgeon recommended microfracture for the chondral defect, and the other
recommended an osteochondral autograft transplantation (OATS). What should the
patient be told?
1: Recovery is faster with microfracture, the outcomes are better with OATS, and
both techniques produce the same reparative surface.
2: Recovery is faster with OATS, the outcomes are better with microfracture, and
3: The outcomes are better with OATS, rehabilitation is faster with OATS, and the
reparative surface is articular cartilage with OATS.
4: Recovery time and outcomes are similar between these 2 techniques, and the
reparative surface with microfracture is fibrocartilage.
5: Recovery and outcomes are similar between these 2 techniques, and the
reparative tissue with OATS is fibrocartilage.
A 42-year-old man has a chondral defect of the medial femoral condyle that is
approximately 1 cm in diameter. He has a very athletic lifestyle, wishes to remain
active, and is now seeking a third opinion. He has seen 2 orthopaedic surgeons;
the first surgeon recommended microfracture for the chondral defect, and the other
recommended an osteochondral autograft transplantation (OATS). What should the
patient be told?
1: Recovery is faster with microfracture, the outcomes are better with OATS, and
2: Recovery is faster with OATS, the outcomes are better with microfracture, and
3: The outcomes are better with OATS, rehabilitation is faster with OATS, and the
reparative surface is articular cartilage with OATS.
4: Recovery time and outcomes are similar between these 2 techniques, and
the reparative surface with microfracture is fibrocartilage.
5: Recovery and outcomes are similar between these 2 techniques, and the
reparative tissue with OATS is fibrocartilage.
Explanation
Short term outcomes and recovery time between OATS
and microfracture are similar, although microfracture is
inferior for lesions >2-4cm. OATS by definition is a
transplant of articular cartilage into the defect,
fibrocartilage fills in the defect following microfracture.
• Alfond JW, Cole BJ: Cartilage restoration, Part 1: Basic

science, historical perspective, patient evaluation, and
treatment options. Am J Sports Med 2005;33:295-306.
• Magnussen RA, Dunn WR, Carey JL, Spindler KP: Treatment
of focal articular cartilage defects in the knee: a systemic
review. Clin Orthop Relat Res 2008:466:952-962. PubMed
PMID: 18196358.
Question #125 (Sports)
Video 125 shows a subscapularis repair viewing from the posterior portal
looking anteriorly at the lateral border of the rotator interval. What serves
as a landmark for appropriate placement of the anchor for the upper
border repair?
1. Biceps tendon
2. Middle glenohumeral ligament
3. Leading edge of the supraspinatus
4. Posterior band of the inferior glenohumeral ligament
5. Superior glenohumeral and coracohumeral ligaments
Video 125 shows a subscapularis repair viewing from the posterior portal
looking anteriorly at the lateral border of the rotator interval. What serves
as a landmark for appropriate placement of the anchor for the upper
border repair?
1. Biceps tendon
2. Middle glenohumeral ligament
3. Leading edge of the supraspinatus
4. Posterior band of the inferior glenohumeral ligament
5. Superior glenohumeral and coracohumeral

ligaments
• The Comma Sign on posterior portal view of the shoulder is the arc shaped tissue of the medial
head of the coracohumeral ligament, as well as a portion of the superior glenohumeral ligament
which allows identification of the Superolateral Border of the Subscapularis onto the lesser
tuberosity .
• Visualization of the subscapularis tendon and its footprint on the lesser tuberosity is best performed through a posterior viewing portal
• The key to finding the subscapularis and differentiating it from the conjoined tendon and the coracoacromial ligament is to locate the “comma sign.”
• The comma sign is a comma-shaped arc of tissue located at the superolateral border of the subscapularis,which will always lead the surgeon to the
• superolateral border of the subscapularis
• The comma is actually the remnant of the medial sling of the biceps, whose footprint before tearing from the bone had been directly adjacent to the superior portion of the
footprint of the subscapularis on the lesser tuberosity of the humerus
• Typically, when the subscapularis fails, the medial sling of the biceps pulls away from the lesser tuberosity as well so that these structures remain together
• The comma is composed of fibers of the medial head of the coracohumeral ligament, as well as a portion of the superior glenohumeral ligament
• Burkhart SS, Brady PC. Arthroscopic subscapularis repair: surgical tips and pearls A to Z. Arthroscopy. 2006 Sep;22(9):1014-27. PubMed PMID: 16952733
• Lo IK, Burkhart SS. The comma sign: An arthroscopic guide to the torn subscapularis tendon.
• Arthroscopy. 2003 Mar;19(3):334-7. PubMed PMID: 12627163.
FIGURE 3. The comma sign is formed by the comma-shaped arc of a portion of the superior glenohumeral ligament/coracohumeral
ligament
complex (*), which has torn off the humerus. The comma-shaped arc (*) extends to the superolateral corner of the subscapularis tendon
( ). Arthroscopic views of a right shoulder showing a retracted subscapularis tear scarred to the inner deltoid fascia and the comma sign.
(A) Posterior viewing portal. (B) Anterolateral viewing portal. (G, glenoid; H, humeral head.)
F&A
Question 145
Q145: Answer
Q145: Explanation
• 23F with low ankle sprain without evidence of

instability (negative anterior drawer) but with
associated peroneal tendon injury
• Surgical intervention indicated exclusively
after failure of extensive non-operative
management
• Early mobilization superior to immobilization
• Therapy focused in neuromuscular control,
proprioception, peroneal muscle
strengthening
Sports
Question 158
• An elite-level pitcher with a history of chronic moderate

medial elbow pain reports a sudden pop and severe pain
along the medial elbow while throwing a pitch. Examination
reveals a positive moving valgus stress test. What is the
most appropriate next treatment step?
– 1. Rehabilitation of the flexor-pronator musculature
– 2. Bracing of the elbow to facilitate a return to pitching
– 3. Early primary repair of the ulnar collateral ligament
– 4. Early ulnar collateral ligament reconstruction
– 5. Early ulnar collateral ligament reconstruction and ulnar nerve
transposition
Question 158
• An elite-level pitcher with a history of chronic moderate

medial elbow pain reports a sudden pop and severe pain
along the medial elbow while throwing a pitch. Examination
reveals a positive moving valgus stress test. What is the
most appropriate next treatment step?
– 1. Rehabilitation of the flexor-pronator musculature
– 2. Bracing of the elbow to facilitate a return to pitching
– 3. Early primary repair of the ulnar collateral ligament
– 4. Early ulnar collateral ligament reconstruction
– 5. Early ulnar collateral ligament reconstruction and ulnar nerve
transposition
Question 158
• UCL injuries in elite athletes in AJSM The Outcome of Elbow

Ulnar Collateral Ligament Reconstruction in Overhead
Athletes
– Although injury to the UCL was once a career-ending injury in
overhead athletes, development and continued evolution of UCL
reconstruction have made return to previous or higher level of athletic
participation in sports highly likely.
– The overall rate of return of 42% may give the athlete some hope of
returning without undergoing surgical treatment.
– The results support the abandonment of obligatory ulnar nerve
transposition, as we found overall that patients treated with obligatory
ulnar nerve transpositions had a nearly 15% lower rate of excellent
results, more than double the rate of all complications, and more than
double the rate of postoperative ulnar neuropathy specifically
compared with those without obligatory ulnar nerve transpositions
Shoulder & Elbow
193. Which of the following is the most important restraint to medial instability of the
long head of the biceps tendon?
1. Tendon of the subscapularis

2. Coracohumeral ligament
3. Superior glenohumeral ligament
4. Morphology of the bicipital groove
5. Origin of the long head of the biceps in the supraglenoid tubercle

Shoulder & Elbow
193. Which of the following is the most important restraint to medial instability of the
long head of the biceps tendon?

2. Coracohumeral ligament
3. Superior glenohumeral ligament
4. Morphology of the bicipital groove
5. Origin of the long head of the biceps in the supraglenoid tubercle

Shoulder & Elbow
Observational studies have demonstrated

an association between multi-tendon rotator
cuff tears and medial subluxation or
dislocation of the long head of the biceps
tendon. The subscapularis insertion forms
an important anatomic restraint to maintain
the position of the biceps tendon in the
intertubercular groove. A number of subtypes
of biceps tendon have been described.
Summary: The subscapularis insertion forms an important anatomic restraint to

maintain the position of the long head of the biceps tendon and subscapularis tears
may be associated with medial subluxation or dislocation of the biceps tendon.
RECOMMENDED READINGS
Walch G, Nové-Josserand L, Boileau P, Levigne C: Subluxations and dislocations of the tendon of the long head of the
biceps. J Shoulder Elbow Surg 1998;7:100-108. PubMed PMID: 9593086.
Maier D, Jaeger M, Suedkamp NP, Koestler W: Stabilization of the long head of the biceps tendon in the context of early
repair of traumatic subscapularis tendon tears. J Bone Joint Surg Am 2007;89:1763-1769. PubMed PMID: 17671016.

Question 202
• An inferior placement of the posterior

shoulder portal endangers which vital
structure?
• 1. Radial nerve
• 2. Axillary nerve
• 3. Long thoracic nerve
• 4. Thoracoacromial artery
• 5. Anterior humeral circumflex artery
Question 202
• An inferior placement of the posterior

shoulder portal endangers which vital
structure?
• 1. Radial nerve
• 2. Axillary nerve
• 3. Long thoracic nerve
• 4. Thoracoacromial artery
• 5. Anterior humeral circumflex artery
Explanation
• The axillary nerve leaves axilla through

quadrangular space and winds around humerus
on deep surface of the deltoid muscle and
passes approx 7 cm below tip of acromion. It is
at risk if the posterior portal is made too
inferior.
• Lo IK, Lind CC, Burkhart SS. Glenohumeral arthroscopy portals
established using an outside-in technique: neurovascular anatomy at
risk. Arthroscopy. 2004 20(6):596-602.PubMed PMID: 15241310.
• Meyer M, Graveleau N, Hardy P, Landreau P. Anatomic risks of
shoulder arthroscopy portals: anatomic cadaveric study of 12
portals. Arthroscopy. 2007 23(5):529-536. PubMed PMID:
17478285.
Question 205
• Toward the end of a preseason football practice, a player approaches his

trainer with difficulty remembering what he is supposed to do during his
position drills. He is confused and disoriented, clearly fatigued, soaked in
sweat, and his skin is pale. What is the most appropriate next step?
• 1. Have the athlete lie down on the sidelines for administration of
intravenous fluid.
• 2. Immediately perform a thorough neurologic evaluation on the sidelines.
• 3. Assure the athlete that he is simply dehydrated and can return after
rehydrating.
• 4. Administer a Sideline Assessment of Concussion test to determine
return to play.
• 5. Obtain a core temperature in a cooled training room while hydrating
the athlete.
Question 205
• Toward the end of a preseason football practice, a player approaches his

trainer with difficulty remembering what he is supposed to do during his
position drills. He is confused and disoriented, clearly fatigued, soaked in
sweat, and his skin is pale. What is the most appropriate next step?
• 1. Have the athlete lie down on the sidelines for administration of
intravenous fluid.
• 2. Immediately perform a thorough neurologic evaluation on the sidelines.
• 3. Assure the athlete that he is simply dehydrated and can return after
rehydrating.
• 4. Administer a Sideline Assessment of Concussion test to determine
return to play.
• 5. Obtain a core temperature in a cooled training room while hydrating
the athlete.
Explanation
• Early symptoms of exertional heat illness include clumsiness,

stumbling, headache, nausea, dizziness, apathy, and confusion.
The diagnosis is made by a obtaining a core temperature.
Immediate whole body cooling and hydration should be initiated.
• American College of Sports Medicine, Armstrong LE, Casa DJ, Millard-

Stafford M, Moran DS, Pyne SW, Roberts WO. American College of Sports
Medicine position stand. Exertional heat illness during training and
competition. Med Sci Sports Exerc. 2007 Mar;39(3):556-72. Review.
• American College of Sports Medicine, Sawka MN, Burke LM, Eichner ER,
Maughan RJ, Montain SJ, Stachenfeld NS. American College of Sports
Medicine position stand. Exercise and fluid replacement. Med Sci Sports
Exerc. 2007 Feb;39(2):377-90. Review. PubMed PMID: 17277604.
• Joy SM. Heat and hydration. In: Kibler WB, ed. Orthopaedic Knowledge
Update: Sports Medicine 4. Rosemont, IL: American Academy of
Orthopaedic Surgeons; 2009:379-385.
227. A 29-year-old athlete reports recurrent anterior
shoulder instability after surgery. Performing an arthroscopic
revision surgery is contraindicated when there is capsular
attenuation or
1. glenoid bone loss of 15%.

2. an associated rotator cuff tear.
3. postthermal capsular necrosis.
4. a Hill-Sachs lesion involving 20% of the humeral
head.
5. the patient participates in sports that involve
contact and collision

227. A 29-year-old athlete reports recurrent anterior
shoulder instability after surgery. Performing an arthroscopic
revision surgery is contraindicated when there is capsular
attenuation or
1. glenoid bone loss of 15%.

2. an associated rotator cuff tear.
4. a Hill-Sachs lesion involving 20% of the humeral
head.
5. the patient participates in sports that involve
contact and collision

The provided resources for this question are not really helpful and in
my mind do not help answer this question, not to mention they only
had 18 patients in one study. I think what they are trying to get at is
why would you abandon arthroscopic techniques and convert to open.
Choice 1 is not a contraindication because open procedures are
recommended only when defects become >25%. Similarly, Choice 3 is
not contraindicated because Hill-Sachs lesions involving 20% of the
head generally do not engage (usually >25% do) and if they do can be
managed arthroscopically with Remplissage. Choice 2 is not
contraindicated because a rotator cuff repair can be performed
arthroscopically at the time of the stabilization procedure. Lastly,
choice 5 is not contraindicated because other studies, not the ones
listed, show that successful arthroscopic revision can be performed in
patients who participate in contact sports. Curiously, the provided
resources mention in their discussion a high rate of failure in revisions
in contact athletes putting the answer in question here. The provided
resource does show that of the 18 patients who underwent revision,
there were 3 failures, and of those all of them had thermal shrinkage
done.

Question 248 (Sports)
• During routine knee arthroscopy, the anterior cruciate

ligament is visualized with the knee in 95 degrees of
flexion. At this angle of knee flexion, the:
• 1. posteromedial bundle is loose and the anterolateral bundle is

tight.
• 2. posterolateral bundle is loose and the anteromedial bundle is
tight.
• 3. anteromedial bundle is loose and the posterolateral bundle is
tight.
• 4. anterolateral bundle is loose and the posteromedial bundle is
tight.
• 5. anterolateral bundle is tight and the posteromedial bundle is
tight.
• During routine knee arthroscopy, the anterior cruciate

ligament is visualized with the knee in 95 degrees of
flexion. At this angle of knee flexion, the:
• 1. posteromedial bundle is loose and the anterolateral bundle is

tight.
• 2. posterolateral bundle is loose and the anteromedial
bundle is tight.
• 3. anteromedial bundle is loose and the posterolateral bundle is
tight.
• 4. anterolateral bundle is loose and the posteromedial bundle is
tight.
• 5. anterolateral bundle is tight and the posteromedial bundle is
tight.
ACL PCL
Tight in flexion AM AL
Tight in extension PL PM
• Know the above chart. Commonly tested concept on the OITE.
• First things first, know which bundles belong to each ligament. You can memorize the above chart;
alternatively, you can start with the “PCL” being your “PAL”, and deduce the rest. You should
immediately remove wrong answer choices based on bundles that don’t exist.
• Know and understand this: generally, anything anterior to the axis knee rotation will be tight in
flexion. Anything posterior to the axis of rotation will be tight in extension. This applies to the
current question at hand. The AM bundle of the ACL will be tight in flexion (or 95 degrees of flexion,
as listed in the vignette), and loose in extension. Likewise, the PL bundle of the ACL will be tight in
extension, and loose in flexion.
• Other ways this concept is commonly tested is when discussing ACL tunnel mal-placement (“the most
common cause of ACL failure”). If the tibial/femoral tunnels are too anterior, the graft will be tight in
flexion, and lax in extension. If the tibial/femoral tunnels are too posterior, the converse will be true.
• The anteromedial bundle of the ACL is tight in flexion.
• Tjoumakaris FP, Donegan DJ, Sekiya JK. Partial tears of the anterior cruciate ligament: diagnosis and treatment. Am J
Orthop (Belle Mead NJ). 2011 Feb;40(2):92-7. Review. PubMed PMID: 21720597.
265
A 29-year-old athlete with postmeniscectomy pain syndrome after prior

arthroscopic meniscectomy is referred for a meniscal allograft. What is the
most likely long-term outcome for a meniscal allograft transplantation?
1. Rejection with early failure

2. Cartilage regeneration
3. Relative acellularity and possible tearing
4. Permanent reduction in pain and swelling
5. Acceleration in the progression of osteoarthritis

265
A 29-year-old athlete with postmeniscectomy pain syndrome after prior

arthroscopic meniscectomy is referred for a meniscal allograft. What is the
most likely long-term outcome for a meniscal allograft transplantation?
1. Rejection with early failure

2. Cartilage regeneration
3. Relative acellularity and possible tearing
4. Permanent reduction in pain and swelling
5. Acceleration in the progression of osteoarthritis

265
• The Rath et al. paper found that “Histologic examination of the removed
tissue revealed reduced cellularity as compared with normal or torn native
menisci…This decreased biologic activity may be a factor that contributes
to the high frequency of retears noted in this and prior studies.” Patients in
this study showed improvement in pain, but still had limitations in function
(permanent relief of pain is nearly impossible). Although this procedure is
done to slow the progression of arthritis in the knee, it does not help
regenerate articular cartilage (even the procedures we do for that purpose
don’t always work). The JAAOS article is a great review. Milachowski et al:
Although fresh-frozen allografts were more likely to have an improved
clinical appearance, both graft types showed a decrease in size, and
neither showed signs of inflammation or rejection.

Sports
Question 275
• Figures 275a through 275c are the radiographs of a 28-year-old
recreational basketball player who underwent autograft anterior
cruciate ligament reconstruction and a partial medial meniscectomy
4 years ago. Although his initial results were favorable, he has
persistent instability symptoms and “giving way” when attempting to
participate in desired sports activities. Examination reveals the
following: a 2A Lachman, 3+ pivot shift, negative external rotation
dial, and a positive McMurray maneuver for the medial compartment.
His recurrent instability symptoms are most likely related to
• 1. an unstable lateral meniscal tear.
• 2. the development of posterolateral instability.
• 3. femoral tunnel placement that did not restore rotatory stability.
• 4. femoral tunnel placement that did not restore the posteromedial
bundle.
• 5. femoral tunnel fixation that did not adequately address the
anterolateral bundle.
Question 275
•
Question 275
• Figures 275a through 275c are the radiographs of a 28-year-old
recreational basketball player who underwent autograft anterior
cruciate ligament reconstruction and a partial medial meniscectomy
4 years ago. Although his initial results were favorable, he has
persistent instability symptoms and “giving way” when attempting to
participate in desired sports activities. Examination reveals the
following: a 2A Lachman, 3+ pivot shift, negative external rotation
dial, and a positive McMurray maneuver for the medial compartment.
His recurrent instability symptoms are most likely related to
• 1. an unstable lateral meniscal tear.
• 2. the development of posterolateral instability.
• 3. femoral tunnel placement that did not restore rotatory stability.
• 4. femoral tunnel placement that did not restore the posteromedial
bundle.
• 5. femoral tunnel fixation that did not adequately address the
anterolateral bundle.
Question 275
• Bundles of the ACL are AM and PL; 4 and 5 are trying to trick you into
confusing ACL with PCL bundles.
• Conventional single-bundle reconstruction techniques often result in

nonanatomic tunnel placement, with a tibial PL to a femoral “high AM”
tunnel position. In vitro studies have demonstrated that these
nonanatomic single-bundle reconstructions cannot completely restore
normal anterior-posterior or rotatory laxity.
• Yasuda K, van Eck CF, Hoshino Y, Fu FH, Tashman S. Anatomic single- and double-bundle anterior
cruciate ligament reconstruction, part 1: Basic science. Am J Sports Med August 2011 39 1789-
1799. PubMed PMID: 21596902.
• Smith CK, Howell SM, Hull ML. Anterior laxity, slippage, and recovery of function in the first year
after tibialis allograft anterior cruciate ligament reconstruction. Am J Sports Med. 2011
Jan;39(1):78-88. Epub 2010 Oct 7. PubMed PMID: 20929933.
Question 11
Question 11
A left-handed 24-year-old minor league pitcher has progressive medial
elbow pain that occurs during pitching. He also reports pain with lifting
when using his left arm. Examination reveals he has pain anterior to the
medial epicondyle. He also has pain with power grip and with resisted
wrist flexion. A standard dynamic valgus stress test does not provoke
pain, but there is pain if the test is performed with his fist clenched and
pronated. What is the most likely diagnosis?
•1- Cubital tunnel syndrome
2- Snapping medial triceps tendon
3- Common flexor-pronator tendonitis
4- A tear of the ulnar collateral ligament
5- Posteromedial impingement from an olecranon
osteophyte
Question 11
A left-handed 24-year-old minor league pitcher has progressive medial
elbow pain that occurs during pitching. He also reports pain with lifting
when using his left arm. Examination reveals he has pain anterior to the
medial epicondyle. He also has pain with power grip and with resisted
wrist flexion. A standard dynamic valgus stress test does not provoke
pain, but there is pain if the test is performed with his fist clenched and
pronated. What is the most likely diagnosis?
•1- Cubital tunnel syndrome

2- Snapping medial triceps tendon
3- Common flexor-pronator tendonitis
4- A tear of the ulnar collateral ligament
5- Posteromedial impingement from an olecranon
osteophyte
Question 11
Common flexor-pronator muscle originates from medial
epicondyle, and provides dynamic support to valgus stress in the
throwing elbow. Throwing athletes may develop a spectrum of
injuries from mild overuse to chronic tendinitis or acute tears.
The player often complains of medial elbow pain during the late
cocking or acceleration phases of throwing and demonstrates
tenderness just distal to the common tendon origin from the
medial epicondyle. These injuries generally respond well to a
period of rest with antiinflammatory medications, PT, and
gradual return to throwing.
•Levine W. The Athlete’s Elbow. In: Levine W, ed. AAOS Monograph Vol. 39.
Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008:71-83.
•Cain EL Jr, Dugas JR, Wolf RS, Andrews JR. Elbow injuries in throwing
athletes: a current concepts review. Am J Sports Med. 2003 Jul-
Aug;31(4):621-35. Review. PubMed PMID: 12860556.
Question 23
•An 8-year-old boy fell and has a painful left knee
and a 15-degree block to extension (Figure 23a).
MR imaging findings are shown in Figure 23b, and
arthroscopic findings are shown in Figure 23c.
What is the best next step?
•1. Observation
•2. Mosaicplasty
•3. Total menisectomy
•4. Meniscal allograft
•5. Arthroscopic saucerization and repair
Figures for Question 23
Question 23
•An 8-year-old boy fell and has a painful left knee
and a 15-degree block to extension (Figure 23a).
MR imaging findings are shown in Figure 23b,
and arthroscopic findings are shown in Figure
23c. What is the best next step?
•1. Observation
•2. Mosaicplasty
•3. Total menisectomy
•4. Meniscal allograft
•5. Arthroscopic saucerization and repair
Explanation for Question 23
• The patient has a symptomatic discoid meniscus. Abnormal development
of the meniscus leads to a hypertrophic and discoid shaped meniscus.
• Widened joint space and squaring of the lateral condyle with cupping of
the lateral tibial plateau is often seen on radiographs.
• Diagnosis is made on MRI with 3 or more 5mm sagittal images with
meniscus continuity (bow-tie sign)
• Observation is only indicated in an asymptomatic discoid meniscus
without tears.
• Given that he is unable to achieve full extension, arthroscopic
saucerization to obtain anatomic looking meniscus and then repair of the
meniscus in the Wrisberg variant (lack of posterior meniscotibial
attachment to the tibia
Question 51
Figures 51a through 51d are the radiographs and sagittal MR knee images of a healthy, active 23-
year-old man who had the acute onset of right knee pain and an inability to fully extend his knee
after trying to stand from a seated position yesterday. He sustained a noncontact injury to his
right knee 2 years ago and underwent primary anterior cruciate ligament (ACL) reconstruction
with bone-patella tendon-bone autograft and medial meniscus repair. He sustained a noncontact
injury to his right knee 8 months later and underwent a revision ACL reconstruction using soft-
tissue allograft and a revision medial meniscus repair. He reported multiple episodes of “giving
way” of the knee but no pain before yesterday’s acute injury. He has positive Lachman and pivot
shift findings and a negative dial test result. What is the best next step?
1. Arthroscopic partial medial menisectomy

2. Arthroscopic revision medial meniscus repair
3. Arthroscopic-assisted revision ACL reconstruction and meniscal surgery as necessary
4. Arthroscopic-assisted revision ACL reconstruction with posterolateral corner augmentation
5. Injection, physical therapy, and functional bracing
Question 51
Figures 51a through 51d are the radiographs and sagittal MR knee images of a healthy, active 23-
year-old man who had the acute onset of right knee pain and an inability to fully extend his knee
after trying to stand from a seated position yesterday. He sustained a noncontact injury to his
right knee 2 years ago and underwent primary anterior cruciate ligament (ACL) reconstruction
with bone-patella tendon-bone autograft and medial meniscus repair. He sustained a noncontact
injury to his right knee 8 months later and underwent a revision ACL reconstruction using soft-
tissue allograft and a revision medial meniscus repair. He reported multiple episodes of “giving
way” of the knee but no pain before yesterday’s acute injury. He has positive Lachman and pivot
shift findings and a negative dial test result. What is the best next step?
1. Arthroscopic partial medial menisectomy

2. Arthroscopic revision medial meniscus repair
3. Arthroscopic-assisted revision ACL reconstruction and meniscal surgery as necessary
4. Arthroscopic-assisted revision ACL reconstruction with posterolateral corner augmentation
5. Injection, physical therapy, and functional bracing
ACL reconstruction failure
• The patient has a malpositioned ACL femoral tunnel (most common cause of ACL reconstruction failure) as
evident by the vertical tunnel on the AP x-rays, resulting in rotational instability and a positive pivot shift
test. This is consistent with the patient’s complaints of knee instability prior to his current injury. The MRI
demonstrates meniscal tissue located within the medial hemi-joint and complex tearing of the posterior
horn of the medial meniscus, which infers a large medial bucket-handle tear which has flipped into the
joint. This intra-articular meniscal tissue blocks the patient’s attempt to fully extend the knee. Knees with
chronic ACL deficiency are associated with complex meniscus tears due to the additional loading of the
meniscus in stabilizing the knee. The solution for this patient is to correct the meniscal block to extension
via partial meniscectomy versus repair (as determined intra-operatively) and concurrently revising the
patient to a properly positioned ACL reconstruction due to his chronic instability and young age.
Question 51
Recommended Readings
• Noyes FR, Barber-Westin SD. Anterior cruciate ligament graft placement
recommendations and bone-patellar tendon-bone graft indications to
restore knee stability. Instr Course Lect. 2011;60:499-521. Review.
• Driscoll MD, Isabell GP Jr, Conditt MA, Ismaily SK, Jupiter DC, Noble PC,
Lowe WR. Comparison of 2 femoral tunnel locations in anatomic single-
bundle anterior cruciate ligament reconstruction: a biomechanical study.
Arthroscopy. 2012 Oct;28(10):1481-9. PMID: 22796141.
Question 62
Figures 62a through 62c are the radiographs of a 27-year-old woman who is
experiencing lack of motion and decreased functional use of her left elbow. She
has no pain and reports that although her functional use recently decreased, she
has never had full motion in that elbow. Examination reveals her left elbow has full
and equivalent flexion and extension with a fixed 20 degrees of pronation. No
further pronation or supination is present actively or passively. No pain is elicited
during the examination. Her right elbow has full motion. She is unhappy with her
range of motion and is requesting treatment. What is the best next step?
1. Observation
2. Excision of the synostosis
3. Derotational osteotomy to position the forearm in neutral
4. Excision of the synostosis and a vascularized interposition fat patch
5. Derotational osteotomy to position the forearm in 20 degrees of pronation
Question 62
Question 62
Figures 62a through 62c are the radiographs of a 27-year-old woman who is
experiencing lack of motion and decreased functional use of her left elbow. She
has no pain and reports that although her functional use recently decreased, she
has never had full motion in that elbow. Examination reveals her left elbow has full
and equivalent flexion and extension with a fixed 20 degrees of pronation. No
further pronation or supination is present actively or passively. No pain is elicited
during the examination. Her right elbow has full motion. She is unhappy with her
range of motion and is requesting treatment. What is the best next step?
1. Observation
2. Excision of the synostosis
3. Derotational osteotomy to position the forearm in neutral
4. Excision of the synostosis and a vascularized interposition fat patch
5. Derotational osteotomy to position the forearm in 20 degrees of pronation
Question 62
PREFERRED RESPONSE: 4
The location of RU synostosis is unrelated to the need for correction and the
indications for surgery based upon a functional deficit reported by the patient, as
in this passage. Patient who have the synostosis taken down with a fascio-fat graft
regain ~20 deg of pro-supination, whereas those which receive an osteotomy of
the radius in addition to the graft regain ~80 deg and is the recommended
treatment should surgery be required.
Cleary JE, Omer GE, Jr. Congenital proximal radio-ulnar synostosis. Natural history
and functional assessment. J Bone Joint Surg -Am Volume 1985; 67(4): 539-45.
PMID: 3980498.
Kanaya F, Ibaraki K. Mobilization of a congenital proximal radioulnar synostosis
with use of a free vascularized fascio-fat graft. J Bone Joint Surg Am Volume 1998;
80( 8): 1186-92. PMID: 9730128.
Question 83
A patient returns for a first postsurgical visit 6 weeks after undergoing
arthroscopic rotator cuff repair. This patient has not been attending formal
physical therapy and has remained in a sling. When compared to control
patients who immediately began formal physical therapy, what is the
expected outcome 1 year after surgery?
1. Increased pain levels
2. Decreased range of motion
3. Decreased likelihood of returning to work
4. Improved functional outcome scores
5. No difference in range-of-motion or outcome scores
Question 83
A patient returns for a first postsurgical visit 6 weeks after undergoing
arthroscopic rotator cuff repair. This patient has not been attending formal
physical therapy and has remained in a sling. When compared to control
patients who immediately began formal physical therapy, what is the
expected outcome 1 year after surgery?
1. Increased pain levels
2. Decreased range of motion
3. Decreased likelihood of returning to work
4. Improved functional outcome scores
5. No difference in range-of-motion or outcome scores
Question 83
Prospective randomized studies comparing early range of motion vs. delayed protocol limiting passive
range of motion demonstrate similar outcomes and range of motion at 1 year. The data is mixed on the
effect of early ROM on the rate of healing with some evidence that immobilization slightly increases
rate of healing (this should not be tested)
Question 99
•A 19-year-old collegiate field hockey player is struck in the head by a stick while challenging for a
loose ball. She is seen by the athletic training staff on the sideline and is determined to be alert and
conversing appropriately. She denies any loss of consciousness but cannot recall the events
immediately preceding the injury. Her motor and sensory examination is unremarkable, with mild
tenderness but no laceration over the posterior aspect of her occiput (the location at which she
was struck). She is eager to return to play. According to an NCAA protocol, when may this athlete
safely return to play?
–1. 15 minutes after sustaining the injury as long as she has no symptoms
–2. During the second half as long as she remains without symptoms and can perform
cardiovascular exercise without experiencing symptoms
–3. 2 to 3 days after sustaining the injury as long as she can progress through the stepwise
rehabilitation protocol without experiencing symptoms
–5. This athlete is not to return to athletics until the following season, and only if symptoms
do not arise.
Question 99
•A 19-year-old collegiate field hockey player is struck in the head by a stick while challenging for a
loose ball. She is seen by the athletic training staff on the sideline and is determined to be alert and
conversing appropriately. She denies any loss of consciousness but cannot recall the events
immediately preceding the injury. Her motor and sensory examination is unremarkable, with mild
tenderness but no laceration over the posterior aspect of her occiput (the location at which she
was struck). She is eager to return to play. According to an NCAA protocol, when may this athlete
safely return to play?
–1. 15 minutes after sustaining the injury as long as she has no symptoms
–2. During the second half as long as she remains without symptoms and can perform
cardiovascular exercise without experiencing symptoms
–5. This athlete is not to return to athletics until the following season, and only if symptoms
do not arise.
Return to play
• A student-athlete diagnosed with sport-related concussion should not
be allowed to return to play in the current game or practice and should be
withheld from athletic activity for the remainder of the day.The initial
management of sport-related concussion is relative physical and cognitive
rest. Athletes diagnosed with sport-related concussion must be removed
from play and must not return to sport-related activity for at least one
calendar day and are to be evaluated by a health care provider with
expertise in sport-related concussion. Once a concussed student-athlete
has returned to baseline level of symptoms, cognitive function and
balance, then the return-to-play progression can be initiated.
•http://www.ncaa.org/health-and-safety/concussion-guidelines Last accessed 8/23/2014.
•Ma R, Miller CD, Hogan MV, Diduch BK, Carson EW, Miller MD. Sports-related concussion: assessment and management. J
Bone Joint Surg Am. 2012 Sep5;94(17):1618-27. Review. PubMed PMID: 22992853.
•McCrory P, Meeuwisse WH, Aubry M, et al. Consensus statement on concussion in sport: the 4th International Conference
on Concussion in Sport held in Zurich, November 2012. Br J Sports Med. 2013 Apr;47(5):250-8. PMID: 23479479
Question 112
A 17-year-old cross-country runner has leg pain that initially occurred
with running but now occurs with any weight-bearing activity. An initial
evaluation of her problem should include
1. A whole-body bone scan.

2. A menstrual and dietary history.
3. Postexercise compartment pressure measurements.
4. A skeletal survey to evaluate for additional areas of stress injury.
5. A functional movement evaluation to detect predisposing factors.
Question 112
A 17-year-old cross-country runner has leg pain that initially occurred
with running but now occurs with any weight-bearing activity. An initial
evaluation of her problem should include
1. A whole-body bone scan.

2. A menstrual and dietary history.
3. Postexercise compartment pressure measurements.
4. A skeletal survey to evaluate for additional areas of stress injury.
5. A functional movement evaluation to detect predisposing factors.
Question 112
• Female athlete triad:
– Eating disorder (16-47% of female athletes)
– Low BMD (22-50% of female athletes)
– Menstrual dysfunction (most commonly amenorrhea)

• Absence of menses for >3 months
• Functional hypothalamic amenorrhea: caused by an
alteration in GRH pulsatility, which in turn causes a
disruption of LH pulses from the pituitary and gonadal
steroid release from the ovaries; reflects a state of estrogen
deficiency
Question 112
Nazem TG, Ackerman KE. The female athlete triad. Sports Health.
2012 Jul;4(4):302-11.
Question 125
A revision anterior cruciate ligament reconstruction was performed with a
soft-tissue allograft, and postoperative radiographs are seen in Figures 125a
and 125b. As opposed to a presurgical knee examination, the revision
reconstruction is expected to improve findings for which test?
1. Dial
2. Pivot shift
3. Anterior drawer
4. Posterior drawer
5. Reverse pivot shift
Question 125
A revision anterior cruciate ligament reconstruction was performed with a
soft-tissue allograft, and postoperative radiographs are seen in Figures 125a
and 125b. As opposed to a presurgical knee examination, the revision
reconstruction is expected to improve findings for which test?
1. Dial
2. Pivot shift
3. Anterior drawer
4. Posterior drawer
5. Reverse pivot shift
Pivot shift test
With pt supine the knee is held at approx 20 degrees of flexion and
in neutral rotation; knee is placed in full extension w/ application of
valgus stress & internal rotation; slowly flex the knee while valgus
and internal rotation is maintained; load is then placed on knee joint
by application of axial or valgus force (or both) while tibia is kept in a
neutral rotation; if test is positive, a subluxation (lateral > medial) will
occur at 20 to 40 deg of flexion, indicating ACL deficiency
The anterior cruciate ligament (ACL) resists the combined abnormal motions of anterior tibial
translation and internal tibial rotation that occur in the pivot-shift phenomenon. The placement of a
single ACL graft high and proximal at the femoral attachment and posterior at the tibial attachment
results in a vertical graft orientation. This graft position has a limited ability to provide rotational
stability. A more oblique ACL graft orientation in the sagittal and coronal planes achieved from a
central anatomic femoral and tibial location provides an orientation that is better in resisting the
pivot-shift phenomenon.
Question 146
Figures 146a and 146b are the radiographs of a 17-year-old football
player who is seen after the season ends. He has anterior knee pain that is
exacerbated by kneeling and squatting. He also has had knee pain on and
off for 3 years and has used a knee pad, nonsteroidal anti-inflammatory
drugs, and ice, but has experienced no relief. Recommended treatment
should consist of
1. hamstring lengthening.
2. injection with prednisolone.
3. a night knee extension brace.
4. ossicle resection and tibial tubercleplasty.
5. continued nonsurgical treatment because his growth plates remain
open.
Question 146
Question 146
Figures 146a and 146b are the radiographs of a 17-year-old football
player who is seen after the season ends. He has anterior knee pain that is
exacerbated by kneeling and squatting. He also has had knee pain on and
off for 3 years and has used a knee pad, nonsteroidal anti-inflammatory
drugs, and ice, but has experienced no relief. Recommended treatment
should consist of
1. hamstring lengthening.
2. injection with prednisolone.
3. a night knee extension brace.
4. ossicle resection and tibial tubercleplasty.
5. continued nonsurgical treatment because his growth plates remain
open.
Question 146
This patient is skeletally mature and has continued pain with extensive non-operative
management of his Osgood-Schlatter disease. The pain typically ceases with ossification of
the physis. With excision of the ossicle and tibial tubercleplasty 75% of patients will return to
pre-symptom function.
Mital MA, Matza RA, Cohen J. The so-called unresolved Osgood-Schlatter lesion: a concept
based on fifteen surgically treated lesions. J Bone Joint Surg Am. 1980 Jul;62(5):732-9.
Pihlajamäki HK, Visuri TI. Long-term outcome after surgical treatment of unresolved osgood-
schlatter disease in young men: surgical technique. J Bone Joint Surg Am. 2010 Sep;92 Suppl 1
Pt 2:258-64. doi:10.2106/JBJS.J.00450. PubMed PMID: 20844181.
Weiss JM, Jordan SS, Andersen JS, Lee BM, Kocher M. Surgical treatment of unresolved
Osgood-Schlatter disease: ossicle resection with tibial tubercleplasty. J Pediatr Orthop. 2007
Oct-Nov;27(7):844-7. PubMed PMID: 17878797.
Question 151
• In the course of closing after an anterior cruciate ligament
reconstruction, the junior resident realizes that a sponge was left
deep in the wound. When he mentions this to the attending
surgeon as the skin is being closed, he is told, “You don’t know what
you’re talking about--the count was correct.” The appropriate
course of action for the resident is to
• 1. assume that he was incorrect and allow the closure to proceed.
• 2. begin removing sutures to prove that a sponge has been left in
the patient.
• 3. perform his own sponge count to address his suspicion that the
count was incorrect.
• 4. repeat his concern and insist that the procedure stop until the
issue is resolved.
• 5. leave the operating room and report the attending surgeon to the
chief medical officer.
Question 151
• In the course of closing after an anterior cruciate ligament
reconstruction, the junior resident realizes that a sponge was left
deep in the wound. When he mentions this to the attending
surgeon as the skin is being closed, he is told, “You don’t know what
you’re talking about--the count was correct.” The appropriate
course of action for the resident is to
• 1. assume that he was incorrect and allow the closure to proceed.
• 2. begin removing sutures to prove that a sponge has been left in
the patient.
• 3. perform his own sponge count to address his suspicion that the
count was incorrect.
• 4. repeat his concern and insist that the procedure stop until the
issue is resolved.
• 5. leave the operating room and report the attending surgeon to the
chief medical officer.
Question 151
• Ethical considerations
– Attending is in charge, should not be subverted
– All team members should have ability to address concerns
– Whether a surgeon should be allowed to operate if his ACL
incision is large enough to miss a full size sponge
• US Department of Health & Human Services Agency for
Healthcare Research and Quality TeamSTEPPS website:
http://teamstepps.ahrq.gov.
• Wiener EL, Kanki BG, Helmreich RL. Cockpit Resource
Management. San Diego, CA:Harcourt Brace;1993.
Question 159
• MRI shows a lateral meniscus tear. Tenderness
over the joint line (70-90%) is more sensitive than
McMurray (50-60%)
• Highly sensitive tests help “rule out” when

negative.
(ie, In cases when the test is negative, it means
the pathology is often also not present)
• Highly specific tests help “rule in” when positive

(ie, In cases when the test is positive, it one
particular pathology is often present versus
others)
Ryzewicz 2007
Question 159
Question 171
•Figures 171a and 171b are the anteroposterior and lateral
radiograph of a 10 yr old boy who hyperextended his knee while
skiing. He has a swollen knee and cannot bear weight. Initial
treatment should consist of
1.Open fixation with a screw
2.Arthroscopic microfracture
3.Arthroscopic fixation with a suture
4.Aspiration of the knee, closed reduction with fluoroscopy, and a
cast in extension
5.Injection of the knee with marcaine, a range of motion brace
locked at 3 degrees of flexion, and therapy
Question 171
Question 171
•Figures 171a and 171b are the anteroposterior and lateral
radiograph of a 10 yr old boy who hyperextended his knee
while skiing. He has a swollen knee and cannot bear weight.
Initial treatment should consist of
1.Open fixation with a screw
2.Arthroscopic microfracture
3.Arthroscopic fixation with a suture
4.Aspiration of the knee, closed reduction with fluoroscopy,
and a cast in extension
5.Injection of the knee with marcaine, a range of motion brace
locked at 3 degrees of flexion, and therapy
Tibial Spine Fx in children
• Pathophys: typically d/t hyperextension and IR of an extended knee versus fall on flexed and IR knee
causing tension along ACL
• Dx:
– inability to bear weight + pain
– Signs joint hemarthrosis with knee in slight flexion
– AP & lat XR (Lat needed for Meyers and McKeever classification)
• Classification: Meyers and McKeever (Wilfinger et al, 2009)
• Treatment:
– Historically operative – sutures, cerclage wires, screw fixation, and later arthroscopically
– Conservative management: knee aspiration, closed fracture reduction, immobilization in extension in long leg
cast
– Data supports that patients achieve good outcomes with conservative management even in Type II
& III injuries and do not experience significant instability, premature degenerative changes or
damage to the ACL.
References:
Wilfinger C, et al. Nonoperative treatment of tibial spine fractures in children-38 patients with a minimum follow-up of 1 year.
J Orthop Trauma. 2009 Aug;23(7):519-24.
Molander ML, et al. Fracture of the intercondylar eminence of the tibia: a review of 35
patients. J Bone Joint Surg Br. 1981 Feb;63-B(1):89-91.
Question 181
Question 181
Question 181
Explanation
• Transosseous equivalent repair (Figure) and
double row better approximate RC footprint and
are mechanically stronger in cadaver studies
• This patient presents with increased pain after
a traumatic fall and X-rays show evidence of
anchor failure indicating traumatic failure of
repair.
• Acute traumatic rupture of RC repairs should
be revised/fixed
• Other causes of RC repair failures are trialed
with PT, indications for revision or reverse
arthroplasty are basically the same as for
primary treatment
Question 188
After recovering from an uncomplicated ankle sprain, a 12-year-old
boy wants to lift weights for football training. In this age group,
weight training leads to
1. increased injury risk.
2. growth disturbances.
3. decreased flexibility.
4. strength gains that are temporary if training ceases.
5. no benefit because of low circulating levels of androgens.
Question 188
After recovering from an uncomplicated ankle sprain, a 12-year-old
boy wants to lift weights for football training. In this age group,
weight training leads to
1. increased injury risk.
2. growth disturbances.
3. decreased flexibility.
4. strength gains that are temporary if training ceases.
5. no benefit because of low circulating levels of androgens.
Question 188
This increase in strength is largely related to the intensity and volume of loading and appears
to be the result of increased neuromuscular activation and coordination, rather than muscle
hypertrophy. Training-induced strength gains are largely reversible when the training is
discontinued. There is no current evidence to support the misconceptions that children need
androgens for strength gain or lose flexibility with training. They are not at an increased risk
for injury.
Guy JA, Micheli LJ. Strength training for children and adolescents. J Am Acad Orthop Surg.
2001 Jan-Feb;9(1):29-36. Review. PubMed PMID: 11174161.
Malina RM. Weight training in youth-growth, maturation, and safety: an evidence-based
review. Clin J Sport Med. 2006 Nov;16(6):478-87. Review. PubMed PMID: 17119361.
Faigenbaum AD, Kraemer WJ, Blimkie CJ, Jeffreys I, Micheli LJ, Nitka M, Rowland TW. Youth
resistance training: updated position statement paper from the national strength and
conditioning association. J Strength Cond Res. 2009 Aug;23(5 Suppl):S60-79. doi:
10.1519/JSC.0b013e31819df407. Review. PubMed PMID: 19620931.
Question 201
1. Male gender does not predict motion deficit
2. Meniscal tear does not predict motion deficit
3. Inability to access formal PT does not predict
motion deficit. If a patient has limited preop
motion, this WILL limit post op motion and
should be addressed.
4. Lateral condyle and lateral tibial plateau are
the typical bone bruises. These DO predict
motion deficit.
5. Delay <45 days was shown to increase risk
of delay motion in patients with typical bone
bruises and limited preop ROM
Quelard 2010
Question 201
Question 209
Figures 209a and 209b are the clinical photographs of a 13-year-old
overweight freshman basketball player who has had a 3-month history of left
anterior knee pain that is refractory to nonsurgical treatment that has
included rest, therapy, nonsteroidal anti-inflammatory drugs, and a patella
sleeve brace. Her knee radiographic findings are normal. What is the best
next step?
1. MRI of left knee
2. Hip exam ad frog pelvis radiograph
3. Knee aspiration and lab tests for lyme arthritis
4. Arthroscopic exam of knee and lateral release
5. Plyometric program and detailed menstrual and dietary history
Question 209
Figures 209a and 209b are the clinical photographs of a 13-year-old
overweight freshman basketball player who has had a 3-month history of left
anterior knee pain that is refractory to nonsurgical treatment that has
included rest, therapy, nonsteroidal anti-inflammatory drugs, and a patella
sleeve brace. Her knee radiographic findings are normal. What is the best
next step?
1. MRI of left knee
2. Hip exam ad frog pelvis radiograph
3. Knee aspiration and lab tests for lyme arthritis
4. Arthroscopic exam of knee and lateral release
5. Plyometric program and detailed menstrual and dietary history
Question 209
In a 13 overweight African American female who pw knee pain-don’t forget SCFE!
Additionally this patient stands with their leg in external rotation
Matava et al discusses knee pain as the initial symptom of SCFE. This

retrospective review of 65 patients found that 15 (23%) noted distal thigh pain,
knee pain, or both as the presenting symptom. Knee and thigh pain resulting from
intra-articular hip pathology is a referred pain phenomenon, and is a common
reason for misdiagnosis of SCFE leading to delay in treatment, possible further
displacement, and worse prognosis.
Question 231
A 26-year-old elite sprinter is evaluated for an injury to the biceps
femoris, semimembranosis, and semitendinosis, and an avulsion of the
tendinous origins is present. What is the best next step?
1.Ultrasound-guided injection of platelet-rich plasma to injury site
2.Surgical repair of all tendons to their origin at the ischial tuberosity
3.Surgical repair of the semimembranosis with tenodesis of the
remaining tendons
4.Initial rest and icing with a progressive strengthening program after
pain subsides
5.Stretching and progressive mobilization with strengthening after this
athlete begins running
Question 231
A 26-year-old elite sprinter is evaluated for an injury to the biceps
femoris, semimembranosis, and semitendinosis, and an avulsion of the
tendinous origins is present. What is the best next step?
1.Ultrasound-guided injection of platelet-rich plasma to injury site
2.Surgical repair of all tendons to their origin at the ischial tuberosity
3.Surgical repair of the semimembranosis with tenodesis of the
remaining tendons
4.Initial rest and icing with a progressive strengthening program after
pain subsides
5.Stretching and progressive mobilization with strengthening after this
athlete begins running
Recommended Reading
•Proximal avulsion ruptures at the tendinous
origin of all three tendons are indicated for
prompt surgical repair.
• Cohen S, Bradley J. Acute proximal hamstring rupture. J Am Acad Orthop Surg. 2007 Jun;15(6):350-5.
• Leferve N, Bohu Y, Naouri JF, et al. Returning to sports after surgical repair of acute proximal hamstring ruptures. Knee Surg Sports Traumatol Arhtrosc.
2013 Mar;21(3):534-9.
Sports
Question 244
Figures 244a through 244c are the radiographs of a 20-

year-old college football offensive lineman who feels a pop
in his foot. He is unable to bear weight after his injury. He
had foot pain earlier in the season. What is the best
treatment option?
1. Intramedullary screw fixation of the fracture

2. Short-leg cast with weight bearing as tolerated
3. Short-leg cast with nonweight bearing activity for 6
weeks
4. Use of a hard-sole shoe with weight bearing as tolerated
5. Open reduction and internal fixation using a lateral plate
and bone grafting
Question 244 - Imaging
Question 244 – Preferred Response
Figures 244a through 244c are the radiographs of a 20-

year-old college football offensive lineman who feels a pop
in his foot. He is unable to bear weight after his injury. He
had foot pain earlier in the season. What is the best
treatment option?
1. Intramedullary screw fixation of the fracture

2. Short-leg cast with weight bearing as tolerated
3. Short-leg cast with nonweight bearing activity for 6
weeks
4. Use of a hard-sole shoe with weight bearing as tolerated
5. Open reduction and internal fixation using a lateral plate
and bone grafting
Question 244 - Explanation
• Diagnosis: Jones Fracture

• Treatment Options:
• Nonoperative
• NWB in cast/splint/boot
• Operative
• Intramedullary cannulated screw
• <4.5mm screw assoc w/ delayed union or nonunion
• Large and long
• Athletes get ORIF
• Decreasd nonunion rate
• Decreased time to return to play
• Should wait until radiographic union to return to play
Porter DA, Duncan M, Meyer SJ. Fifth metatarsal Jones fracture fixation with a 4.5-mm cannulated stainless steel screw in the competitive and
recreational athlete: a clinical and radiographic evaluation. Am J Sports Med. 2005 May;33(5):726-33. Epub 2005 Feb 16. PubMed PMID: 15722272.
Rosenberg GA, Sferra JJ. Treatment strategies for acute fractures and nonunions of the proximal fifth metatarsal. J Am Acad Orthop Surg. 2000 Sep-
Oct;8(5):332-8. Review. PubMed PMID: 11029561.
Question 252
Figure 252 is an oblique foot radiograph of a 15-year-old Amateur Athletic Union
basketball star who has a 1-year history of left ankle sprains, a stiff left flat foot, and a
heel in mild valgus. Toe walking does not correct the valgus.Multiple nonsurgical
treatments including a cam walker boot and physical therapy have failed to relieve his
symptoms. Treatment should now involve
1. custom orthotics.
2. a triple arthrodesis.
3. high-top basketball shoes and a lace-up ankle sleeve.
4. resection of the calcaneal navicular coalition and interposition of fat.
5. resection of the subtalar coalition and interposition of the extensor brevis muscle.
Question 252
Question 252
Figure 252 is an oblique foot radiograph of a 15-year-old Amateur Athletic Union
basketball star who has a 1-year history of left ankle sprains, a stiff left flat foot, and a
heel in mild valgus. Toe walking does not correct the valgus.Multiple nonsurgical
treatments including a cam walker boot and physical therapy have failed to relieve his
symptoms. Treatment should now involve
1. custom orthotics.
2. a triple arthrodesis.
3. high-top basketball shoes and a lace-up ankle sleeve.
4. resection of the calcaneal navicular coalition and interposition of fat.
5. resection of the subtalar coalition and interposition of the extensor brevis muscle.
Question 252
Calcaneonavicular coaliations can present with pain worsened with
activity, recurrent ankle sprains, and hindfoot valgus. Radiographs will
show the “ant-eater sign,” which is an extension of the anterior
process of the calcaneus. Initial treatment is immobilization with
casting or orthotics. If pain continues despite conservative treatment,
surgical management involves resection of the coalition with
interpositioning of fat or extensor brevis muscle.
Question 252
Khoshbin A, Law PW, Caspi L, Wright JG. Long-term functional outcomes of resected tarsal
coalitions. Foot Ankle Int. 2013 Oct;34(10):1370-5. doi: 10.1177/1071100713489122. Epub 2013
May 12. PubMed PMID: 23667048.
Mubarak SJ, Patel PN, Upasani VV, Moor MA, Wenger DR. Calcaneonavicular coalition: treatment
by excision and fat graft. J Pediatr Orthop. 2009 Jul-Aug;29(5):418-26. doi:
10.1097/BPO.0b013e3181aa24c0. PubMed PMID: 19568010.

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University of Pennsylvania Department of Orthopaedic Surgery

• Arthroscopic remplissage of the shoulder is

• Arthroscopic remplissage of the shoulder is

• Remplissage is a procedure performed for shoulder

• 72. The femoral origin of the medial patellofemoral

• 72. The femoral origin of the medial patellofemoral

A 20-year-old collegiate pitcher has a 6-week history of pain

• 1. Immobilization of the elbow

University of Pennsylvania Department of Orthopaedic Surgery

A 20-year-old collegiate pitcher has a 6-week history of pain

• 1. Immobilization of the elbow

University of Pennsylvania Department of Orthopaedic Surgery

• This patient had an insidious onset of pain

University of Pennsylvania Department of Orthopaedic Surgery

• Figure 94 is a sagittal knee MRI scan of an

• Figure 94 is a sagittal knee MRI scan of an

• 1. MRI scan of both knees

• 1. MRI scan of both knees

• Patellofemoral pain is the most common condition affecting adolescents and

• Dalton’s review of adolescent athlete injuries reports that overuse or

• Outerbridge and Micheli present a Level 5 review discussing that adolescents

University of Pennsylvania Department of Orthopaedic Surgery

University of Pennsylvania Department of Orthopaedic Surgery

University of Pennsylvania Department of Orthopaedic Surgery

A 21-year-old Division I collegiate football player sustained the injury

A 21-year-old Division I collegiate football player sustained the injury

• Intramedullary screw fixation is a reliable way to fix Jones

• Full-weight bearing is initiated one week post-op.

• Consider this option in patients who desire quick return to full

Excessive resection of a posterior olecranon

A 30-year-old distance runner has a 6-week history of

The clinical diagnosis of an injury to the posterior

University of Pennsylvania Department of Orthopaedic Surgery

The clinical diagnosis of an injury to the posterior

University of Pennsylvania Department of Orthopaedic Surgery

University of Pennsylvania Department of Orthopaedic Surgery

Figures 249a and 249b are the plain radiographs of a 14-year-old

1. Iliotibial band tenodesis with over-the-top femoral fixation

1. Iliotibial band tenodesis with over-the-top femoral fixation

The primary function of the posterior oblique ligament of the knee is to

1. internal tibial rotation in full extension.

University of Pennsylvania Department of Orthopaedic Surgery

The primary function of the posterior oblique ligament of the knee is to

1. internal tibial rotation in full extension.

University of Pennsylvania Department of Orthopaedic Surgery

In the study cited below and performed by Griffith et

University of Pennsylvania Department of Orthopaedic Surgery

During preparticipation physicals for college football, an athlete

During preparticipation physicals for college football, an athlete

• Otherwise unexplained, exertion related death is

Figure 39 is the anteroposterior radiograph of a marathon runner

Figure 39 is the anteroposterior radiograph of a marathon runner

Denervation most typically associated with the finding seen in Figure

Denervation most typically associated with the finding seen in Figure

Spinoglenoid notch cysts causes atrophy of infraspinatous and loss of external

• 1. carry a lower risk for equinus contracture.

• 1. carry a lower risk for equinus contracture.

• Willits et al, JBJS 2010: RCT comparing operative treatment + accelerated

3. 3-phase bone scan

4. Rib series radiographs

5. Posteroanterior chest radiograph

3. 3-phase bone scan