Sports Medicine Practice Questions

Q: A 45-year-old man has shoulder pain after a motorcycle fall. Radiographs are negative for fracture and dislocation. On examination, a positive lift-off test is noted. What is the most likely diagnosis?

Subscapularis tear. **Explanation:** The clinical presentation of shoulder pain following trauma with negative radiographs and a **positive lift-off test** is pathognomonic for a **subscapularis tear**. **1. Why Subscapularis is correct:** The subscapularis is the only rotator cuff muscle responsible for **internal rotation** of the humerus. The **Gerber’s Lift-off Test** specifically isolates this muscle. It is performed by placing the patient's hand behind their back (lumbar region) and asking them to lift the hand away from the back against resistance. Inability to do so indicates a tear or weakness of the subscapularis. **2. Why other options are incorrect:** * **Supraspinatus (B):** The most commonly injured rotator cuff muscle. It is responsible for the first 15° of abduction. Clinical tests include the **Empty Can (Jobe’s) test** and the **Drop Arm test**. * **Infraspinatus (C):** Responsible for **external rotation** with the arm at the side. It is tested using resisted external rotation. * **Teres Minor (D):** Also an external rotator. It is specifically tested using the **Hornblower’s sign** (resisted external rotation with the arm in 90° abduction). **Clinical Pearls for NEET-PG:** * **Rotator Cuff Muscles (SITS):** Supraspinatus, Infraspinatus, Teres minor, and Subscapularis. * **Belly Press Test:** An alternative test for subscapularis if the patient cannot internally rotate enough to place the hand behind the back. * **Imaging Gold Standard:** While X-rays rule out fractures/dislocations, **MRI** is the investigation of choice for soft tissue/rotator cuff tears. * **Subscapularis Insertion:** It is the only SITS muscle that inserts into the **lesser tuberosity** of the humerus; the others insert into the greater tuberosity.

Q: A 21-year-old javelin thrower is diagnosed with a full-thickness ulnar collateral ligament (UCL) tear. On presentation, he complains of numbness and tingling in the ring and small fingers. Which muscle group would he be most likely to have motor weakness?

Abductor digiti minimi. **Explanation:** The clinical presentation describes a **Uinar Collateral Ligament (UCL) injury** (common in overhead athletes like javelin throwers) associated with **Ulnar Nerve neuropathy**. The ulnar nerve runs in close proximity to the UCL within the cubital tunnel at the medial elbow. Chronic valgus stress or acute UCL tears can lead to ulnar nerve irritation or entrapment, manifesting as sensory loss in the ring and small fingers and motor weakness in ulnar-innervated muscles. **Why Abductor Digiti Minimi (ADM) is correct:** The **Abductor Digiti Minimi** is an intrinsic muscle of the hand (hypothenar eminence) supplied by the **deep branch of the ulnar nerve (C8, T1)**. In ulnar nerve palsy at the elbow, the intrinsic muscles of the hand are the most sensitive indicators of motor weakness. **Analysis of Incorrect Options:** * **Brachioradialis:** Supplied by the **Radial nerve**. It is a flexor of the forearm in the mid-prone position and is unaffected by ulnar nerve pathology. * **Extensor Carpi Ulnaris (ECU):** Despite the name "ulnaris," this muscle is located in the posterior compartment of the forearm and is supplied by the **Posterior Interosseous Nerve (a branch of the Radial nerve)**. * **Palmaris Longus:** A superficial flexor of the forearm supplied by the **Median nerve**. **NEET-PG High-Yield Pearls:** * **Tommy John Surgery:** The eponym for UCL reconstruction, typically using the Palmaris Longus tendon autograft. * **Mannerfelt-Stack Syndrome:** Rupture of the FPL tendon in rheumatoid arthritis (not to be confused with ulnar nerve issues). * **Froment’s Sign:** Tests for ulnar nerve palsy; specifically assesses the **Adductor Pollicis** muscle. * **Wartenberg’s Sign:** Inability to adduct the small finger due to weakness of the third palmar interosseous muscle (ulnar nerve).

Q: What is the most common symptomatic type of plica syndrome?

Medial plica. **Explanation:** Plica syndrome occurs when embryonic synovial remnants (folds) in the knee joint become thickened or inflamed due to trauma or overuse. Among the various types, the **Medial Plica** (specifically the mediopatellar plica) is the most common symptomatic type. **Why Medial Plica is correct:** The medial plica is located between the medial patellar facet and the medial femoral condyle. When it becomes fibrotic or hypertrophied, it can get "bowstrung" across the medial femoral condyle during knee flexion (usually between 30°–60°). This mechanical friction leads to synovitis, chondromalacia, and localized pain, making it the most clinically significant and frequently diagnosed plica syndrome. **Analysis of Incorrect Options:** * **Suprapatellar Plica:** This is the most common plica found anatomically (present in up to 90% of people), but it is rarely symptomatic as it does not typically interfere with joint mechanics. * **Infrapatellar Plica (Ligamentum Mucosum):** This is the most common plica overall, but it is usually an incidental finding. It rarely causes symptoms unless it is severely hypertrophied or torn. * **Lateral Plica:** This is the rarest anatomical variant and is very seldom a cause of clinical symptoms. **NEET-PG High-Yield Pearls:** * **Clinical Presentation:** Patients often present with "pseudo-locking," a snapping sensation, and pain over the medial femoral condyle. * **Physical Exam:** A positive **Plica Stutter Test** or tenderness over the medial joint line (mimicking a medial meniscus tear). * **Diagnosis:** MRI is useful, but **Arthroscopy** remains the gold standard for both diagnosis and treatment (resection). * **Differential Diagnosis:** Often confused with medial meniscal tears or patellofemoral pain syndrome.

Q: Torsion of the knee most commonly results in injury to which structure?

Tibial collateral ligament. **Explanation:** The **Tibial Collateral Ligament (Medial Collateral Ligament - MCL)** is the most frequently injured structure in the knee during torsional (twisting) injuries. This is due to its anatomical position and the common mechanism of injury involving a **valgus stress** combined with external rotation of the tibia. Because the MCL is the primary stabilizer against valgus force, it is the first structure to yield under such tension. **Analysis of Options:** * **Tibial Collateral Ligament (MCL):** (Correct) It is the most common ligamentous injury of the knee. It is often injured in isolation or as the first component of the "Unhappy Triad." * **Medial Meniscus:** While frequently injured, it is less common than MCL tears. It is often injured secondary to MCL tears because the deep fibers of the MCL are firmly attached to the medial meniscus. * **Anterior Cruciate Ligament (ACL):** The ACL is the most common *intra-articular* ligament to be ruptured, but in the overall hierarchy of knee structures, the MCL is injured more frequently. * **Fibular Collateral Ligament (LCL):** This is the least common injury because it requires a varus stress, and the opposite leg usually protects the knee from such forces. **High-Yield Clinical Pearls for NEET-PG:** * **O’Donoghue’s Unhappy Triad:** Consists of injuries to the **MCL, Medial Meniscus, and ACL** (though recent studies suggest the Lateral Meniscus is more commonly involved in acute ACL tears). * **Pellegrini-Stieda Disease:** Post-traumatic calcification at the proximal attachment of the MCL following a chronic or partially healed tear. * **Mechanism:** MCL injuries are tested via the **Valgus Stress Test** at 30° of flexion.

Q: A 22-year-old male basketball player presents with a swollen, painful left knee. He was on a fast break and as he began to jump for an alley-oop, he felt his knee give out and he collapsed to the floor. What is the most likely diagnosis?

Anterior cruciate ligament injury. **Explanation:** The clinical presentation describes a classic non-contact deceleration injury involving a sudden change in direction and vertical loading (jumping), which is the hallmark mechanism for an **Anterior Cruciate Ligament (ACL) injury**. 1. **Why ACL is correct:** The ACL is the primary stabilizer against anterior tibial translation. In basketball, "giving way" (instability) followed by immediate swelling (hemarthrosis) after a landing or pivoting maneuver is highly suggestive of an ACL tear. Patients often report a "pop" sound at the time of injury. 2. **Why other options are incorrect:** * **Patello-femoral dislocation:** Usually occurs due to a forceful contraction of the quadriceps with the knee in slight flexion and valgus. While it causes swelling, the patella is often visibly displaced laterally or there is exquisite tenderness over the medial patellofemoral ligament (MPFL). * **Medial Collateral Ligament (MCL) injury:** Typically results from a **valgus stress** (a blow to the lateral side of the knee). While common, it rarely causes the knee to "give out" as dramatically as an ACL tear unless associated with other injuries. * **Posterior Cruciate Ligament (PCL) injury:** Usually occurs due to a **"dashboard injury"** (direct blow to the proximal tibia with a flexed knee) or extreme hyperextension. It is much less common in non-contact jumping scenarios. **High-Yield Clinical Pearls for NEET-PG:** * **Lachman Test:** The most sensitive clinical test for acute ACL injury. * **Pivot Shift Test:** The most specific test for ACL deficiency. * **Segond Fracture:** A small avulsion fracture of the lateral tibial condyle; it is pathognomonic for an ACL tear. * **Golden Period:** The first 1–2 hours after injury before significant swelling (hemarthrosis) occurs, making clinical examination easier.

Q: Which muscle is strained in athletic pubalgia?

Rectus abdominis. **Explanation:** **Athletic Pubalgia**, commonly referred to as a "Sports Hernia," is a clinical syndrome characterized by chronic groin pain resulting from a soft tissue injury in the pelvic region. It is not a true hernia but rather a strain or tear of the muscles and tendons at the pubic symphysis. **Why Rectus Abdominis is correct:** The core pathology involves an imbalance between the strong adductor muscles and the relatively weaker abdominal wall muscles. The **Rectus abdominis** and the **Adductor longus** share a common aponeurotic insertion on the pubic crest [1]. During high-intensity pivoting or twisting, the adductors pull the pelvis downward while the rectus abdominis pulls it upward [1]. This "tug-of-war" leads to micro-tears or avulsion of the rectus abdominis at its insertion point on the pubis. **Why the other options are incorrect:** * **Gluteus:** These muscles (Maximus, Medius, Minimus) are located posteriorly and are involved in hip extension and abduction; they are not part of the anterior pubic aponeurosis. * **Rectus femoris:** This is part of the quadriceps group originating from the Anterior Inferior Iliac Spine (AIIS). While it can be strained in athletes, it is not the primary muscle involved in the specific pathology of pubalgia. * **Quadriceps:** These are anterior thigh muscles responsible for knee extension. While they stabilize the hip, they do not insert onto the pubic crest where the pubalgia lesion occurs. **Clinical Pearls for NEET-PG:** * **The "Joint" Concept:** The pubic symphysis acts as a fulcrum. Injury to the rectus abdominis often co-exists with **Adductor longus** tendinopathy. * **Clinical Presentation:** Pain is exacerbated by Valsalva maneuvers, resisted sit-ups, or hip adduction. * **Imaging:** MRI is the gold standard to visualize the "secondary cleft sign" or fluid at the pubic symphysis.

Q: Which investigation is the investigation of choice for a sport injury of the knee?

Arthroscopy. **Explanation:** **Arthroscopy** is considered the "Gold Standard" investigation of choice for sports-related knee injuries. Its superiority lies in its dual role: it provides **direct visualization** of intra-articular structures (ACL, PCL, menisci, and articular cartilage) with nearly 100% accuracy and allows for **simultaneous therapeutic intervention** (e.g., meniscal repair or ACL reconstruction). While MRI is the non-invasive investigation of choice, Arthroscopy remains the definitive diagnostic tool when surgical management is anticipated. **Analysis of Incorrect Options:** * **A. Ultrasonography:** While useful for superficial soft tissue pathologies like Baker’s cysts or patellar tendonitis, it lacks the resolution and depth to accurately evaluate deep intra-articular structures like the cruciate ligaments. * **B. Plain Radiography:** This is the initial investigation to rule out fractures (e.g., Segond fracture) or bony avulsions, but it cannot visualize the soft tissue injuries (ligament/meniscal tears) that comprise the majority of sports injuries. * **C. Arthrography:** This invasive procedure involving dye injection was historically used to detect meniscal tears but has been rendered obsolete by the superior imaging of MRI and the direct visualization of Arthroscopy. **Clinical Pearls for NEET-PG:** * **Investigation of Choice (Non-invasive):** MRI. * **Gold Standard (Definitive):** Arthroscopy. * **Triad of O'Donoghue:** Injury to the ACL, Medial Collateral Ligament (MCL), and Medial Meniscus (though recent studies suggest Lateral Meniscus involvement is more common in acute phases). * **Most common ligament injured in the knee:** ACL.

Q: Torsion of the knee results in injury most commonly to which structure?

Anterior cruciate ligament. **Explanation:** Torsion, or a twisting mechanism of the knee (especially during sudden deceleration or pivoting), is the most common cause of **Anterior Cruciate Ligament (ACL)** injury. While the medial meniscus and collateral ligaments are frequently involved in knee trauma, the ACL is statistically the most common structure to be completely ruptured during a non-contact rotational force. * **Anterior Cruciate Ligament (Correct):** The ACL is the primary stabilizer against anterior tibial translation and rotational stress. During torsion, the femur rotates externally on a fixed tibia (or vice versa), placing maximum strain on the ACL, leading to its failure. * **Medial Meniscus (Incorrect):** While often injured alongside the ACL (as part of O'Donoghue’s Unhappy Triad), isolated meniscal tears usually require a combination of weight-bearing and compression alongside rotation. In pure torsional trauma, the ACL typically yields first. * **Tibial (Medial) Collateral Ligament (Incorrect):** The MCL is primarily injured by **valgus stress** (a blow to the lateral side of the knee). While it can be involved in rotational injuries, it is not the most common structure injured by torsion alone. * **Fibular (Lateral) Collateral Ligament (Incorrect):** The LCL is the least commonly injured of the four major ligaments and usually requires a **varus stress** or high-energy trauma. **NEET-PG High-Yield Pearls:** * **Mechanism:** Non-contact pivoting/deceleration is the classic history for ACL tears. * **Clinical Sign:** Patients often report a **"pop" sound** followed by immediate swelling (hemarthrosis). * **Gold Standard Investigation:** MRI is the investigation of choice. * **Most Sensitive Test:** The **Lachman test** is more sensitive than the Anterior Drawer test for diagnosing ACL deficiency. * **Segond Fracture:** An avulsion fracture of the lateral tibial condyle is pathognomonic for an ACL tear.

Q: A football player presents with a twisting injury to the left leg, experiencing pain. The X-ray was normal, but clinical examination reveals positive anterior drawer and Lachman tests. What is the most likely diagnosis?

ACL tear. **Explanation:** The clinical presentation of a twisting injury in an athlete followed by a positive **Lachman test** and **Anterior Drawer test** is pathognomonic for an **Anterior Cruciate Ligament (ACL) tear**. 1. **Why ACL Tear is Correct:** The ACL is the primary stabilizer preventing anterior translation of the tibia on the femur. The **Lachman test** is the most sensitive clinical test for ACL deficiency (sensitivity ~95%). A positive result (increased anterior excursion of the tibia with a soft end-point) confirms the diagnosis. While X-rays are usually normal (unless a Segond fracture is present), MRI is the gold standard for confirmation. 2. **Why Incorrect Options are Wrong:** * **Medial Meniscus Tear:** Presents with joint line tenderness and positive McMurray’s or Apley’s grind tests, not anterior instability. * **PCL Tear:** Would present with a positive **Posterior Drawer test** or "Sag sign." It usually results from direct trauma to the pretibial area (dashboard injury). * **Proximal Tibia Fracture:** This would be clearly visible on an X-ray and would typically involve significant bony tenderness and inability to bear weight. **High-Yield Clinical Pearls for NEET-PG:** * **Segond Fracture:** An avulsion fracture of the lateral tibial condyle; it is highly specific for an ACL tear. * **Terrible Triad (O'Donoghue):** Simultaneous injury to the ACL, Medial Collateral Ligament (MCL), and Medial Meniscus (though lateral meniscus tears are more common in acute ACL injuries). * **Pivot Shift Test:** The most specific test for ACL tear, indicating rotatory instability. * **Hemarthrosis:** ACL tears are the most common cause of post-traumatic hemarthrosis in the knee.

Q: Structural integrity of collateral ligaments is best tested by which maneuver?

Varus/valgus stress test at 30 degrees of flexion. ### Explanation The **Varus and Valgus stress tests** are the gold standard clinical maneuvers for assessing the integrity of the Lateral Collateral Ligament (LCL) and Medial Collateral Ligament (MCL), respectively. **Why 30 degrees of flexion is the correct answer:** In **full extension**, the knee joint is in its most stable position. The posterior capsule, cruciate ligaments (ACL/PCL), and the interlocking of the femoral condyles provide significant secondary stability. This "masks" isolated collateral ligament laxity. By flexing the knee to **30 degrees**, the posterior capsule is relaxed and the joint is "unlocked." In this position, the collateral ligaments become the primary structures resisting varus and valgus forces, allowing for a more specific and sensitive assessment of their structural integrity. **Analysis of Incorrect Options:** * **Full Extension (Option B):** If there is laxity in full extension, it usually indicates a more severe injury involving not just the collateral ligaments, but also the cruciate ligaments and the posterior capsule. * **Full Flexion/90 Degrees (Options A & D):** At 90 degrees of flexion, the geometry of the joint and the tension of other soft tissue structures interfere with the isolation of the collateral ligaments, making the test unreliable for grading ligamentous tears. **High-Yield Clinical Pearls for NEET-PG:** * **Valgus Stress Test:** Tests the **MCL**. Increased laxity at 30° flexion = Isolated MCL tear. Laxity at 0° extension = Combined MCL and Cruciate/Capsular injury. * **Varus Stress Test:** Tests the **LCL**. * **Grading:** * Grade I: Pain but no laxity. * Grade II: Partial tear with some endpoint. * Grade III: Complete tear with no definite endpoint (significant opening of the joint space). * **MCL** is the most commonly injured ligament of the knee.

Question 1

A 45-year-old man has shoulder pain after a motorcycle fall. Radiographs are negative for fracture and dislocation. On examination, a positive lift-off test is noted. What is the most likely diagnosis?

Accepted Answer

Subscapularis tear

Answer

Supraspinatus tear

Answer

Infraspinatus tear

Answer

Teres minor tear

Question 2

A 21-year-old javelin thrower is diagnosed with a full-thickness ulnar collateral ligament (UCL) tear. On presentation, he complains of numbness and tingling in the ring and small fingers. Which muscle group would he be most likely to have motor weakness?

Accepted Answer

Abductor digiti minimi

Answer

Brachioradialis

Answer

Extensor carpi ulnaris

Answer

Palmaris longus

Question 3

What is the most common symptomatic type of plica syndrome?

Accepted Answer

Medial plica

Answer

Suprapatellar plica

Answer

Lateral plica

Answer

Infrapatellar plica

Question 4

Torsion of the knee most commonly results in injury to which structure?

Accepted Answer

Tibial collateral ligament

Answer

Anterior cruciate ligament

Answer

Medial meniscus

Answer

Fibular collateral ligament

Question 5

A 22-year-old male basketball player presents with a swollen, painful left knee. He was on a fast break and as he began to jump for an alley-oop, he felt his knee give out and he collapsed to the floor. What is the most likely diagnosis?

Accepted Answer

Anterior cruciate ligament injury

Answer

Patello-femoral dislocation

Answer

Medial collateral ligament injury

Answer

Posterior cruciate ligament injury

Question 6

Which muscle is strained in athletic pubalgia?

Accepted Answer

Rectus abdominis

Answer

Gluteus

Answer

Rectus femoris

Answer

Quadriceps

Question 7

Which investigation is the investigation of choice for a sport injury of the knee?

Accepted Answer

Arthroscopy

Answer

Ultrasonography

Answer

Plain radiography

Answer

Arthrography

Question 8

Torsion of the knee results in injury most commonly to which structure?

Accepted Answer

Anterior cruciate ligament

Answer

Medial meniscus

Answer

Fibular collateral ligament

Answer

Tibial collateral ligament

Question 9

A football player presents with a twisting injury to the left leg, experiencing pain. The X-ray was normal, but clinical examination reveals positive anterior drawer and Lachman tests. What is the most likely diagnosis?

Accepted Answer

ACL tear

Answer

Medial meniscus tear

Answer

PCL tear

Answer

Proximal tibia fracture

Question 10

Structural integrity of collateral ligaments is best tested by which maneuver?

Accepted Answer

Varus/valgus stress test at 30 degrees of flexion

Answer

Varus/valgus stress test in full flexion

Answer

Varus/valgus stress test in full extension

Answer

Varus/valgus stress test at 90 degrees of flexion

Sports Medicine — MCQs

Sports Medicine — MCQs

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