81. Which nerve injury results in medial scapular winging?
A) Spinal accessory nerve
B) Axillary nerve
C) Suprascapular nerve
D) Long thoracic nerve

82. O’Donoghue’s triad (the unhappy triad) consists of tears of which of the following?
A) Anterior cruciate ligament (ACL), medial collateral ligament (MCL), and lateral meniscus
B) ACL, MCL, and medial meniscus
C) ACL, MCL, and lateral collateral ligament (LCL)
D) ACL, MCL, and posterior collateral ligament (PCL)

83. Where is the lesion if a patient presents with isolated infraspinatus weakness and atrophy?
A) The suprascapular notch
B) The C5 nerve root
C) The spinoglenoid notch of the scapula
D) The upper trunk of the brachial plexus

84. Scapula winging is caused by an injury to which one of the following nerves?
A) Radial nerve
B) Suprascapular nerve
C) Long thoracic nerve
D) Axillary nerve

85. The primary function of tendon is to:
A) Transmit the force generated by a muscle to bone
B) Attach bone to bone
C) Be primary joint stabilizers
D) Provide nutrition to bone

86. Ankle eversion injuries often injure the:
A) Deltoid ligament
B) Anterior talofibular ligament
C) Calcaneofibular ligament
D) Posterior talofibular ligament

87. Rotator cuff tears are characterized by:
A) Symptoms similar to rotator cuff tendinitis
B) Pain at night with side-lying on the affected side
C) Examination findings of supraspinatus weakness, external shoulder rotator weakness, and positive drop arm test D) All of the above

88. Which of the following is true regarding impact seizures after a mild head injury?
A) Do not require treatment
B) Occur commonly
C) Are associated with structural brain injury
D) Always indicates that the patient should stop participating in that sport

89. In Erb’s palsy, what part of the brachial plexus is affected?
A) The lower trunk (C8-T1)
B) Both upper and lower trunks
C) Middle trunk (C7)
D) The upper trunk (C5-C6)

90. When is it safe for a patient to return to play after a concussion is diagnosed?
A) Patient can return to the game once they are asymptomatic
B) Neuroimaging must confirm that there is no structural damage
C) Patient must follow a stepwise approach and will be cleared once asymptomatic in all steps
D) Patient is able to play as long as there was no loss of consciousness

91. Shoulder impingement may result from:
A) C6 radiculopathy
B) Loss of competency of the biceps tendon
C) Loss of competency of scapula-stabilizing muscles
D) Thoracic outlet syndrome

92. Which of the evaluations below is the most important part of the physical evaluation of an athlete?
A) Nephrology evaluation
B) Pulmonary evaluation
C) Cardiovascular evaluation
D) Neurologic evaluation

93. A 22-year-old football player presents with right knee pain. His history reveals that he received a posteriorly directed force to his bent knee. Physical examination reveals a positive posterior drawer sign. What injury has the patient most likely sustained?
A) Patello-femoral syndrome
B) Anterior cruciate ligament (ACL) injury
C) Posterior cruciate ligament (PCL) injury D) Medial collateral ligament (MCL) injury

94. What is a Bankart lesion?
A) Tear or avulsion of the anterior glenoid labrum
B) Compression fracture of the posterior humeral head
C) Injury to the superior glenoid labrum and biceps tendon (long head)
D) Compression of the brachial plexus and/or subclavian vessels as they exit between the superior shoulder girdle and first rib

95. A positive Froment’s sign hints to which nerve being injured?
A) Median nerve
B) Radial nerve
C) Ulnar nerve
D) Musculocutaneous nerve

96. What causes Boutonnière deformity?
A) Ruptured flexor digitorum profundus (FDP) tendon
B) Thickening and nodule formation in the flexor tendon sheath
C) Median nerve entrapment
D) Rupture of the central slip and volar migration of lateral bands

97. Compression of which nerve is commonly misdiagnosed as lateral epicondylitis?
A) Posterior interosseous nerve (PIN)
B) Anterior interosseous nerve
C) Median nerve D) C8/T1 nerve roots

98. Little League elbow:
A) Involves the lateral elbow region
B) Is an acute dislocation of the elbow
C) Occurs most commonly between the ages of 13 and 15
D) Occurs in athletes complaining of medial elbow pain

99. Tennis elbow typically:
A) Is an acute lesion, lasting less than a few weeks
B) Presents with pain and tenderness over the medial epicondyle
C) Does not affect grip strength
D) Can occur as a result of a poor tennis backhand stroke

100. What describes a swan neck deformity?
A) Hyperextended metacarpophalangeal (MCP) and distal interphalangeal (DIP) joints, and flexion deformity at the proximal interphalangeal (PIP) joint
B) Synovitis at the ulnar styloid with resultant disruption of the ulnar collateral ligament
C) Hyperextension of the MCP and DIP joints with flexion of the PIP joint D) MCP and PIP joint hyperextension with flexion deformity at the DIP joint

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81. D) Long thoracic nerve injury or palsy will result in serratus anterior weakness. The long thoracic nerve originates from the C5-C7 nerve roots, and travels below the brachial plexus and clavicle before ultimately innervating the serratus anterior muscle. The serratus anterior muscle works to protract the scapula and cause its upward rotation, pulling it forward against the rib cage. In medial scapular winging, the scapula comes away from the chest wall medially. Forward flexion of the shoulder is often weaker and limited to 90° relative to the unaffected side. Injury to the spinal accessory nerve results in lateral scapular winging.
82. B) The ACL, MCL, and medial meniscus are structures that are damaged in the unhappy triad. This usually occurs in contact sports, usually with valgus stress and rotation of the knee. Lateral meniscus tears can also be seen with ACL and MCL injuries.
83. C) The suprascapular nerve is commonly compressed at the level of the suprascapular notch, resulting in deep, boring shoulder pain along the superior scapula and weakness of shoulder abduction and external rotation. If nerve entrapment occurs at the level of the spinoglenoid notch, then the only appreciable finding may be isolated atrophy and weakness of the infraspinatus muscle. Pain is not so prominent at this level because the sensory fibers have already exited.
84. C) Injury to the long thoracic and spinal accessory nerves causes weakness of the serratus anterior and trapezius muscles, respectively, and are most commonly associated with scapular winging. Patients present with symptoms of pain in the upper back or shoulder, muscle fatigue, and weakness with the use of the shoulder. Initial management includes immobilization to prevent overstretching of the weakened muscle.
85. A) Tendons consist of dense, regularly arranged collagen fibers meshed with elastin and a proteoglycan/glycosaminoglycan ground substance. The primary function of the tendon is to transmit the force generated in muscle to the bone allowing for the generation of movement of the extremities.
86. A) Eversion injuries are not as common as inversion injuries but can cause damage to the deltoid ligament. The anterior talofibular ligament, calcaneofibular ligament, and posterior talofibular ligament can be injured in inversion injuries.
87. D) A full thickness tear can cause immediate functional impairments. The pain quality can be described as dull and achy, and symptoms are similar to those of rotator cuff tendinitis. The greatest limitation is difficulty performing overhead activities.
88. A) Seizures can occur within seconds of the insult and do not warrant treatment. They are uncommon and are not associated with structural brain injury or long-term risks. The athlete should not necessarily be eliminated from the sport.
89. D) In Erb’s palsy, the upper trunk of the brachial plexus is affected (C5-C6) resulting in shoulder abduction, elbow flexion, and forearm supination weakness. It is the most common brachial plexopathy seen in newborns.
90. C) Patients must be asymptomatic before starting the stepwise approach, which goes from light aerobic activity to sport-specific training to non–contact drills to full contact practice to game play. The patient is able to progress as long as they are asymptomatic in all steps.
91. C) Impingement can result from extrinsic compression or as a result of loss of competency of the rotator cuff and/or scapula-stabilizing muscles. The biceps tendon also passes within the space. The impingement interval, which is the space between the undersurface of the acromion and the superior aspect of the humeral head, is maximally narrowed when the arm is abducted.
92. C) It is important to identify and prevent sudden cardiac death during physical activity. Conditions such as hypertrophic cardiomyopathy, arrhythmias, coronary artery anomalies, ruptured aortic aneurysms, and commotio cordis are some examples of dangerous and life-threatening conditions.
93. C) This injury can occur when there is a force to a flexed knee. PCL injuries can also be seen in motor vehicle collisions. Isolated PCL injury rehabilitation is focused on quadriceps strengthening and closed kinetic training.
94. A) When there is shoulder instability, there are recurrent episodes of subluxation where the humeral head partially comes out of the socket. Anterior instability is more commonly seen than posterior instability, hence dislocations also more commonly occur anteriorly. With recurrent anterior dislocations (where the humeral head remains fully out of socket), the anterior glenoid labrum may become torn or even avulsed off of the glenoid rim (called a Bankart lesion). Choice (B) describes a Hill-Sachs lesion; choice (C) is a SLAP lesion; and choice (D) describes the setting of thoracic outlet syndrome. Image source: Brown DP, Freeman ED, Cuccurullo SJ, et al. In: Physical Medicine and Rehabilitation Board Review, Third Edition. (Cuccurullo SJ ed.) New York, NY: Demos Medical Publishing LLC; 2015:160.
95. C) Froment’s sign is performed by asking the patient to pinch a piece of paper between his or her index finger and thumb while the examiner tries to pull the paper away. If the patient flexes the first interphalangeal joint, suggesting adductor pollicis weakness, the test is considered a positive Froment’s sign and indicates possible ulnar nerve palsy. Image source: Friedrich J, Akuthota V. In: Sports Medicine: Study Guide and Review for Boards, Second Edition. (Harrast MA, Finnoff JT, eds.) New York, NY: Demos Medical Publishing LLC; 2017:510.
96. D) Boutonnière deformity is seen in patients with rheumatoid arthritis and is a consequence of disruption of the central slip of the extensor tendons with volar migration of the lateral bands. This results in hyperflexion of the proximal interphalangeal (PIP) joint. Treatment in early stages includes splinting of the PIP joint in extension.
97. A) The PIN is a deep branch of the radial nerve, which if compressed may present with lateral elbow pain. The PIN usually gets compressed by a fibrous band located between two heads of the supinator muscle (the radial tunnel). Patients may present with symptoms similar to lateral epicondylitis, but remain refractory to treatment. In such situations, an electromyogram (EMG)/nerve conduction study (NCS) should be sought to evaluate for PIN compression.
98. D) Little League elbow is suspected in a throwing athlete between the ages of 9 and 12 with medial elbow pain and a recent history of throwing. There is tenderness over the medial epicondyle and pain with resisted flexion of the wrist and valgus stress testing of the elbow. There may also be a slight elbow flexion contracture. The pathology is irritation and inflammation of the growth plate on the medial epicondyle.
99. D) Tennis elbow is commonly known as lateral epicondylitis. Patients present with pain and tenderness over the lateral epicondyle as well as over the extensor tendon. There is pain with resistance to wrist and third digit extension. Occasionally, grip strength testing elicits pain. Acutely, there will be inflammatory responses to tension overload placed in the tendon-bone junction. Lateral epicondylitis typically lasts longer than a few weeks. It is caused by a poor backhand stroke in tennis, although this is not always the cause.
100. 100.D) Swan neck deformity is characteristic of rheumatoid arthritis. The deformity may start at the MCP, PIP, or DIP joint. If the flexor tendon at the MCP joint tightens, this may result in hyperextension at the PIP joint. Alternatively, if the PIP volar capsule becomes lax secondary to tenosynovitis, the PIP joint will hyperextend causing swan necking of the remaining joints. More commonly, however, stretching or disruption of the distal extensor mechanism results in a mallet finger deformity, which leads to eventual PIP hyperextension.

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