Joint & Connective Tissue Disorders

Question 1

What is the best predictor of fractures in a person with osteoporosis?

(a) Low body weight
(b) Recent falls
(c) Low physical activity
(d) Prior fractures

Answer 1

Answer: (d)
Commentary: The best predictor of future fractures is prior fractures. Low body weight is also a
major risk factor. Recent falls and low physical activity are additional risk factors.

Reference: Khosla S, Melton LJ. Osteopenia. N Engl J Med 2007;356:2294-7

2013

Question 2

In a patient with inflammatory arthritis, which type of exercise is LEAST likely to raise the white
blood cell count in the synovial fluid of the affected joint?

(a) Isotonic
(b) Isometric
(c) Isokinetic
(d) Plyometric

Answer 2

Answer: (b)
Commentary: Isometric exercise allows for tension to be generated in the muscle without any
visible joint movement occurring. An example of an isometric exercise would be pushing against
a wall. Isometric exercise does not alter synovial fluid composition, in contrast to other forms of
exercise that can increase white blood cell count and synovial fluid volume in patients with a
history of inflammatory arthritis.

Isotonic exercises use constant external resistance with variable speed of movement. An example of this would be performing a biceps curl with a dumbbell.

Isokinetic exercises are characterized by constant joint speed and variable external
resistance. Special equipment is needed for this type of exercise. In both isotonic and isokinetic exercise, there is visible joint movement.

Plyometric exercise involves fast, powerful movements. An example of a plyometric exercise would be jumping from a squatting position

2013

Question 3

Which pharmacologic and non-pharmacologic treatment combination is the most appropriate
initial program in a patient with fibromyalgia?

(a) Duloxetine (Cymbalta) plus aerobic exercise
(b) Amitriptyline (Elavil) plus high intensity strength training
(c) Diazepam (Valium) plus trigger point injections
(d) Fentanyl (Duragesic) plus cognitive behavioral therapy

Answer 3

Answer: (a)
Commentary: Pharmacologic treatments used for fibromyalgia include tricyclic antidepressants (e.g., amitriptyline), serotonin-norepinephrine reuptake inhibitors (SNRIs, e.g., duloxetine, venlafaxine), and some anticonvulsants such as pregabalin. Opiates (e.g., fentanyl) and benzodiazepines (e.g., diazepam) are generally not recommended.

Non-pharmacologic therapies include cognitive behavioral therapy, aerobic exercise (low impact), and complementary therapies. To reduce the pain associated with exercise, it is
recommended to “start low, go slow,” with gradual progression in exercise intensity. Patients with fibromyalgia would not likely comply with a high intensity strength training program.

2013

Question 4

An injured worker with complex regional pain syndrome (CRPS), type 1, asks his physician to
prescribe methadone instead of morphine because of ongoing pain. The physician orders blood
work and an electrocardiogram (EKG) first. What finding would be a strong contraindication to
prescribing methadone for this patient?

(a) Hyperkalemia
(b) Hypermagnesemia
(c) QT interval prolongation
(d) Premature atrial complexes

Answer 4

Answer: (c)
Commentary: A prolonged QT interval and serious arrhythmia (torsades de pointes) have been
reported during treatment with methadone. Patients with cardiac hypertrophy, concomitant
diuretic use, hypokalemia or hypomagnesemia are at higher risk for development of prolonged
QT interval because methadone inhibits cardiac potassium channels. Premature atrial complexes
without other cardiac abnormalities that would predispose the patient to QT interval prolongation
would not be considered an absolute contraindication.

Reference: U.S. Food and Drug Administration website

2013

Question 5

A 55-year-old postal worker with a 1-year history of increasing left knee pain and decreasing
ability to ambulate arrives at your office. Her history is significant for 30 minutes of morning
stiffness and a left medial meniscal tear that was repaired arthroscopically 5 years ago. Her exam
is significant for a body mass index of 35, left knee varus deformity, and mild quadriceps
weakness. Her radiograph demonstrates medial compartment narrowing and bony sclerosis. She
has

(a) rheumatoid arthritis.
(b) osteoarthritis.
(c) parvovirus infection.
(d) pseudogout.

Answer 5

Answer: (b)
Commentary: Osteoarthritis (OA) is the leading cause of impaired mobility in elderly persons.
Risk factors include obesity, malalignment, prior trauma or surgery, and occupational bending or
lifting. Radiographs of knee OA demonstrate joint space narrowing, osteophytes, bony sclerosis
and cysts.

2012

Question 6

What shoe modification can be used to treat medial compartment knee osteoarthritis?

(a) Rocker bottom sole
(b) Solid ankle cushioned heel
(c) Medial wedge
(d) Lateral wedge

Answer 6

Answer: (d)
Commentary: Medial compartment osteoarthritis results in genu varum. A lateral wedge can help
relieve pain by placing a valgus force at the knee. A medial wedge would exacerbate the problem.
Solid ankle cushioned heel is a type of prosthetic foot. A rocker bottom sole is helpful for other
conditions such as forefoot fractures, hallux rigidus, foot arthritis, and insensitive feet.

2011

Question 7

A 60-year-old woman with rheumatoid arthritis is concerned about her fingers being crooked.
The ulnar deviation of her fingers at the metacarpal phalangeal joints is due to the rupture of the
(a) lateral retinaculum of the extensor tendon sheath.
(b) central slip of the extensor tendon.
(c) radial retinaculum.
(d) ulnar collateral ligament.

Answer 7

Answer: (c)
Commentary: Rupture of the radial retinaculum produces ulnar subluxation of the metacarpal
phalangeal (MCP) joints. Rupture of the lateral retinaculum of the extensor tendon sheath at the
proximal interphalangeal joints produces swan-neck deformities. Rupture of the central slip of
the extensor tendon produces boutonniere deformities. Rupture of the ulnar collateral ligament
would result in radial deviation of the fingers.

2011

Question 8

In a patient with inflammatory arthritis, which type of exercise is LEAST likely to raise the white blood cell count in the synovial fluid of the affected joint?

(a) Isotonic
(b) Isometric
(c) Isokinetic
(d) Plyometric

Answer 8

Answer: (b)
Commentary: Isometric exercise allows for tension to be generated in the muscle without any visible joint movement occurring. An example of an isometric exercise would be pushing against a wall. Isometric exercise does not alter synovial fluid composition, in contrast to other forms of exercise that can increase white blood cell count and synovial fluid volume in patients with a history of inflammatory arthritis.
Isotonic exercises use constant external resistance with variable speed of movement. An example of this would be performing a biceps curl with a dumbbell.
Isokinetic exercises are characterized by constant joint speed and variable external resistance. Special equipment is needed for this type of exercise. In both isotonic and isokinetic exercise, there is visible joint movement.
Plyometric exercise involves fast, powerful movements. An example of a plyometric exercise would be jumping from a squatting position.

2013

Question 9

What is the best predictor of fractures in a person with osteoporosis?

(a) Low body weight
(b) Recent falls
(c) Low physical activity
(d) Prior fractures

Answer 9

Answer: (d)
Commentary: The best predictor of future fractures is prior fractures. Low body weight is also a major risk factor. Recent falls and low physical activity are additional risk factors

2013

Question 10

A 28-year-old male firefighter sustained deep dermal burns across his lower face, neck, anterior chest, and shoulders. To help manage the formation of hypertrophic scars, you recommend

(a) corticosteroid injections directly into localized, early hypertrophic scars.
(b) compression garments to be worn 12 hours a day.
(c) topical silicone to large areas of hypertrophic scar.
(d) ultrasound treatments with passive stretching.

Answer 10

Answer: (a)
Commentary: Corticosteroid injections directly into localized, early hypertrophic scars can be useful, especially in highly cosmetic locations (face or neck) or in scars that are very pruritic. Compression garments should be worn 23 hours a day until wound erythema begins to abate, usually about 12-18 months after injury. Topical silicone, applied as a sheet, is effective in the
Page 13 of 23
management of small areas of hypertrophic scar. In a prospective randomized double-blind study, the effectiveness of ultrasound with passive stretching versus placebo ultrasound with passive stretching showed no difference in joint range of motion or perceived pain between the 2 treatment groups. This finding suggests that, although widely used, ultrasound may not have a beneficial effect on contractures that form secondary to hypertrophic scarring

2013

Question 11

. A 60-year-old woman with right medial knee pain has a genu varum deformity that is observed
while she is standing and walking. What shoe modification can help her pain?

(a) Medial wedge
(b) Lateral wedge
(c) Rocker bottom
(d) Arch support

Answer 11

Answer: (b)
Commentary: Medial compartment osteoarthritis causes a genu varum deformity. Lateral heel
wedges can be used for conservative treatment of medial compartment osteoarthritis. A medial
wedge would exacerbate the genu varum. An arch support would help with pes planus (flatfoot)
which may be helpful for genu valgum deformity. Rocker bottoms may be used to offload
pressure from the metatarsal heads.

2010

Question 12

Answer: (b)
Commentary: The ATNR is typically present at birth and integrates between 4 and 6 months of
age. An obligatory “fencer” position is abnormal at any age. A persistent or obligatory ATNR
may be an early clue that a child has a disorder of motor control, most often cerebral palsy

Answer 12

Answer: (a)
Commentary: A straight cane should be used on the unaffected side to lessen the force exerted on
the hip with pathology. A Lofstrand crutch is also known as a Lofstrand forearm orthosis. It
includes a cuff placed along the lateral aspect of the forearm. Lofstrand crutches are often used
bilaterally. Because it does not require the use of the hand or wrist, and does not apply pressure
through them, a platform crutch is helpful for patients who need an assistive device and have
wrist/ hand pain or weakness.

2010

Question 13

A 55-year-old postal worker with a 1-year history of increasing left knee pain and decreasing
ability to ambulate arrives at your office. Her history is significant for 30 minutes of morning
stiffness and a left medial meniscal tear that was repaired arthroscopically 5 years ago. Her exam
is significant for a body mass index of 35, left knee varus deformity, and mild quadriceps
weakness. Her radiograph demonstrates medial compartment narrowing and bony sclerosis. She
has
(a) rheumatoid arthritis.
(b) osteoarthritis.
(c) parvovirus infection.
(d) pseudogout.

Answer 13

Answer: (b)
Commentary: Osteoarthritis (OA) is the leading cause of impaired mobility in elderly persons.
Risk factors include obesity, malalignment, prior trauma or surgery, and occupational bending or
lifting. Radiographs of knee OA demonstrate joint space narrowing, osteophytes, bony sclerosis
and cysts.

2012

Question 14

A 72-year-old woman underwent right total knee arthroplasty 2 days ago. When you see her in
consultation, she tells you that she has numbness along the lateral portion of the incision site.
What is the most likely cause?
(a) Femoral or peroneal nerve injury
(b) Deep vein thrombosis
(c) Cutaneous nerve injury
(d) Temporary side effect from anesthesia

Answer 14

Answer: (c)
Commentary: Cutaneous sensory loss is a very common complication following primary total
knee arthroplasty. One study from 1995 found that 100% of patients had lateral skin flap
numbness, and more recent studies in 2004 and 2009 found 81%-86% of patients had lateral skin flap numbness. In most cases, the numbness does improve with time (50% recovered in 2 years in the 2009
study). Deep vein thrombosis (DVT) and common peroneal nerve palsy are other known
complications of total knee arthroplasty.

2012

Question 15

A 25-year-old man with a history of plantar fasciitis complains of low back and buttock pain.
The pain is worse at rest and better with activity. Schober test (signifying restricted lumbar
flexion) is positive. The laboratory or radiology result that would help confirm your most likely
diagnosis is a positive
(a) antinuclear antibody (ANA).
(b) human leukocyte antigen (HLA) B27.
(c) discogram.
(d) myelogram.

Answer 15

Answer: (b)
Commentary: The patient may have ankylosing spondylitis (AS). Enthesitis, such as plantar
fasciitis, is common in patients with AS. HLA B27 is usually positive in this condition, which is
a seronegative spondyloarthropathy. Schober test is performed by marking a point 5 cm below
the iliac crest line and 10 cm above. On forward flexion, the line should increaseby more than 5
cm. An ANA test, discogram and myelogram would not help to diagnosis AS.

2012

Question 16

A 60-year-old man has first metatarsophalangeal joint pain. Joint fluid analysis confirms your
suspected diagnosis. What lifestyle or medication changes would reduce flare-ups of his
condition?
(a) Increase seafood intake
(b) Decrease alcohol intake
(c) Increase diuretic use
(d) Decrease vitamin C use

Answer 16

Answer: (b)
Commentary: Alcohol increases uric acid production and can provoke an acute gout attack.
Seafood and red meat contain purines which increase serum uric acid levels and thus increase
gout flares. Gout can also be provoked by trauma and drugs such as thiazide diuretics. In
contrast, vitamin C has been found to decrease gout attacks.

2012

Question 17

93. A 35-year-old woman sustained an ischemic stroke and is currently undergoing workup in the
    acute care hospital. Systemic lupus erythematosus (SLE) is suspected. An immunoglobulin G
    (IgG) or IgM anticardiolipin antibody analysis is ordered to evaluate for which associated
    condition?
    (a) Antiphospholipid antibody syndrome
    (b) Activated protein C resistance
    (c) Antinuclear antibody
    (d) Antithrombin III deficiency

Answer 17

Answer: (a)
Commentary: Antiphospholipid antibody is associated with systemic lupus erythematosus (SLE)
and can increase risk of thrombosis. SLE is diagnosed with an abnormal serum level of IgG or
IgM anticardiolipin antibodies, positive lupus anticoagulant, or false-positive serologic test for
syphilis. Activated protein C resistance and antithrombin III deficiency are risk factors for
thrombosis and stroke, but do not have the same association with SLE. Antinuclear antibody is
usually positive in SLE and is part of the diagnostic criteria, but is not associated with
thrombosis.

2012

Question 18

A 55-year-old woman comes to your office with a 2-month history of aching and stiffness of her neck and shoulders. Recently, she has had similar symptoms in her hips. She describes difficulty moving in the morning for at least 1 hour after arising. Upon further questioning, she also has fatigue, loss of appetite, and jaw pain with eating. On exam, she has limitation in active range of motion of her shoulders and hips due to pain, but does not have joint synovitis. Plain radiographs are unremarkable. You order laboratory tests and expect to find:

A. normal C-reactive protein (CRP) level.
B Elevated ESR
C Normal hemoglobin and hematocrit
D presence of antinuclear antibodies

Answer 18

Option b is correct.

This woman has polymyalgia rheumatica. Diagnostic criteria include age greater than 50 years, bilateral aching and stiffness for more than 1 month in the shoulder and hip girdle, elevated erythrocyte sedimentation rate, morning stiffness lasting more than 1 hour, rapid response to prednisone and absence of other disease that may cause musculoskeletal symptoms. Patients also demonstrate on laboratory findings mild to moderate anemia of chronic disease and elevated CRP. Antinuclear antibodies are usually negative.

2014

Question 19

A patient’s dual-energy x-ray absorptiometry (DXA) scan shows a T score of -1.5 at the lumbar spine, -2.0 at the femur, and -1.2 at the radius. This patient has

A. normal bone density.
B Osteopenia
C Osteomalacia
D Osteoporosis

Answer 19

Option b is correct.

The T score is the number of standard deviations above or below the mean bone mineral density of normal young adults. Normal bone density is less than 1 standard deviation below the mean. Osteopenia is defined by the World Health Organization as -1 to -2.5 standard deviations below the mean. Osteoporosis is -2.5 or more standard deviations below the mean. Osteomalacia is a softening of bone from decreased mineralization, frequently from vitamin D deficiency.

2014

Question 20

What is the most frequent pulmonary complication of polymyositis and dermatomyositis?

A. Aspiration pneumonia
B. Interstitial lung disease
C Pulmonary arterial hypertension
D Spontaneous pneumothorax

Answer 20

B is correct

Interstitial lung disease occurs in up to 65% of patients with myositis and is a significant contributor to morbidity and mortality. Patients with myositis have further pulmonary complications with respect to muscle weakness and vascular disease resulting in secondary complications of aspiration pneumonia, infection, respiratory muscle failure, pulmonary edema and pulmonary arterial hypertension. Spontaneous pneumothorax is not commonly associated with myositis.

2014

Question 21

Which factor signals and increased risk for underlying malignancy in dermatomyositis?

A Male gender
B Age younger than 40 years
C Elevated CRP
D Erythroderma (exfoliating dermatitis)

Answer 21

Option c is correct.

Dermatomyositis is associated with underlying malignancy in approximately 25% of patients. The erythrocyte sedimentation rate and C-reactive protein are generally elevated in persons with underlying malignancy. The risk of malignancy is higher in older patients and gender does not appear to be a risk factor. Erythroderma may be a presenting symptom of dermatomyositis but does not appear to be a risk factor for malignancies. Several other features of the rash, such as cutaneous necrosis, ulceration or vasculitis, may be associated with underlying malignancy.

2014

Question 22

In trying to differentiate psoriatic arthritis (PA) from rheumatoid arthritis (RA), persons with PA have as a distinguishing characteristic

A dactylitis.
B involvement of the metacarpophalangeal joints.
C erosions on radiographs.
D positive family history.

Answer 22

Option A is correct

Dactylitis (diffusely swollen digits due to tenosynovitis and arthritis) are distinguishing characteristics of PA and not RA. The other choices occur in both psoriatic arthritis and rheumatoid arthritis patients.

2014

Question 23

In contrast to adults with rheumatoid arthritis, which joints are more commonly involved in children with juvenile idiopathic arthritis?

a. Metacarpophalangeal
b Shoulder
c. Interphalangeal
d Temporomandibular

Answer 23

Option d is correct.

Temporomandibular joints (TMJ) are involved in 50% of children with juvenile idiopathic arthritis (JIA) and this involvement can affect development of the mandible, leading to micrognathia. Shoulder involvement in JIA is infrequent, as is involvement of the small joints of the hand.

2014

Question 24

Which medication is most likely to cause osteoporosis?

a Atorvastatin
B. Enalapril
C Phenytoin
d Metformin

Answer 24

Option c is correct.

Anticonvulsants such as phenytoin cause the liver to increase metabolism of 25-hydroxyvitamin D to inactive metabolites, resulting in metabolic bone disease and osteoporosis.Many medications can contribute to bone loss. These include corticosteroids, thyroxine, anticonvulsants such as phenytoin and carbamazepine, cholestyramine, barbiturates, heparin, warfarin, cyclosporine, aromatase inhibitors, and gonadotropin-releasing hormone agonists.

2014

Question 25

A ballet dancer is seen in clinic complaining of knee pain. On physical examination, her knees hyperextend more than 10 degrees. What additional physical exam finding would help support your diagnosis of joint hypermobility syndrome?

a. Extend the 5th digit to 90 degrees.
b. Abduct the thumb to 90 degrees.
c. Touch fingertips to the floor when standing.
d. Appose the posterior heels 180 degrees.

Answer 25

Option a is correct.

A 9-point Beighton score, as described below, can be used to assess for joint hypermobility syndrome. Passive dorsiflexion of the fifth metacarpophalangeal joint to 90o or more (1 point per side).Opposition of the thumb to the volar aspect of the ipsilateral forearm (1 point per side).Hyperextension of the elbow to 10o or more (1 point per side).Hyperextension of the knee to 10o or more (1 point per side).Placing of hands flat on the floor without bending the knees (1 point). A Beighton score of 4 or greater is a major criterion in the Brighton criteria for joint hypermobility syndrome.

2014

Question 26

3. A 45-year-old woman is currently hospitalized for an acute flare of her dermatomyositis. On
   consultation, you recommend

(a) passive range-of-motion exercises.
(b) isometric strengthening exercises at the bedside.
(c) ambulation with a walker in the hallways.
(d) aquatic therapy

Answer 26

Answer: A
Commentary: Passive range of motion to maintain joint movement is recommended during periods of acute flares. With resolution of the flare, active-assisted exercises may be started, progressing to strengthening exercises

2009

Question 27

The most significant risk factor for continued structural destruction of the knee in osteoarthritis is

(a) joint malalignment.
(b) obesity.
(c) prior surgery.
(d) occupational bending and lifting.

Answer 27

(a)
Joint malalignment is the most significant risk factor for further joint deterioration, since it creates uneven focal loading.

2008

Question 28

A 35-year-old man with history of psoriatic arthritis complains of localized low back pain of insidious onset. The pain is worse in the morning and improves as the day progresses. What is the most likely cause of his back pain?

(a) Piriformis strain
(b) Sacroiliitis
(c) Quadratus lumborum strain
(d) Discitis

Answer 28

(b)
Spondylonegative spondylarthropathies, such as psoriatic arthritis, are often associated with sacroiliitis. The Gelling phenomenon, characterized by stiffness after prolonged immobility, occurs with many inflammatory arthropathies.

2008

Question 29

A forty-year-old woman with rheumatoid arthritis (RA) complains of right wrist pain that limits her ability to use her computer and phone at work as a computer analyst. On exam, she has metacarpal phalangeal ulnar deviation, wrist radial deviation, and several boutonniere deformities in her fingers. There is no active synovitis. You suggest occupational therapy and

(a) oral prednisone.
(b) short forearm cast.
(c) a resting wrist orthotic.
(d) finger splints.

Answer 29

(c)
Resting wrist splints provide light support for a painful joint and are well tolerated. They are the most commonly prescribed orthotic in RA.

2008

Question 30

The arthropathy in persons with systemic lupus erythematosus (SLE) generally is in the wrists, knees and small joints of the hands. It is also

(a) symmetric and non-erosive.
(b) symmetric and erosive.
(c) asymmetric and non-erosive.
(d) asymmetric and erosive.

Answer 30

(a)
The arthritis in SLE is symmetric and non-erosive. It is also generally non-deforming and reducible due to its involvement of the para-articular tissues.

2008

Question 31

In addition to routine weight-bearing exercises and calcium supplements, vitamin D is important in persons with osteoporosis because it

(a) decreases the amount of calcium supplementation needed.
(b) enhances muscle strength and reduces the risk of falling.
(c) decreases bone turnover.
(d) improves the mechanism of action of biphosphonates.

Answer 31

(b)
Vitamin D is essential for skeletal maintenance and has been shown to enhance muscle strength and reduce the risk of falling.

2008

Question 32

What articular abnormality is associated with systemic lupus erythematosus and its treatment?

(a) Avascular necrosis
(b) Erosions with subchondral sclerosis
(c) Erosions with overhanging edges
(d) Syndesmophytes

Answer 32

(a)
Avascular necrosis (or ostenecrosis) is the second form of joint disease that occurs in persons with SLE; it is associated with use of corticosteroids. Erosions are not seen with systemic lupus erythematosus. Erosions with subchondral sclerosis are seen in rheumatoid arthritis and overhanging edge in gout. Syndesmophytes occur in spondyloarthropathies at the anterior and posterior longitudinal ligaments of the spine.

2008

Question 33

A patient presents to your office with knee pain from a flare of rheumatoid arthritis. She has a mild
effusion and warmth at her knee. The therapist wants to use ultrasound to her knee for treatment.
You advise that ultrasound

(a) accelerates healing.
(b) helps with pain control.
(c) is contraindicated.
(d) will not help with the pain

Answer 33

(c) Ultrasound use is contraindicated in acute rheumatoid arthritis. Ultrasound has been shown to help with
pain, but not in the context of acute inflammation.

2008

Question 34

You receive a call from your 70-year-old patient with osteoporosis. She has been takingalendronate (Fosamax) for 3 years. The news reports and her friends are all talking about hipfractures in patients taking biphosphonates. You state that based upon scientific evidence there is

(a) increased risk of femoral fractures.
(b) increased risk with the initiation of bisphosphonates at a younger age.
(c) no increased risk in patients with prior fractures.
(d) no increased risk of femoral fractures.

Answer 34

Answer: (d)
Commentary: Recent secondary analysis of 3 large, randomized biphosphonate studies did not
find increased risk of subtrochanteric or femoral fractures. Proposed risk factors such as youngerage upon initiation of biphosphonate treatment has not been confirmed or studied. A risk factor for future fractures is a history of prior fractures.

2011

Question 35

A 40-year-old woman is currently hospitalized for a severe flare of her polymyositis. Onconsultation, you recommend that while in the hospital she begin

(a) passive range-of-motion exercises to prevent contractures.
(b) isometric strengthening exercises at the bedside to maintain her strength.
(c) ambulation with a walker in the hallways supervised by her therapist.
(d) strengthening exercises with light hand and ankle weights.

Answer 35

Answer: (a)
Commentary: Passive range of motion to maintain joint movement is recommended during
periods of acute flares. With resolution of the flare, active-assisted exercises may be started,
progressing to strengthening exercises and ambulation.

2011

Question 36

Risk factors for osteoporotic long bone fractures in children with cerebral palsy include

(a) spastic hemiplegia.
(b) adequate oral nutrition.
(c) vitamin D supplementation.
(d) decreased mobility.

Answer 36

Answer (d)
Commentary: Fracture risk is shown to increase with decreased mobility, nutrition via gastrostomy tube and tetraplegia. Nutritional status is also linked to low bone mineral density (BMD). Deficiencies in vitamin D, calcium, folate, iron and magnesium have been found in children with cerebral palsy. Vitamin D and calcium are especially important in maintaining bone
mineral density (BMD).

2011

Question 37

The initial treatment for osteoarthritis is

(a) medication to reverse articular cartilage damage.
(b) surgical correction of joint deformities.
(c) therapy to relieve joint symptoms.
(d) immobilization of the joint to prevent deformity

Answer 37

(c) General treatment principles of osteoarthritis include medications and/or therapy to relieve joint symptoms, along with maintaining or improving function and minimizing drug toxicity. To date, no medications can reverse or repair damaged articular cartilage. Exercises, such as range of motion and strengthening, are part of nonpharmacologic therapy of osteoarthritis. Surgical correction is not an initial treatment strategy.

2007

Question 38

Which injury level is the most common location for an osteoporotic vertebral compression fracture?

(a) Upper thoracic spine
(b) Middle thoracic spine
(c) Thoracolumbar junction
(d) Middle lumbar spine

Answer 38

(b) The most common location for vertebral compression fractures due to osteoporosis is the midthoracic spine, followed by the thoracolumbar junction. If fractures are seen at other levels, a higher degree of suspicion for a pathologic (due to cancer) fracture should be raised

2007

Question 39

83. Which of the following is the most important lifestyle modification for prevention of osteoporosis?
    (a) Avoiding cigarette smoking and high intake of caffeine
    (b) Decreasing the intake of alcohol
    (c) Minimizing the use of nonsteroidal anti-inflammatory medications
    (d) Eating a diet high in protein and phosphorus

Answer 39

(a) Factors that impact bone mineral density negatively are smoking and high intake of caffeine, protein, and phosphorus. An active lifestyle with regular weight-bearing exercise is advised. Eliminating fall hazards such as throw rugs throughout the home is also essential.

2007

Question 40

A 40-year-old man with psoriatic arthritis consults you regarding his hand pain. On examination, you notice that his left index finger is noticeably shorter than all of his other fingers and has extra folds of skin. The most likely diagnosis is

(a) arthritis mutilans.
(b) Auspitz’s sign.
(c) dactylitis.
(d) Jaccoud’s arthritis.

Answer 40

(a) Arthritis mutilans is osteolysis of the phalanges and metacarpals, which results in telescoping, or shortening, of the involved digit. It is a highly characteristic feature of psoriatic arthritis. Auspitz’s sign is pinpoint bleeding after scraping a psoriatic plaque. Dactylitis, or “sausage digits,” is a combination of tenosynovitis and arthritis of the distal or proximal interphalangeal joint. Jaccoud’s arthritis is a non-erosive deforming arthritis in systemic lupus erythematosus.

2007

Question 41

Etidronate disodium (Didronel) is used in the management of heterotopic ossification to

(a) improve range of motion.
(b) reverse immature ossification.
(c) reverse mature ossification.
(d) prevent ossification.

Answer 41

(d) Etidronate blocks the late phase of bone formation (mineralization), by preventing the conversion of amorphous calcium phosphate to hydroxyapatite. The drug has no effect on the early phase of ossification.

2007

Question 42

(a) Supination in weight bearing is a triplanar motion involving multiple joints of the foot and ankle.
Supination incorporates ankle plantar flexion, talus external rotation, and forefoot adduction.
Obligate tibial and femoral external rotation occurs with supination

Answer 42

(d) Arthritis in systemic lupus erythematosus is non-erosive and does not have articular cartilageinvolvement. In rheumatoid arthritis, periarticular bony erosions and osteopenia are seen onradiographs. Radiographic changes in gouty erosions are usually slightly removed from the jointspace and have atrophic and hypertrophic features (an overhanging edge and soft-tissue tophus).
Characteristic radiographic findings of osteoarthritis include bony proliferation at the joint margin,asymmetric joint-space narrowing, and subchondral bone sclerosis.

2006

Question 43

A 42-year-old woman presents with a 3-month history of difficulty walking up stairs and rising from
chairs. She has no headaches or scalp pain and is currently on no medications. Physical
examination reveals bilateral weakness of her proximal legs and arms. Laboratory studies reveal a
markedly elevated creatine phosphokinase (CPK) level and a normal erythrocyte sedimentation rate
(ESR). The most likely diagnosis is
(a) myasthenia gravis.
(b) polymyalgia rheumatica.
(c) polymyositis.
(d) rhabdomyolysis.

Answer 43

(c) The hallmark features of polymyositis, or idiopathic inflammatory myopathy, are symmetric muscle
weakness of the shoulder and pelvic girdles, occasionally accompanied by mild pain and
tenderness. Eventually, weakness of the proximal leg and arm muscles follows. The symptoms
usually appear insidiously, with no identifiable precipitating event. Laboratory examination shows
AAPM&R
an elevation in skeletal muscle enzymes, especially creatine phosphokinase. Electromyographic
changes are consistent with inflammatory myopathy: short small, polyphasic motor units;
filbrillations; positive waves; and high frequency, repetitive discharges. The absence of headaches
and scalp pain makes polymyalgia rheumatica less likely. Rhabdomyolysis is typically more acute
in onset and is associated with trauma or use of certain medications such as the statins.

2006

Question 44

A 20-year-old man develops weakness accompanied by difficulty in relaxation of the hand and foot
muscles. The muscle biopsy demonstrates prominent ring fibers, centrally located nuclei, and
disorganized sarcoplasmic masses. This condition has been associated with mutation on which
chromosomes?
(a) X
(b) Y
(c) 5
(d) 19

Answer 44

(d) The disease is myotonic dystrophy, which is an autosomal dominant disease. The affected gene has
been localized to chromosome 19. Myotonic dystrophy is relatively common and is best thought of
as a systemic disease since it causes cataracts, testicular atrophy, heart disease, dementia, and
baldness in addition to muscular dystrophy

2006

Question 45

What test is most sensitive for diagnosing myasthenia gravis?

(a) Facial nerve repetitive studies at 30 hertz
(b) Ulnar nerve repetitive studies at 3 hertz
(c) Single fiber electromyography
(d) Acetylcholine receptor antibodies

Answer 45

(c) With a sensitivity of 92% to 100%, single fiber electromyography, which includes measurement of
jitter, is the most sensitive test in assessing for myasthenia gravis. The sensitivity of repetitivestimulation of distal and proximal nerves is 77% to 100%, and acetylcholine receptor antibodysensitivity is 73% to 90%.

2006

Question 46

Which of the following is a rare extra-articular manifestation of rheumatoid arthritis?

(a) Rheumatoid nodules
(b) Keratoconjunctivitis sicca
(c) Glomerular disease
(d) Microcytic anemia

Answer 46

(c) Rheumatoid nodules are present in up to 50% of persons with rheumatoid arthritis (RA).
Keratoconjunctivitis sicca and microcytic anemia are also very common. Glomerular disease is
very rare in RA, but requires management when found

2006

Question 47

A 35 year-old man with ankylosing spondylitis develops a painful left red eye with photophobia and
blurred vision. What is the most likely reason for urgently referring this man to an ophthalmologist
in an effort to prevent vision loss or impairment?
(a) Viral conjunctivitis
(b) Blepharitis
(c) Subconjunctival hemorrhage
(d) Acute anterior uveitis

Answer 47

(d) An ophthalmologist is needed to evaluate for acute anterior uveitis. Acute anterior uveitis is usually unilateral, and occurs at some time in one-third of patients with ankylosing spondylitis (AS). It may also be recurrent. If untreated, it may lead to scarring, pupil irregularity, and vision loss. The other options are also reasons for visiting an ophthalmologist but are not associated with
vision loss in patients with AS

2006

Question 48

Which seronegative spondylarthropathy frequently follows enteric or urogenital infections?

(a) Ankylosing spondylitis
(b) Reiter’s syndrome
(c) Psoriatic arthritis
(d) Juvenile spondyloarthropathy

Answer 48

(b) Reiter’s syndrome or reactive arthritis most frequently follows certain urogenital infections with
Chlamydia trachomatis or enteric infections such as Shigella, Salmonella, and Campylobacter
organisms. The other choices are not associated with such infections.

2006

Question 49

Which treatment or medication is effective in treating both the skin and joint disease in persons with
psoriatic arthritis?
(a) Photochemotherapy
(b) Nonsteroidal anti-inflammatory drugs
(c) Intra-articular injections of corticosteroids
(d) Methotrexate (Rheumatrex, Trexall)

Answer 49

(d) Methotrexate is effective for both skin disease and peripheral arthritis treatment.
Photochemotherapy is for the treatment of skin disease, or psoriasis, only. Nonsteroidal antiinflammatory drugs are effective as the initial treatment option for persons with mild joint disease. For persons with limited joint involvement (1 or 2 joints), intra-articular steroids are a treatment
choice for joint disease only.

2006

Question 50

A 47-year-old man complains of generalized weakness and dysarthria that worsens throughout the
day. He has dysphagia primarily with dinner and his wife reports that “he looks sleepy.” On
examination, ptosis is prominent along with proximal muscle weakness. The most likely diagnosis is
(a) myotonic dystrophy.
(b) amyotrophic lateral sclerosis.
(c) myasthenia gravis.
(d) hyperkalemic periodic paralysis.

Answer 50

(c) Myasthenia gravis is not infrequent in men, and progression with activity is common. Ptosis is a
common finding.

2006

Question 51

Which statement regarding the proven effects of Tai Chi in persons with osteoporosis is TRUE?

(a) It helps retard bone loss in both trabecular and cortical weight bearing bones.
(b) It helps with muscle strength but has no effect on retarding bone loss.
(c) It helps retard bone loss only in trabecular bone.
(d) It helps retard bone loss only in cortical bone.

Answer 51

(a) A Tai Chi program over the course of 12 months has been shown to be beneficial in retarding bone
loss in both trabecular and cortical bone when compared to a sedentary lifestyle

2006

Question 52

A patient presents with joint pain and swelling with symmetric involvement of the ankles,
heels, spine, and sacroiliac joints with calcaneal spurs and periosteal proliferation near the
involved joints. This is characteristic of the arthropathy associated with
A. psoriatic arthritis
B. reactive arthritis (Reiter disease)
C. chondrocalcinosis
D. Behçet syndrome

Answer 52

CORRECT ANSWER: B
Class 1 code: B1e | Class 2 code: A2
Reference: Fishman S et al. Bonica’s Management of Pain. 4th ed. 2010, page 442.

ABPMR 2015

Question 53

a 34 yr old woman diagnosed with fibromyalgia presents with symptoms consistent with central pain sensitization and depressed mood. You are considering initiating a trial of an antidepressant medication, which you hope will also help with her pain. Based on its mechanism of action, which medication would ONLY be expected to help with her mood and NOT also help with her pain, independent of its antidepressant effect?

a. Nortriptyline (Pamelor)
b. Duloxetine (Cymbalta)
c. Milnacipran (Savella)
d. Citalopram (Celexa)

Answer 53

d

when prescribing an antidepressant medication for pain it is important to consider the impact of each medication on serotonin and norepinephrine. Serotonin upregulation is typically believed to help with mood, and noreepinephrine upregulation is typically believed to help with central pain. Nortriptyline is a TCA which enhances both serotonin and norepinephrine neurotransmission. Duloxetine and milnacipran are SNRIs and therefore are expected to enhance both serotonin and norepi neurotransmission. Citalopram, on the other hand, is an SSRI and therefore does not directly enhance norepi neurotransmission.

2015.

Question 54

Which orthosis best corrects a swan neck deformity in RA?

a. ring splint
b. spica splint
c. sugar tong splint
d. ulnar deviation splint

Answer 54

a

ring splints can be used to help correct swan neck deformities in RA. They allow flexion but block hyperextension at the proximal interphalangeal joint. (PIP). Thumb spica splints are used for conditions such as DeQuervain tenosynovitis and OA. Sugar tong splints are used to immobilize a joint such as the

2015