MSK Flashcards
Thumb extension nerve root
C8
Finger abduction nerve root
T1
Ankle dorsiflexion nerve root
L4
Big toe extension nerve root
L5
Ankle plantarflexion nerve root
S1
Knee flexion nerve root
S2
Elbow flexion and wrist extension nerve root
C6
Elbow extension and wrist flexion nerve root
C7
Scapula elevation nerve root
C4
Shoulder abduction nerve root
C5
A hyperirritable band of tight muscle and fascia that produces local numbness and tingling along with radiating pain is also known by which of the following names?
AMyalgia
BTrigger point
CTender point
DMyofascial pain
Answer: A
* A trigger point is defined as in the question stem. A trigger point can be palpated and appreciated by the physician. A tender point is something that cannot be truly felt by the physician, and does not typically radiate pain outward. * Myofascial pain and myalgias are subjective feelings of pain arising from muscle + fascia, and muscle, respectively.
A 40 year-old male is water skiing when he develops sudden onset left knee pain after a wipeout. On exam, valgus stress testing is positive for laxity and reproduction of knee pain. MRI reveals a grade 3 medial collateral ligament tear in the knee (MCL tear). There is no evidence of avulsion fracture or other ligament tearing. Strength, sensation, and reflexes are otherwise intact. What is the next best step in management?
AKnee brace
BPhysical therapy
CSurgical MCL repair
DProlotherapy injection into the MCL
Answer: A
• MCL tears can be treated nonoperatively. A patient with advanced-grade tearing (as in this patient) should be treated with a knee brace to protect the MCL and facilitate healing, followed by gentle ROM and physical therapy.
• Surgery would be indicated if other complications were present such as other ligaments being torn, avulsion fractures, etc. Prolotherapy would not be appropriate for large ligament tears in general.
A patient with rheumatoid arthritis develops a swan neck deformity. How would you describe this abnormal finger position? DIP: distal interphalangeal joint. PIP: proximal interphalangeal joint. MCP: metacarpophalangeal joint.
ADIP flexion, PIP extension, MCP extension
BDIP extension, PIP flexion, MCP extension
CDIP extension, PIP flexion, MCP flexion
DDIP flexion, PIP extension, MCP flexion
Answer: D
“DIP flexion, PIP extension, MCP flexion” correctly describes a swan neck deformity. This is treated with a swan neck ring splint (imagine that!).
A 26 year-old male quarterback in a football game is tackled to the ground. He grabs his right ankle in pain. You rush onto the field and diagnose a torn tibiofibular interosseous ligament. X-rays demonstrate a Maisonneuve fracture. You advise the quarterback that:
APhysical therapy alone is recommended
BOrthopedic surgery consultation is recommended
CKnee bracing and rest will be sufficient
DHis playing days are over
Answer: B
• A Maisonneuve fracture is a proximal fibula fracture that may occur following a high ankle sprain (tibiofibular syndesmosis tear/rupture). Essentially the tearing of the syndesmosis extends all the way up proximally until the forces continue into the proximal fibula, causing a fracture there. X-rays of the knee are thus required following a high ankle sprain; Maisonneuve fracture generally requires orthopedic surgery consultation.
Which of the following nerves innervates the muscles of the deep posterior compartment of the leg?
A Tibial
B Sciatic
C Deep fibular
D Superficial fibular
Answer: A
Explanation:
• The deep posterior leg compartment contains the tibialis posterior, flexor digitorum longus, and flexor hallucis longus, which are all innervated by the tibial nerve.
Heterotopic ossification (HO) is most common at which of the following locations? AHip BKnee CElbow DShoulder
Answer: A
• In most patients, HO is most common at the hip.
• In burn patients, HO is most common at the elbow.
In evaluating a patient with pain, you decide to squeeze her left tibia together by wrapping your hands around the medial and lateral borders of the tibia and squeezing. The purpose of this test is to diagnose which of the following conditions? AAchilles tendon rupture BTibial plateau fracture CMaisonneuve fracture DShin splints
Answer: D
• Squeezing the tibia and reproducing a patient’s pain is indicative of shin splints (medial tibial stress syndrome).
• One may also perform a squeeze test to examine a high ankle sprain, but x-rays would be the best test for Maisonneuve fracture (a complication of a high ankle sprain), not physical exam.
A patient presents to your clinic with 5 months of right shoulder pain. On exam, you attempt passive abduction of the shoulder, which takes greater than usual force for you to abduct it, and the patient cries out in pain when you reach 70 degrees of abduction. Empty can, Neer, Hawkins, Speed, and O’Brien tests are positive. What is the most likely diagnosis? ARotator cuff tear BFrozen shoulder CSubacromial impingement/bursitis DLabral tear
Answer: B
• The key to answering this is the high difficulty in simply abducting the shoulder, as well as the limited degrees of abduction, which together imply a very tight shoulder capsule.
• Frozen shoulder (adhesive capsulitis) frequently shows pan-positive exam findings suggestive of other diseases.
• The other answer choices by themselves would not restrict shoulder range of motion to the same degree that frozen shoulder does.
A 6 year-old boy and his mother present to the ED with sudden-onset left elbow pain. The patient was on a walk with his mother. After his mother pulled him quickly away from the street where there were oncoming cars, he began to cry, and wouldn’t let his mother touch his left arm, holding it close to his body. What is the most likely underlying pathology?
ABehavioral etiology
BLateral epicondylitis
CSubluxation of the radial head away from the annular ligament
DPosterior elbow dislocation
Answer: C
• Nursemaid elbow is a subluxation of the radial head out of the annular ligament’s grasp. It is typically caused by a sudden axial force directed distally along the radius, which pulls the radial head out of the annular ligament’s grasp, causing the radial head to float anteriorly; this causes severe pain in the elbow.
• Treatment is physical exam, xrays, and closed reduction.
• Behavioral concerns should be the a diagnosis of exclusion after physical pathology has been ruled out. Lateral epicondylitis presents chronically.
• Posterior elbow dislocation typically occurs with trauma.
Which of the following is the function of the iliofemoral ligament regarding the hip?
ALimit abduction, flexion, internal rotation
BLimit abduction, extension, internal rotation
CLimit abduction, extension, external rotation
DLimit abduction, flexion, external rotation
Answer: C
• The iliofemoral ligament extends from the ileum to femur on the anterior side of the hip joint. Its function is to limit hip abduction, extension, and external rotation.
A 59 year-old female presents with left knee pain of gradual onset without a history of trauma. She points to the medial knee in a vague, large circle when you ask where the pain is. On exam strength, sensation, and reflexes are intact. Valgus stress testing is negative. Varus stress testing causes medial knee pain. There is pain with resisted hamstring strength. Palpation of the medial tibia below the knee elicits concordant pain. The left medial tibia appears swollen compared to the right. What is the most likely diagnosis? APes anserine bursitis BHamstring tendonitis CLCL sprain DMedial meniscus tear
Answer: A
• This patient depicts classic findings of pes anserine bursitis. The pes anserine consists of sartorius, gracilis, and semitendinosus which insert onto the medial tibia below the knee. There is also a bursa here which can become inflamed and distended.
A 27 year-old male attempts to cut to the right during a soccer game, and experiences sudden-onset left knee pain and swelling. Anterior drawer is negative. Lachman test is positive. X-rays of the knee should be taken to rule out a Segund fracture, which can be described as which of the following?
A Avulsion fracture of the medial tibial condyle
B Avulsion fracture of the lateral tibial condyle
C Avulsion fracture of the medial femoral condyle
D Avulsion fracture of the lateral femoral condyle
Answer: B
Explanation:
• ACL tears can be associated with Segund fractures, which is an avulsion fracture of the lateral tibial condyle. X-rays are important to rule out this fracture following an acute ACL tear.
ACL tears can be associated with Segund fractures, which is an avulsion fracture of the lateral tibial condyle. X-rays are important to rule out this fracture following an acute ACL tear. Which of the following maneuvers describes the Jerk test with respect to the shoulder?
ANone of these answers is correct
BFlexing shoulder beyond 90 degrees and applying posteroinferiorly directed axial force along humerus
CFlex to 90°, internal rotation, adduction across midline while applying posterior axial force
DAbducting, externally rotating, and applying anteriorly directed force on the humerus.
Answer: C
• Flexing the shoulder to 90 degrees, internally rotating, and adducting across midline with a posterior axial force describes the Jerk test, which is a test for posterior shoulder instability.
• The Kim test (flexing shoulder beyond 90 degrees and applying posteroinferior force) is also a shoulder posterior instability test.
• Abducting, externally rotating, and applying anterior force describes the anterior apprehension test, which unsurprisingly tests for anterior shoulder instability.
A 29 year-old male presents in follow up for left tennis elbow. He has tried RICE, PT, acetaminophen/NSAIDs, and corticosteroid injection to only minimal benefit. It is summer time, and he is disappointed because he is looking forward to playing in an upcoming tournament in London. He wonders if there is anything else he can do. Which of the following is the most appropriate recommendation?
A. Surgery
B. TENS
C. Needle tenotomy of common extensor tendon
D. Repeat corticosteroid injection
Answer: C
• This patient has failed conservative treatments as well as one corticosteroid injection which provided no benefit. At this point regenerative interventions may be considered, including needle tenotomy, platelet-rich plasma, prolotherapy, etc.
• Percutaneous needle tenotomy is the use of a needle to make small holes in a tendon through the skin. Repeated needlesticks can break up scar tissue and cause bleeding in a tendon, prompting the inflammatory cascade and helping the body’s own cells to begin rebuilding the tendon.
A 45 year-old male presents to your pain clinic with complaints of left elbow pain. On exam you note pain in the muscles and tendons just distal to the medial epicondyle. This patient’s condition is typically caused by which of the following A. Excessive varus forces B. Excellent sporting technique C. Trauma D. Overuse
Answer: D
• Golfer elbow (medial epicondylitis) is inflammation of the common flexor tendon of the elbow due to microtears/overuse of the wrist and finger flexors, which originate at the common flexor tendon off the medial epicondyle. It is typically caused by overuse and poor technique.
You are examining a patient from behind. Their stance has caught your attention. You notice that you can only see two of the patient’s left toes, but you can see all five of the patient’s right toes. What pathology do you suspect the most? A. Tibialis anterior insufficiency B. Tibialis posterior insufficiency C. Fibularis brevis insufficiency D. Fibularis longus insufficiency
Answer: B
• The “too many toes” sign is described here, caused by weakness/insufficiency of the tibialis posterior muscle/tendon unit.
• The tibialis posterior is a plantarflexor and invertor; thus, failure of this tendon to work properly allows the foot to be pulled pathologically into a hyperpronated position, causing more toes than usual to be observed from behind the patient (too many toes, indeed!).
A 65 year-old female is seen in follow-up for right shoulder pain. She has moderate to severe glenohumeral joint space narrowing on shoulder xray. She has completed a course of physical therapy and performs a home exercise program daily. Acetaminophen and ibuprofen provide mild benefit. She states that her function has improved but her pain remains in the shoulder. A corticosteroid injection you performed was of limited benefit. What is the next best step?
A Refer for spinal cord stimulator trial
B Start trial of oxycodone
C Orthopedic surgery referral
D Repeat corticosteroid injection
Answer: C
Explanation:
• This patient with advanced shoulder OA who has failed conservative treatments and injection should be considered for shoulder replacement via orthopedic surgery referral.
• Opioids are not indicated here. Repeat steroid injection has little utility here. Spinal cord stimulator trial would not be appropriate for this focal, structural source of pain.
A 29 year-old male presents to your general PM&R clinic with complaints of chronic bilateral shoulder pain. He denies weakness, numbness/tingling, and history of trauma. On exam, you note extreme hypermobility in multiple joints. Physical exam is grossly negative for reproduction of pain. What is the most appropriate treatment for this patient?
A There are no firm guidelines
B Physical therapy
C Surgery
D EMG
Answer: B
Explanation:
• This patient is suffering from bilateral shoulder dislocations, with a hint to that being the patient’s global hypermobility, which implies ligamentous laxity, which leads to the recurrent dislocations.
• Typically these patients lack trauma history, and their global hypermobility leads to both shoulders being bothered, rather than one, as typically is seen in traumatic unilateral shoulder dislocations.
• Bilateral shoulder dislocations due to hypermobility are most appropriately treated with rehab/physical therapy.
• Surgery may be considered failing therapy.
When deciding what type of work a patient is cleared to return to, “light duty work” is defined as lifting no more than how many lbs while on the job?
A 40
B 30
C 20
D 10
Answer: C
Explanation:
• Light duty is defined as no lifting over 20 lbs. Very light duty is lifting no more than 10 lbs.
The fifth extensor compartment of the wrist contains which of the following tendons?
A Extensor indicis proprius
B Extensor digiti minimi
C Extensor carpi ulnaris
D Extensor pollicis longus
Answer: B
Explanation:
• 1st extensor compartment contains Abductor pollicis longus and Extensor pollicis brevis tendons.
• 2nd extensor compartment contains Extensor carpi radialis longus and Extensor carpi radialis brevis tendons.
• 3rd extensor compartment contains Extensor pollicis longus tendon.
• 4th extensor compartment contains Extensor digitorum and Extensor indicis.
• 5th extensor compartment contains the Extensor digiti minimi tendon.
A patient with rheumatoid arthritis develops a Boutonniere deformity. How would you describe this abnormal finger position? DIP: distal interphalangeal joint. PIP: proximal interphalangeal joint. MCP: metacarpophalangeal joint.
A DIP flexion, PIP extension, MDP extension
B DIP extension, PIP flexion, MCP extension
C DIP extension, PIP flexion, MCP flexion
D DIP flexion, PIP extension, MCP flexion
Answer: B
Explanation:
• “DIP extension, PIP flexion, MCP extension” correctly describes a Boutonniere deformity. This is treated with a Boutonniere ring splint (imagine that!).
A 28 year-old male presents to your clinic with right ankle pain. You decide to stabilize the distal lower leg while grabbing the calcaneus and inverting the hindfoot. Which ligament are you attempting to test?
A Tibiofibular syndesmosis
B Posterior talofibular ligament
C Calcaneofibular ligament
D Anterior tibiofibular ligament
Answer: C
Explanation:
• Talar tilt test (described here) is a test for the ATFL (anterior talofibular ligament - NOT tibiofibular ligament as noted in this question) and the CFL (calcaneofibular ligament).
• It is used to define the extent of a lateral ankle sprain in terms of ligament involvement.
A 31 year-old female is involved in a skiing accident. She develops aching elbow pain shortly afterward. On exam you notice that, when extended, her elbow assumes a valgus angulation. Cozen test is weakly positive. When applying a laterally directed force across the elbow joint while stabilizing the arm and forearm, she cries out in pain. What is the most likely mechanism of injury in this patient?
A Excessive varus force across the elbow
B Excessive valgus force across the elbow
C Rupture of the common extensor tendon
D Overuse of the common extensor tendon
Answer: A
Explanation:
• This patient’s chief exam maneuver reproducing her pain foremost is the varus stress test, as demonstrated in the question stem.
• This test pulls apart the radial collateral ligament and causes pain if the ligament is already sprained or torn.
• Excessive varus forces across the elbow cause sprain of this ligament.
• Cozen being weakly positive is a red herring, as people in great pain will often demonstrate pan-positive exam findings.
• The purpose of Cozen’s test (also known as the “resisted wrist extension test” or “resistive tennis elbow test”) is to check for lateral epicondylalgia or “tennis elbow”.
○ The patient should be seated, with the elbow extended forearm maximal pronation, wrist radially abducted, and hand in a fist.
○ The therapist should stabilise elbow while palpating lateral epicondyle, other hand placed on the dorsum of the hand.
○ The patient is asked to move the wrist to dorsal flexion and the therapist provides resistance to this movement, in the position described above. The test is positive if pain on the lateral epicondyle is elicited.
A 22 year-old male sustains a lateral ankle sprain. Anterior drawer of the ankle, and talar tilt tests are positive. You grab your ultrasound machine because you are concerned about a secondary injury to which of the following structures most likely?
A Tibialis posterior tendon
B Tibialis anterior tendon
C Deltoid ligament
D Fibularis longus tendon
Answer: D
Explanation:
• A possible complication of lateral ankle sprains is a fibularis longus or brevis tendon injury.
• This is due to the fact that these tendons wrap around the lateral malleolus; thus, severe inversion forces can cause abrupt stretching and possible tearing of these tendons.
• Diagnostic ultrasound scan would be useful as an in-office, quick evaluation of the tendon anatomy.
A 20 year-old male is in a wrestling competition when he attempts to suplex his opponent by grabbing him about the waist and performing a deep squat while pivoting to his right. He experiences sudden-onset right knee pain afterward. Which of the following is the most likely diagnosis for the knee pain?
A MCL tear
B LCL tear
C Medial meniscus tear
D Lateral meniscus tear
Answer: D
Explanation:
• The important thing to learn in this question is the typical mechanism for meniscus injuries, which involves large axial forces on the knee (e.g. picking up another human being) while simultaneously performing a twisting/grinding motion upon the knee.
Further, know that deep squatting while pivoting under resistance is a classic mechanism for lateral meniscus tears.
A 21 year-old female long distance runner develops gradual onset bilateral medial shin pain. She is currently training for a marathon. She denies trauma. On exam, squeezing the medial and lateral tibia together reproduces her medial shin pain located along the tibia. What is the next best step?
A X-rays
B Physical therapy
C Reduce mileage
D Reassurance
Answer: A
Explanation:
• Bilateral shin pain in the context of long distance running, without trauma, is indicative of medial tibial stress syndrome (shin splints).
• However, a tibial stress fracture would present very similarly, and must be ruled out before the fracture line propagates into a larger fracture.
• Tibial x-rays are necessary.
• Relative rest, shoe orthotics, correct running gait (overpronation of the ankle is a common training error), physical therapy are all reasonable treatment options for shin splints (assuming x-rays are negative for stress fracture).
The tibialis posterior’s function is to do which of the following?
A Dorsiflexion and eversion
B Dorsiflexion and inversion
C Plantarflexion and eversion
D Plantarflexion and inversion
Answer: D
Explanation:
• The Tibialis posterior’s function is plantarflexion and inversion of the ankle.
For acutely inflamed joints in rheumatoid arthritis, which of the following is the most appropriate type of exercise?
A Isorheumatic
B Isometric
C Isotonic
D Isokinetic
Answer: B
Explanation:
• Isometric exercise is the best type of exercise for any acutely inflamed joint, as it limits the damage that can be done to the joint via range of motion (ROM) exercises.
A 37 year-old male is throwing the ‘ol pigskin (football) around to prove to his friends that he’s “still got it”. He is quickly tackled, and develops sudden-onset right ankle pain. With your priorities in line, you quickly point out that he has not in fact “still got it”. You then rush over and squeeze his lower leg with your two hands, which reproduces his pain. He does not appreciate that insult to injury and lets you know this. X-rays of the leg are normal. He says he wants to be treated like a high-level professional athlete who needs to return to the field as soon as possible. What is the next best step?
A Make non-weight-bearing in CAM boot
B Orthopedic surgery
C MRI
D Repeat x-ray in 1 week
Answer: C
Explanation:
• NWB status in a CAM boot is good treatment for high ankle sprains without bony fractures
However, MRI is indicated in cases of high suspicion for high ankle sprain with negative X-rays. The MRI would be important in order to define the extent of soft tissue injury in a high-level professional athlete.
A 17-year-old football player is the local high school’s star running back. In the 2nd game of the season, he attempts to make a cut on a planted right foot. He feels a ”pop” in his right knee and his leg gives out. He has immediate pain and swelling in his right knee and is unable to bear weight on that leg. MRI of the right knee the following day reveals a tear of his ACL (anterior cruciate ligament) and he undergoes surgical reconstruction. Which of the following orthoses is most appropriate post-operatively?
A Lenox-Hill derotation orthosis
B Unloader knee brace
C Swedish knee cage
D Hinged knee brace
Answer: A
Explanation:
• Following ACL reconstruction, a Lenox-Hill derotation orthosis is often used to control axial rotation of the knee as well as medial-lateral and anterior-posterior control
• Swedish knee cages are used for knee recurvatum to prevent knee hyperextension.
• Unloader braces are used most often for knee osteoarthritis; forces are “unloaded” from the more affected/symptomatic compartment, either medial or lateral; these forces are loaded onto the less symptomatic/arthritic side.
• Hinged knee braces offer increased stability and can be used for a wide array of knee pathologies.
- Which of the following muscles is not a wrist extensor?
A They are all wrist extensors
B Extensor digiti minimi
C Extensor indicis proprius
D Extensor digitorum
Answer: A
Explanation:
• All these muscles cross the wrist joint on the dorsal surface of the body; thus, they all provide some degree of wrist extension force.
A patient with a complete tear of the acromioclavicular (AC) ligament and partial tear of the coracoclavicular (CC) ligament has what grade of AC joint separation, and what should the treatment be?
A 3, surgery
B 3, rehab
C 2, surgery
D 2, rehab
Answer: D
Explanation:
• AC joint separations occur as grades 1-6.
• Grade 1: partial AC tear, intact CC, rehab.
• Grade 2: complete AC tear, partial CC tear, rehab.
• Grade 3: complete AC and CC tears, clavicle floats upward, rehab vs. surgery.
• Grade 4: complete AC and CC tears, clavicle floats superiorly and posteriorly, surgery.
• Grade 5: complete AC and CC tears, clavicle floats even more superiorly and posteriorly, surgery.
• Grade 6: complete AC and CC tears, clavicle floats downward, surgery.
A 29 year-old female presents with several months of widespread body pain. She has tried physical therapy to no benefit. She feels fatigued on most days. She is tender to palpation at multiple different locations throughout her body. You decide to recommend water aerobics and which other appropriate intervention?
A Duloxetine
B Tramadol
C TENS
D NSAIDs
Answer: A
Explanation:
• Fibromyalgia presents classically as this patient does. Generally no medical or imaging workup is required. There is often comorbid fatigue, anxiety, and depression, as well as lifestyle stressors.
• Aquatherapy/water aerobics is an excellent first-line treatment.
• SNRIs, SSRIs, TCAs, and gabapentin or pregabalin are also appropriate as medication trials.
• Generally a primary care physician or psychiatrist should handle an SSRI prescription.
• Opioids are NOT indicated in fibromyalgia.
• Duloxetine is an excellent initial pharmacologic therapy as a pain + mood medication.
“Standard” MSK-pain treatment modalities may not be effective in fibromyalgia, which carries a strong psychiatric component, hence Duloxetine’s appropriateness over TENS or NSAIDs.
A 68 year-old obese male presents with progressive, gradual onset right knee pain. He says the pain is “all over” the knee, and is associated with stiffness in the morning lasting 30 minutes. The pain is worse with weight-bearing and walking. Which of the following interventions will likely be the most impactful and appropriate for his knee pain?
A Orthopedic surgery consultation
B Knee corticosteroid injection
C Cane to offload the knee
D Weight loss
Answer: D
Explanation:
• Weight loss is the single most impactful intervention on knee OA pain due to obesity.
• Physical therapy should be combined with weight loss unless the patient is already at a healthy BMI.
In pronator teres syndrome, all median nerve-innervated muscles are affected EXCEPT which of the following? AFlexor pollicis longus BPronator quadratus CFlexor carpi radialis DPronator teres
Answer: D
Explanation:
• In PT (pronator teres) syndrome, the median nerve is compressed within the PT muscle, affecting all downstream median nerve-innervated muscles, except the PT (pronator teres) itself, which is actually innervated by a more proximal nerve branch that is not involved in the PT’s tight compression of the median nerve.
• All remaining median nerve and anterior interosseous nerve muscles will be affected, however (the remaining answer choices).
A patient with New York Heart Association (NYHA) class 3 heart failure is expected to be able to perform activities in which of the following MET (metabolic equivalent) ranges? A5-7 B2-5 C2-3 D1-2
Answer: B
Explanation: • NYHA class 1 patients can perform activities over 7 METs. • NYHA class 2: anything between 5-7 METs. • NYHA class 3: anything between 2-5 METs. • NYHA class 4: there is dyspnea at rest.
A 23 year-old male presents with gradual onset 1 year of right knee pain. He is a division 1 basketball player and the national postseason tournament is about to begin. He is adamant that he must play, as his team is expected to win the championship. He has ibuprofen, tried 2 rounds of physical therapy and home exercises, as well as relative rest, all of which has not helped his pain. He has tenderness to palpation of his patellar tendon, and there is pain at the patellar tendon with resisted knee extension. His right patellar tendon appears swollen compared to his left. He has had unremarkable knee x-rays, and a knee MRI showed intact soft tissue structures. On diagnostic ultrasound scan, you note a thickened, hypoechoic, wavy appearance of the right patellar tendon compared to the fibrillar, relatively hyperechoic appearance of the left patellar tendon. Color doppler scan reveals punctate red and blue dots within the right patellar tendon, but not the left. What is the most appropriate next step?
ASit out the rest of the season and tournament
BUltrasound-guided patellar tendon scraping
COrthopedics consult
DUltrasound-guided corticosteroid injection
Answer: B
Explanation:
• This patient presents with classic findings of patellar tendonitis that has progressed into patellar tendonosis.
• Recall that tendonosis is a degenerative condition of a tendon that occurs due to tendon overuse. The tendon becomes wavy, thickened, and hypoechoic (dark) on ultrasound.
• Neurogenic inflammation accompanies this, in which neovessels and neonerves sprout from the Hoffa (infrapatellar) fat pad and extend into the patellar tendon, which causes chronic knee pain.
• Tendon scraping under ultrasound guidance involves guiding a needle between the patellar tendon and Hoffa fat pad (not into the tendon itself, despite the name “tendon scraping”) and moving the needle back and forth (superior to inferior and vice versa) in order to sever these neonerves and neovessels, thus treating the patient’s source of pain (the neonerves), and breaking the cycle of tendonosis, allowing the patient to progress in PT without the pain limitation from the neonerves.
• Orthopedic surgery is a last resort. Also, the patient may weight-bear immediately and perform physical activities after a tendon scraping, because the tendon itself was not pierced by a needle or scalpel, and so is still structurally intact.
The supraspinatus and deltoid contribute how many degrees to the function of shoulder abduction, respectively? A165, 15 B15, 165 C150, 30 D30, 150
Answer: B
Explanation:
• The supraspinatus contributes to the first 15 degrees of shoulder abduction; beyond that point the deltoid tends to “take over”. This is due to both strength and mechanical/physical placement of these muscles.
All of the following are muscles of active inspiration except which of the following? AInternal intercostals BTrapezius CLevator scapula DScalenes
Answer: A
Explanation:
• Muscles of active inspiration include diaphragm, external intercostals, sternocleidomastoids, levator scapulae, scalenes, pectorals, and trapezius.
• Muscles of expiration include internal intercostals and abdominal muscles.
Which of the following muscles/tendons is not contained within the tarsal tunnel? AFlexor digitorum brevis BFlexor hallucis longus CFlexor digitorum longus DTibialis posterior
Answer: A
Explanation:
• Flexor digitorum brevis does NOT pass through the tarsal tunnel.
Which of the following is not a risk factor for the development of knee osteoarthritis (OA)? ANSAID use BWeak knee extensors CWeak hip abductors DHistory of ACL tear
Answer: A
Explanation:
• ACL tears and weak musculature controlling the knee and hip are risk factors for developing knee OA, as is obesity.
A 21 year-old male medical student presents to your clinic with complaints of anterior right knee pain for the past month. He is disappointed because he enjoys “wheeling and dealing” on the basketball court during competitive medical school basketball games. He denies significant trauma from basketball. On exam, resisted knee extension reproduces anterior knee pain. There is minimal tenderness to palpation of the soft tissue immediately superior to the patella. There is sharp tenderness to palpation of the soft tissue immediately inferior to the inferior pole of the patella. What is the most appropriate next step?
AKnee MRI to rule out tendon/ligament tear
BKnee injection
CPhysical therapy
DX-rays to rule out fracture
Answer: C
Explanation:
• This patient presents with classic patellar tendonitis, commonly associated with jumping sports (basketball, volleyball).
• Pain is located over the patellar tendon, generally where it inserts onto the patella, as described here.
• Treatment is relative rest, physical therapy, NSAIDs.
• There is no indication for imaging in this initial presentation of patellar tendonitis without trauma; this is a clinical diagnosis.
Kienbock Disease consists of which of the following pathologies, and what is the most appropriate treatment?
AIdiopathic avascular necrosis of the capitate; surgery
BIdiopathic avascular necrosis of the capitate; splinting
CIdiopathic avascular necrosis of the lunate; surgery
DIdiopathic avascular necrosis of the lunate; splinting
Answer: C
Explanation:
• Kienbock disease is another name for osteonecrosis of the lunate, which is idiopathic avascular necrosis of the lunate.
• Treatment is orthopedic surgery.
Regarding shoulder abduction range of motion, the number of degrees attributed to scapulothoracic motion compared to glenohumeral motion is which of the following? A60:120 B130:50 C50:130 D90:90
Answer: A
Explanation:
• The 180 degrees of normal shoulder abduction ROM is due to 60 degrees of scapulothoracic ROM in combination with 120 degrees of glenohumeral range of motion.
• The key point here is this 2:1 ratio of glenohumeral ROM compared to scapulothoracic ROM, as well as knowing that abducting the shoulder is not purely because of movement of the ball within the socket, but because the scapula actually rotates upward to “help out” with this ROM; otherwise lots of subacromial shoulder impingement would occur.
Which of the following maneuvers describes the Jerk test with respect to the shoulder?
ANone of these answers is correct
BFlexing shoulder beyond 90 degrees and applying posteroinferiorly directed axial force along humerus
CFlex to 90°, internal rotation, adduction across midline while applying posterior axial force
DAbducting, externally rotating, and applying anteriorly directed force on the humerus
Answer: C
Explanation:
• Flexing the shoulder to 90 degrees, internally rotating, and adducting across midline with a posterior axial force describes the Jerk test, which is a test for posterior shoulder instability.
• The Kim test (flexing shoulder beyond 90 degrees and applying posteroinferior force) is also a shoulder posterior instability test.
• Abducting, externally rotating, and applying anterior force describes the anterior apprehension test, which unsurprisingly tests for anterior shoulder instability.
A 20 year-old male presents to your clinic with the chief complaint of right foot pain. The pain occurred gradually without trauma. On exam there is slight swelling proximal to the 3rd toe. Foot x-rays demonstrate a 3rd metatarsal stress fracture. This is otherwise known by what name? AJones fracture BCuboid fracture CMarch fracture DNutcracker fracture
Answer: C
Explanation:
• A March fracture is a metatarsal stress fracture.
• A Nutcracker fracture is a cuboid fracture and vice versa.
• A Jones fracture is a fracture across the base of the 5th metatarsal.
A 34 year-old male presents to your clinic for the evaluation of left periscapular pain. He has a history of motorcycle accident 1 year ago and has had this pain ever since then. On exam, you note his left scapula is positioned further laterally than the right scapula. Which nerve is implicated in this condition? AUpper subscapular nerve BLong thoracic nerve CSpinal accessory nerve DThoracodorsal nerve
Answer: C
Explanation:
• With a laterally winged scapula, the spinal accessory nerve (retracts) commanding the trapezius is deficient.
• With a medially winged scapula, the long thoracic nerve (protracts) commanding the serratus anterior would be deficient.
• The thoracodorsal nerve innervates the latissimus dorsi and does NOT cause a winged scapula when injured.
• The upper subscapular nerve innervates the subscapularis and teres major and does NOT cause a winged scapula when injured.
Which of the following is the most normal/ideal synovial fluid white blood cell count (WBC)? A1000 B100 C50 D0
Answer: D
Explanation:
• Normal synovial fluid WBC should be zero (0) or nearly zero.
A 33 year-old male presents with right ankle pain and heel pain over the achilles tendon. He also endorses pain with urination. Which of the following etiologies is most likely responsible?
A Chlamydia
B Calcium pyrophosphate deposition
C Uric acid deposition
D Neisseria gonorrhea
Answer:
Explanation:
• Reactive Arthritis presents with asymmetric arthritis affecting especially the feet and ankles as well as enthesitis (e.g. achilles tendon pain).
• It also presents with urethritis and uveitis.
• This constellation of symptoms is “reactive” to an infection, typically chlamydia, campylobacter, or salmonella.
• Treatment involves antibiotics, NSAIDs, and physical therapy.
- You are performing a physical exam on a patient with knee pain. You lie the patient prone, flex their knee 90 degrees, and apply an axial force upon the patient’s heel (force directed superiorly from the heel into the calcaneus and tibia). What is the name of this test?
A McMurray
B Apley
C Thessaly
D D’Angelo
Answer: B
Explanation:
• The Apley Grind test is described here, and is a test for medial or lateral meniscus tears in the knee.
• Apley’s Distraction & Apley’s Gind tests:
○ If rotation plus distraction is more painful or shows increased rotation relative to the normal side, the lesion is most likely to be ligamentous.
○ If the rotation plus compression is more painful or shows decreased rotation relative to the normal side, the lesion is most likely to be a meniscus injur.
A 77 year-old female sustains a ground-level fall. She is brought to the ED where she complains of severe right groin pain. X-rays of her right hip reveal a complete fracture line across the femoral neck without displacement. What is the Garden classification of this fracture?
A Stage 4
B Stage 3
C Stage 2
D Stage 1
Answer: C
Explanation:
• This patient has suffered a Garden Stage 2 fracture.
• The Garden classification system of femoral neck fractures (intracapsular = within the hip capsule) is as follows.
• Stage 1: incomplete fracture line, nondisplaced.
• Stage 2: complete fracture line (fracture extends all the way across the femoral neck), nondisplaced.
• Stage 3: complete and partially displaced.
• Stage 4: complete and fully displaced (capsule is completely torn).
A 45 year-old male presents to your pain clinic with complaints of left elbow pain. On exam you note pain in the muscles and tendons just distal to the medial epicondyle. This patient’s condition is typically caused by which of the following?
A Excessive varus forces
B Excellent sporting technique
C Trauma
D Overuse
Answer: D
Explanation:
• Golfer elbow (medial epicondylitis) is inflammation of the common flexor tendon of the elbow due to microtears/overuse of the wrist and finger flexors, which originate at the common flexor tendon off the medial epicondyle.
• It is typically caused by overuse and poor technique.
A 32 year-old male suffers a fall onto his outstretched hand. He has immediate shoulder disfigurement which is corrected by a bystander. In the ED, MRI of the shoulder reveals an anterior labrum injury. This is commonly known by which of the following names?
A Bankart lesion
B Westfall lesion
C Hill-Sachs lesion
D O’Brien lesion
Answer: A
Explanation:
• This patient has suffered an anterior shoulder dislocation.
• MRI evidence of anterior labrum injury in the setting of shoulder disfigurement (= dislocation) is known as a Bankart lesion.
• Hill-Sachs lesion is a posterolateral humeral head compression fracture as a result of an anterior shoulder dislocation.
• The O’Brien and Westfall “lesions” are fictional.
A 24 year-old male, stiff-arming the competition in football, is about to score a touchdown when he decides to juke his defender. He plants his right foot on the ground and attempts to juke to the left when he experiences sudden-onset right knee pain and swelling. You rush onto the field to examine him. Anterior drawer and Lachman tests are negative. What is the most likely diagnosis?
A ACL tear
B PCL tear
C MCL tear
D Quadriceps tendon rupture
Answer: A
Explanation:
• An athlete attempting a noncontact cutting maneuver and experiencing sudden knee pain with instant swelling is a classic example of an ACL tear.
• It does not matter if Lachman/anterior drawer are negative; they could be falsely negative due to muscle spasm.
• The other structures are possibly torn in this patient, but the ACL should remain the highest on your differential in this scenario.
Which of the following is the most common cause of spinal cord injury?
A Violence
B Sports
C Motor vehicle accidents
D Falls
Answer: C
Explanation:
• Motor vehicle accidents remain the most common cause of SCI.
• Falls are the next most common cause.
A 14-year old male complains of bilateral knee pain of gradual onset for the past 2 months. He denies trauma or neurologic changes. His pain is located inferior to the patella, is worse during his basketball games, and is improved with ice. Knee x-rays demonstrate irregularities of the tibial tubercles. Which of the following is the most likely etiology of this patient’s pain?
A Ligament tear
B Quadriceps tendon inflammation
C Abnormal patellar tracking
D Traction apophysitis
Answer: D
Explanation:
• This patient presents with Osgood-Schlatter Disease (OSD).
• This is an overuse injury of the proximal tibia, usually due to excessive jumping activity involving the legs (e.g. basketball/volleyball) as the patellar tendon pulls on the tibia, leading to tibial tubercle traction apophysitis and fragmentation.
• X-rays may be normal or show tibial tubercle irregularities.
• Abnormal patellar tracking refers to patellofemoral pain syndrome, another common source of knee pain; however, this would likely NOT be solely located below the patella, and would NOT show tibial tubercle irregularities on X-ray.
• Quadriceps tendon inflammation would cause more superior pain near the quadriceps tendon, not inferior to the patella.
• Ligament tear would typically be associated with an acute presentation and a history of trauma, along with positive physical exam findings stressing the ligament in question and reproducing the patient’s pain.
- A 13 year-old male presents with back pain. He denies trauma. On exam you notice a forward-flexed posture. Spine x-rays demonstrate thoracic kyphosis of 50 degrees with anterior vertebral body wedging and Schmorl nodes in multiple segments. Which of the following is the most likely diagnosis?
A Friedreich ataxia
B Becker muscular dystrophy
C Scheuermann disease
D Idiopathic scoliosis
Answer: C
Explanation:
• This patient presents with Scheuermann disease, involving idiopathic juvenile kyphosis which can lead to a restrictive lung pattern.
• X-rays show kyphosis, vertebral body wedging, and Schmorl nodes.
○ Schmorl node: a common spinal disc herniation in which the soft tissue of the intervertebral disc bulges out into the adjacent vertebrae through an endplate defect.
• Treatment is physical therapy, bracing, and surgery.
• Scoliosis would show a coronal plane curvature, not simply kyphosis.
• Becker muscular dystrophy would also present with gradual onset weakness and disability.
• Friedreich ataxia would also demonstrate weakness, disability, cardiomyopathy, and vision and hearing dysfunction.
Which of the following muscles is the primary supinator of the forearm?
A Biceps brachii
B Supinator
C Brachialis
D Pronator teres
Answer: A
Explanation:
• Biceps brachii is the most powerful supinator of the forearm. This has been known to cause embarrassment for the muscle known as “supinator”.
• Biceps brachii: innervated by musculocutaneous nerve
• Supinator: innervated by posterior interosseous nerve (a branch of radial nerve)
Which of the following types of exercise places the greatest stress upon a tendon, leading to highest risk for tendon rupture?
A Fast eccentric
B Slow eccentric
C Fast concentric
D Slow concentric
Answer: A
Explanation:
• Concentric contractions occur with the muscle shortening as it contracts against a load.
• Eccentric contractions occur with the muscle lengthening as it fights to contract against this lengthening force.
• Fast eccentric contractions place the most acute stress upon a tendon, leading to highest risk of tendon rupture.
You are evaluating a patient for posterior heel pain. A lower extremity MRI reveals a complete tear of the achilles tendon. However, when you perform the Thompson test, it is negative. How is this possible?
A It is simply a false positive Thompson test
B A bifid achilles tendon is present
C The MRI diagnosis is incorrect
D The plantaris is intact
Answer: D
Explanation:
• In a patient with complete achilles tendon rupture, the Thompson test should be positive.
• Recall that a positive Thompson test is detected by squeezing the patient’s calf and documenting a lack of plantarflexion, indicating a complete achilles tendon tear.
• If a patient has a confirmed achilles tendon rupture on MRI, yet demonstrates a falsely negative Thompson test, this seems like it would be impossible, but in reality the examiner is likely squeezing enough to cause contraction of the plantaris tendon, which also attaches to the calcaneus, and can perform plantarflexion.
• In summary, squeezing the calf does NOT only squeeze the gastrocnemius and soleus, but also the plantaris muscle and tendon, which sit between the gastrocnemius and soleus, and all of these muscles may provide plantarflexion function to the ankle.
• An MRI-confirmed achilles tendon rupture is NOT likely to be incorrect.
• Naturally occurring bifid achilles tendons are fictional.
• This Thompson test is a false negative result, not a false positive.
With knee extension the ACL (anterior cruciate ligament of the knee) becomes which of the following?
A Loose
B Tight
C Neither
D Both
Answer: B
Explanation:
• The ACL runs anteroinferomedially to insert onto the tibia. It tenses with knee extension and limits anterior translation of the tibia (hence the Anterior Drawer and Lachman tests.
• With knee flexion the ACL pulls the femur anteriorly.
You are performing a physical exam on a patient with knee pain. You flex the hip and knee, internally rotate the tibia, and apply a varus force to the knee while extending the knee. This test is known typically by what name?
A Apley
B Thessaly
C McMurray
D Bounce Home
Answer: C
Explanation:
• The McMurray test is a test for meniscus tears in the knee.
• By externally rotating the ankle and applying a valgus force while extending the knee, you are testing the medial meniscus for tears.
• Internal rotation the ankle with varus force is a test for the lateral meniscus.
• Both are called the McMurray test.
• Tip: the heel itself moves toward the meniscus being tested; i.e. with external rotation, the heel moves medially, and thus, the medial meniscus is tested (with external rotation + valgus stress to the knee).
Rheumatoid factor is found in rheumatoid arthritis and which of the following other diseases?
A Psoriatic arthritis
B CREST syndrome
C Sjogren syndrome
D Systemic lupus erythematosus (SLE)
Answer: C
Explanation:
• Rheumatoid factor (RF) can be found in rheumatoid arthritis patients as well as those with Sjogren syndrome.
The scarf test is primarily a test for which joint?
A Cervical spine
B Scapulothoracic
C Glenohumeral (GHJ)
D Acromioclavicular (AC)
Answer: D
Explanation:
• Scarf test is performed by adducting the affected shoulder across midline, grabbing the other shoulder in the process and inducing pain if the patient has disease within the AC joint.
○ The test is performed by passively bringing the patient’s arm into 90 degrees of forward flexion, with their elbow also flexed to 90 degrees. The examiner then horizontally adducts the flexed arm across the patient’s body, bringing their elbow towards the contralateral shoulder.
• Thus, this is a test for the AC joint.
• Adducting the right shoulder across midline is the scarf test for the right AC joint.
A 31 year-old female presents to your clinic with 6 weeks of anterior left ankle pain. She denies trauma, weakness, numbness, or tingling. She is a soccer player and has been playing lots of tournaments lately. On exam, passive plantarflexion reproduces her pain, as does resisted dorsiflexion. Interestingly she also has pain with resisted inversion. Ankle x-rays are normal. What is the next best step?
A Corticosteroid injection
B Orthopedic surgery consultation
C Rest, ice, NSAIDs
D Ankle MRI
Answer: C
Explanation:
• This patient’s symptoms are suspicious for left tibialis anterior tendonopathy/tenosynovitis.
• Initial treatment involves rest, ice, NSAIDs, and gradual return to increasing levels of activity as tolerated. Physical therapy is also beneficial. Corticosteroid injection into the tendon sheath can help in resistant cases.
• MRI is not needed for this diagnosis.
• Surgery is indicated in cases of tendon rupture.
A 34 year-old male is snowboarding down some intense moguls. The moguls get the best of him, and he is launched into the air. He lands awkwardly and sustains a left tibial fracture. Snow patrol is called. The patient is initially resting on the ground in tolerable pain, but as the minutes pass he increasingly moans in pain. Snow patrol arrives, and passive plantarflexion causes the patient to scream in extreme pain. What is probably going to be the most important early intervention for this patient?
A Emergent fasciotomy
B Emergent casting
C Emergent pain control
D Emergent fracture repair
Answer: A
Explanation:
• Acute compartment syndrome is an emergency condition in which the pressure within a muscle compartment (usually the lower leg or the forearm) rises so quickly, and to such high levels, such that blood can pump in, but it cannot pump out; this is usually in the setting of trauma/fracture, and most commonly takes place in the anterior compartment.
• Passive stretch of the muscle within that compartment causes extreme pain out of proportion to the injury.
• If allowed to progress, the patient will develop pain, paresthesias due to nerve compression, and paralysis due to nerve compression and ischemia.
• Workup involves compartment pressure testing via needle manometry.
• Treatment is emergent fasciotomy to avoid longterm sequelae such as sensory abnormalities and permanent weakness.
All of the following bones belong in the distal row of carpal bones except which of the following?
A Hamate
B Trapezoid
C Triquetrum
D Trapezium
Answer: C
Explanation:
• The proximal row of carpal bones contains scaphoid, lunate, triquetrum, and pisiform.
• The distal row of carpal bones contains trapezium, trapezoid, capitate, hamate.
• “Some Lovers Try Positions That They Can’t Handle.”
A 63 year-old female presents to your PM&R clinic with complaints of left wrist swelling. She denies pain, numbness, tingling, or weakness. She says she has had this swelling for several months, and has noticed fluctuations in its size. On exam, it is not tender to palpation, and it is soft and compressible. Her skin color over the swelling appears normal. What is the most likely underlying pathophysiology for this process?
A Tendon swelling due to chronic disease
B Outpouching of synovial fluid
C Infection
D Benign adipose cell proliferation
Answer: B
Explanation:
• This patient presents with findings suspicious for ganglion cyst, which is typically a painless outpouching of synovial fluid from a joint space or tendon sheath.
• Management may include observation, aspiration, or surgical removal.
The “roof” of the tarsal tunnel is also known as which of the following?
A Ligament of Johnson
B Flexor retinaculum
C The tarsal conduit
D Extensor retinaculum
Answer: B
Explanation:
• The roof of the tarsal tunnel can be thought of as the flexor retinaculum, under which the structures of the tarsal tunnel pass.
• Tarsal tunnel syndrome is a compression, or squeezing, on the posterior tibial nerve.
• Tarsal tunnel contains Tibialis posterior tendon, Flexor digitorum longus tendon, Tibial vein, Tibial artery, Tibial nerve, Flexor hallucis longus tendon.
The ACL’s (anterior cruciate ligament of the knee) primary function is to do which of the following?
A Prevent posterior tibial translation
B Prevent posterior femur translation
C Prevent anterior tibial translation
D Prevent posterior femur translation
Answer: C
Explanation:
• The ACL runs anteroinferomedially to insert onto the tibia. It tenses with knee extension and limits anterior translation of the tibia (hence the Anterior Drawer and Lachman tests. With knee flexion the ACL pulls the femur anteriorly.
You are performing a physical exam on a patient with knee pain. You flex the hip and knee, externally rotate the ankle, and apply a valgus force to the knee while extending the knee. Which structure are you assessing for a tear?
A Medial meniscus
B Lateral meniscus
C MCL
D LCL
Answer: A
Explanation:
• McMurray tes is a test for meniscus tears in the knee.
• By externally rotating the ankle and applying a valgus force while extending the knee, you are testing the medial meniscus for tears; internal rotation with varus force is a test for the lateral meniscus. Both are called the McMurray test.
- You are performing a physical exam on a patient with knee pain. You flex the hip and knee, externally rotate the ankle, and apply a valgus force to the knee while extending the knee. Which structure are you assessing for a tear?
A Medial meniscus
B Lateral meniscus
C MCL
D LCL
Answer: A
Explanation:
• McMurray tes is a test for meniscus tears in the knee.
• By externally rotating the ankle and applying a valgus force while extending the knee, you are testing the medial meniscus for tears; internal rotation with varus force is a test for the lateral meniscus. Both are called the McMurray test.
Which of the following is a known sequela of rheumatoid arthritis?
A Ulnar deviation of the wrist; ulnar deviation of the fingers
B Ulnar deviation of the wrist; radial deviation of the fingers
C Radial deviation of the wrist; radial deviation of the fingers
D Radial deviation of the wrist; ulnar deviation of the fingers
Answer: D
Explanation:
• In rheumatoid arthritis, one of the sequelae is a deformity resulting in radial wrist deviation with ulnar finger deviation.
A 75 year-old male with history of bilateral knee replacements presents to your clinic with complaints of right groin pain. He denies trauma. It has developed gradually over the past several months along with low back pain. He denies numbness or tingling, but feels weak in his right leg. On exam, strength is neurologically intact. There is no tenderness to palpation of the anterior, lateral, or posterior right hip. FABERE reproduces his right groin pain, but not back pain. What is the most likely diagnosis?
A Iliopsoas tendonitis
B Hip osteoarthritis
C Lumbar radiculitis
D Labral tear of hip
Answer: B
Explanation:
• This patient presents with classic gradual onset osteoarthritis of the hip. True hip pain manifests as groin pain.
• An aging individual with a history of presumably knee OA leading to total knee replacements and gradual onset groin pain without trauma is most likely indicating “wear and tear” femoroacetabular joint arthritis.
• There is NO reason to suspect a labral tear in this patient without trauma and presenting to you for the first time.
• Further, an elderly patient presenting in this fashion would suggest osteoarthritis before you should consider a labral tear.
• Tendons are nontender on exam, and there is low suspicion for radicular pathology, given that his exact groin pain was reproduced on exam with FABERE testing.
A 37 year-old male presents with 7 months of gradual onset low back pain. He denies trauma. On exam while supine, hanging one leg off the edge of the exam table reproduces his low back pain. What is the name of this maneuver?
A Gillet
B FABER
C Yeoman
D Gaenslen
Answer: D
Explanation:
• This question describes the Gaenslen test.
• A positive test reproducing low back pain is suggestive of sacroiliac joint dysfunction/pain.
You are the sideline physician at a basketball game when a 23 year-old male falls to the floor, landing on his right shoulder. There is visible skin tenting superficial to the distal end of the clavicle. He is in significant pain. What is the underlying pathology causing his presentation?
A Tear of both the acromioclavicular and coracoclavicular ligaments
B Tear of the coracoclavicular ligament
C Tear of the acromioclavicular ligament
D Tear of the superior glenohumeral ligament
Answer: A
Explanation:
• This patient has sustained an acromioclavicular (AC) joint separation. The AC and CC ligaments are the ligaments implicated in this process.
• The AC ligament is typically first to tear, followed by the CC ligament.
• When they are both torn, the clavicle is no longer anchored down and becomes displaced, thus floating upward and causing the skin tenting seen here.
A 50 year-old female presents with bilateral knee pain of gradual onset for the past 5 months. She says she first noticed the pain after a long day of moving furniture. She has felt fatigued with occasional fever. She also notes 60-90 minutes of knee stiffness when she wakes up. Knee x-rays reveal symmetric medial and lateral compartment narrowing. Which of the following is the most likely diagnosis?
A Septic arthritis
B Lupus arthritis
C Rheumatoid arthritis
D Osteoarthritis
Answer: C
Explanation:
• Rheumatoid arthritis presents with several weeks at least of joint pain involving typically the knees, MCPs, PIPs, MTPs, C1-C2 joint) along with > 1 hour of morning stiffness in addition to fatigue and fever.
• X-rays will show symmetric joint space narrowing, rather than asymmetric narrowing typical of osteoarthritis.
• Septic arthritis is more likely to be monoarticular with persistent fever and joint swelling.
• Lupus arthritis would also present with other symptoms of lupus, such as malar rash, photosensitivity, mouth ulcers, pericarditis, pleuritis, etc.
A patient with a complete tear of the acromioclavicular (AC) ligament, complete tear of the coracoclavicular (CC) ligament, and clavicle that is displaced inferiorly has what grade of AC joint separation, and what should the treatment be?
A 7, surgery
B 6, surgery
C 5, surgery
D 4, surgery
Answer: B
Explanation:
• AC joint separations occur as grades 1-6.
• Grade 1: partial AC tear, intact CC, rehab.
• Grade 2: complete AC tear, partial CC tear, rehab.
• Grade 3: complete AC and CC tears, clavicle floats upward, rehab vs. surgery.
• Grade 4: complete AC and CC tears, clavicle floats superiorly and posteriorly, surgery.
• Grade 5: complete AC and CC tears, clavicle floats even more superiorly and posteriorly, surgery.
• Grade 6: complete AC and CC tears, clavicle floats downward, surgery.
The conjoint hamstring tendon houses which tendons?
A Semimembranosus, semitendinosus
B Semimembranosus, biceps femoris
C Semitendinosus, biceps femoris
D None of the above combinations
Answer: C
Explanation:
• The conjoint hamstring tendon contains semitendinosus and biceps femoris tendons medially on the ischial tuberosity.
• The semimembranosus tendon originates laterally from the other two tendons (paradoxically, as it becomes the most medial hamstring muscle as the muscles extend distally).
Typically the 2nd ligament to be torn in a lateral ankle sprain is which of the following? ATFL: anterior talofibular ligament. CFL: calcaneofibular ligament. PTFL: posterior talofibular ligament.
A Deltoid ligament
B PTFL
C ATFL
D CFL
Answer: D
Explanation:
• Generally the order of ligaments most commonly torn in a lateral ankle sprain is:
• Anterior talofibular ligament > Calcaneofibular ligament > Posterior talofibular ligaemnt.
• Deltoid ligament is torn in medial ankle sprains.
A 78 year-old male with a history of poorly controlled diabetes mellitus presents to your clinic with 1 year of progressive right knee pain. He denies trauma history. Acetaminophen provides some relief. He notes numbness and tingling in his toes bilaterally. He notes low back pain with this. He denies bowel or bladder dysfunction. On exam he has intact strength, sensation, and reflexes. He has tenderness to palpation of his right knee medial joint line. McMurray test is positive. He ambulates with a Trendelenburg lean to the right. What is the most appropriate next step?
A Knee x-rays
B Physical therapy
C Knee MRI
D Corticosteroid injection
Answer: B
Explanation:
• This patient demonstrates classic symptoms of knee osteoarthritis (OA).
• He has numbness and tingling from diabetes as a red herring here. He also has back pain, most likely as a result of his gait dysfunction due to the osteoarthritis.
• The first step in treating knee OA is to initiate physical therapy.
• If he fails physical therapy, knee X-rays should be considered to evaluate the degree of the suspected OA, and a corticosteroid injection into the knee could be considered vs. other regenerative injection options for the knee.
• MRI of the knee is useful for identifying meniscal tears, which this patient indeed may have, but MRI of the knee would not be the first step here, as minor meniscal tears should be rehabilitated first instead of surgically intervened upon.
A 72 year-old male presents to your clinic with complaints of 1 year of progressive left thumb pain. He has tried acetaminophen, NSAIDs, and a thumb spica splint to minimal relief. He denies weakness, numbness, or tingling, but says it has become more difficult to open doors and perform household tasks due to the pain. On exam, applying an axial force to the thumb while rotating it around reproduces the patient’s pain. What is the next best step?
A Surgical referral
B Corticosteroid injection
C EMG
D MRI
Answer: B
Explanation:
• This patient presents with first CMC arthritis, which is typically a “wear and tear” condition of the base of the thumb.
• 1st CMC grind test is positive, as described in the question, indicated 1st CMC arthritis.
• Conservative treatments of splinting and oral medications have failed.
• A reasonable next step would be to trial a corticosteroid injection to provide relief for him.
• Surgery would be a last resort.
• EMG is not indicated in a clear clinical diagnosis of 1st CMC OA without any numbness, tingling, or weakness.
• X-ray would be appropriate as an initial imaging test, but not MRI.
A 67 year-old female with a T score of -2.7 on a most recent DXA scan asks you for advice regarding bone health. Which of the following is the most reasonable action to take to improve her bone health?
A Limit how often she walks
B Canoeing
C Swimming
D Resistance exercises
Answer: D
Explanation:
• This patient with T score -2.7 fits DXA criteria for osteoporosis.
• In order to improve her bone density, weight-bearing exercise is recommended, such as resistance training, ambulation, stair-climbing, golf, tennis, etc.
• Swimming and canoeing are excellent physical activities, but will not offer maximal impact in terms of improving her bone health.
• Putting limits on this patient’s walking will only encourage disability.
A 26 year-old male falls on his outstretched hand and sustains a right humeral midshaft fracture. If you were to find weakness in this patient’s right upper limb, which muscle would be most likely to be weak following this fracture?
A Flexor carpi radialis
B Extensor indicis proprius
C Triceps
D Flexor carpi ulnaris
Answer: B
Explanation:
• Midshaft humeral fractures raise suspicion for radial nerve injury in the spiral groove.
• Triceps and Anconeus are already innervated at this point, so we must look for any distal radial nerve-innervated muscle.
• Extensor indicis proprius is the only muscle that fits this category, as it has posterior interosseous nerve innervation which itself is a branch of the radial nerve.
When extended, the human elbow typically demonstrates what type of natural alignment?
A Curved
B Varus
C Valgus
D Straight
Answer: C
Explanation:
• There is slight normal valgus angulation of the elbow when extended.
A patient develops gradual onset knee pain due to a redundant fold of synovial tissue in the knee that has become thickened and inflamed, leading to knee pain with locking and catching of the knee. The patient has tried physical therapy and corticosteroid injection to only minimal relief. They ask what else they should consider. What is your response?
A Surgery
B Knee bracing
C Prolotherapy injection
D Pain management
Answer: A
Explanation:
• This question describes a knee plica causing pain and inflammation.
• It is best treated with physical therapy, corticosteroid injection into the plica, or surgical resection of the plica.
• Synovial plica syndrome: Patients often mention anterior knee pain, clicking, clunking, and a popping sensation on patellofemoral loading activity such as squatting.
○ According to their location, the synovial plicae are classified as suprapatellar, mediopatellar, infrapatellar, or lateral; the medial plica is the most commonly symptomatic one.
○ A pathological synovial plica that has been through this inflammatory process can become inelastic, tight, thickened, fibrotic, and sometimes hyalinized.
○ A synovial plica affected by such changes may bowstring across the femoral trochlea, causing impingement between the patella and femur in knee flexion.
The lateral collateral ligament (LCL) of the knee originates on the lateral femoral condyle and inserts onto which of the following structures?
A Fibular head
B Gerdy’s tubercle of the tibia
C Pes anserine of the tibia
D Fibular shaft
Answer: A
Explanation:
• The LCL originates on the lateral femoral condyle and attaches onto the fibular head.
A 21-year-old basketball player attempts to catch a pass from his teammate but drops the ball and immediately experiences pain in his distal third digit. Instant replay shows the basketball hitting his third fingertip causing a forced flexion moment at the DIP. He is taken out of the game and seen by the team physician; during initial examination, the patient is unable to actively extend the DIP of his third finger. Xrays are negative for acute fracture. What splint is most appropriate to promote proper healing of his injury?
A Stax splint
B Boutonniere ring splint
C Swan neck ring splint
D Resting hand splint
Answer: A
Explanation:
• The vignette describes a mallet finger injury, which is often seen in sports such as basketball or baseball.
○ Typically, a ball hits the distal aspect of a finger, causing flexion of the DIP and resultant extensor tendon rupture. This leads to inability to actively extend the DIP.
○ X-rays are appropriate to rule out avulsion fracture.
○ A stax splint or DIP extension splint is appropriate to allow for healing of the DIP extensor tendon.
• A swan-neck ring splint and Boutonniere ring splint are examples of static-motion blocking splints that are used to treat their respective namesake.
• A resting hand splint promotes ROM of joints of the hand to avoid contracture formation, typically after stroke.
A patient develops sudden onset calf pain when playing basketball. On exam, you squeeze his calf muscle and watch as his ankle plantarflexes during the squeeze. What is the name of this test?
A Johannson test
B Thompson test
C Thomas test
D Johnson test
Answer: B
Explanation:
• This question describes the Thompson test.
• In a positive test, the ankle will fail to plantarflex during the calf squeeze, indicating a ruptured achilles tendon.
The function of the anterior talofibular ligament (ATFL) is to do which of the following?
A Resist lateral translation of the talus
B Stabilize the medial ankle by resisting eversion forces
C Resist anterior translation of the talus
D Stabilize the lateral ankle by resisting eversion forces
Answer: C
Explanation:
• The function of the anterior talofibular ligament (ATFL) is to resist anterior talar translation.
• The ATFL’s integrity can be tested using the anterior drawer test of the ankle, in which the examiner stabilizes the calf distally and pulls anteriorly on the calcaneus, thus drawing the talus anteriorly, separating it away from the fibula and, thus, stretching/stressing the ATFL.
• If it is torn, there will be NO firm endpoint.
A 34 year-old male falls off a ladder and lands on his feet. He soon develops right midfoot pain. You suspect a right Nutcracker fracture. In addition to foot x-rays to confirm the diagnosis (because your diagnostic skills are supreme), what will be your recommendation?
A Soft custom insole
B Orthopedic surgery consult
C MRI
D EMG
Answer: B
Explanation:
• Nutcracker fractures (cuboid fractures) require X-rays and orthopedic surgery consultation.
A 32 year-old female presents to you with 3 weeks of right lateral elbow pain. She has been working to improve her tennis game lately and has been taking lessons daily. She is a big fan of Roger Federer. On exam, you elicit concordant elbow pain with resisted wrist extension. Which of the following is an appropriate recommendation for this patient?
A Increase string tension
B Decrease string tension
C Play on grass courts
D Play on hard courts
Answer: B
Explanation:
• With tennis elbow (lateral epicondylitis, described in the question stem), it is important to help repair the common extensor tendon at the elbow (typically the extensor carpi radialis brevis - ECRB - bears most of the pain in tennis elbow).
• We do this by following RICE (rest, ice, compression, elevation).
• Once acute inflammation resolves and the patient is pain-free at rest, physical therapy to strengthen and stretch the common extensor tendon is important.
• Other important ways to reduce sudden inappropriate forces through the common extensor tendon include decreasing string tension on the racquet, playing on slower courts (e.g. clay), increasing grip size, and improving swing technique, notably the backhand technique.
