MSK Flashcards
A 22-year-old female gymnast presents to your clinic after a patellar dislocation during practice. She was treated in the emergency room with reduction of the patella and immobilization.
Radiographs and magnetic resonance imaging of the knee are negative for fracture or evidence of osteochondral lesions. You choose to treat her with immobilization for 2 weeks and then begin physical therapy. The most appropriate therapy recommendation is to focus on improving
(a) flexibility of gastrocnemius-soleus complex.
(b) strength of the iliopsoas.
(c) flexibility of the biceps femoris.
(d) strength of the vastus medialis
Answer: (d)
Commentary: Physical therapy in this patient should focus on strengthening of her medial
quadriceps muscles and restoration of normal patellar motion. Surgery in select instances addresses realignment of the patella by a lateral retinacular release and/or medial retinaculum repair when torn.
Reference: Diduch D, Scuderi GR, Scott WN. Knee injuries. In: Scuderi GR, McCann PD,
editors. Sports medicine: a comprehensive approach. 2nd ed. Philadelphia: Elsevier; 2005. p
376-7.
2013
A 62-year-old woman complains of right knee pain and stiffness. On physical examination, she
has a genu varum deformity. A physical therapy prescription should include
(a) isokinetic hamstring strengthening.
(b) isometric hamstring strengthening.
(c) closed kinetic chain quadriceps strengthening.
(d) open kinetic chain quadriceps strengthening
Answer: (c)
Commentary: For knee osteoarthritis, quadriceps strengthening has been well studied and is shown to be beneficial. In closed kinetic chain exercises, the distal aspect of the limb is fixed against a source of resistance, whereas in open kinetic chain exercises, the distal part of the limb is free in space. Closed chain exercises are preferred because they result in less shear force across
the joints and are also more functional.
Reference: Stitik TP, Foye PM, Stiskal D, Nadler RR. Osteoarthritis. In: DeLisa JA, Gans BM, Walsh NE. Physical medicine and rehabilitation: principles and practice.4th ed. Philadelphia: Lippincott Williams & Wilkins; 2005. p 772.
2013
A 25-year-old man comes to your office for evaluation of low back pain. As part of the physical
examination, you mark a point at the L5 vertebral body and another point midline 10 cm above.
You ask him to flex forward maximally while keeping his knees extended and measure the
distance between the two points. This distance is 13.5 cm. You suspect he may have what
diagnosis?
(a) Lumbar spondylolisthesis
(b) Scheuermann disease
(c) Lumbar herniated disc
(d) Ankylosing spondylitis
Answer: (d)
Commentary: The Schober test is used to assess restricted range of motion seen in ankylosing
spondylitis as the disease progresses. The distance between the 2 points with forward flexion Page 14 of 23
exceeds 15 cm in normal individuals. This clinical test is not used for the assessment of lumbar
spondylolisthesis, Scheuermann disease, or lumbar herniated discs.
Reference: Borg-Stein J, Bermas B. Spondyloarthropathies. In: Slipman CW, Derby R, Simeone
FA, Mayer TG, editors. Interventional spine: an algorithmic approach. 1st ed. Philadelphia:
Elsevier; 2008
2013
A 27-year-old manual laborer presents with a 6-month history of right shoulder pain. He has a
past medical history of a right shoulder dislocation after a water-skiing accident 3 years ago. On
physical exam, he has normal strength and sensation with symmetric reflexes. The shoulder
apprehension test is positive. Impingement tests and the O’Brien active compression test are
negative. Which diagnosis is most consistent with this presentation?
(a) Rotator cuff tendinitis
(b) Anterior-inferior labrum tear
(c) Glenohumeral osteoarthritis
(d) Superior labral anterior to posterior (SLAP) lesion
Answer: (b)
Commentary: This patient presents with an anterior-inferior labrum tear related to chronic
anterior shoulder instability following a prior traumatic event (dislocation). Unidirectional
instability refers to instability in only 1 direction, anterior direction being the most common. This type of instability is common after a traumatic event. Multidirectional instability refers to laxity in more than 1 direction and is associated with congenital laxity or chronic repetitive microtrauma. Anatomically, there is disruption in the anterior-inferior glenohumeral joint capsule and anterior-inferior labrum. Superior labral anterior to posterior (SLAP) lesions may occur, but that possibility is less likely in this patient, because of his history and a negative O’Brien compression test.
Reference: Finnoff JT. Musculoskeletal problems of the upper limb. In: Braddom RL, editor. Physical medicine and rehabilitation. 3rd ed. Philadelphia: Elsevier; 2007. p 832-3, 835
2013
A 60-year-old woman had a left total hip arthroplasty 4 weeks ago. During her gait evaluation,
she is noted to have a left lateral trunk lean during left stance phase. This gait deviation is most
likely a result of weakness in which left lower limb muscle?
(a) Gluteus medius
(b) Gluteus maximus
(c) Tensor fascia lata
(d) Vastus lateralis
Answer: (a)
Commentary: Gluteus medius weakness leads to a Trendelenburg gait. This woman’s lateral trunk
lean is a compensated Trendelenburg gait. Gluteus medius or hip abductor weakness is common
following total hip arthroplasty. In one study, 36 of 76 (47%) patients with total hip arthroplasty
had hip abductor weakness. Of those 36 patients, all 36 had weakness in the gluteus medius, 28
had weakness in the gluteus minimus, and 4 had weakness in the tensor fascia latae.
Reference: (a) Hicks JE, Joe GO, Gerber LH. Rehabilitation of the patient with inflammatory
arthritis and connective-tissue disease. In: DeLisa JA, Gans BM, Walsh NE. Physical medicine and rehabilitation: principles and practice. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2005. p 736. (b) Bhave A, Mont M, Tennis S, Nickey M, Starr R, Etienne G. Functional problems and treatment solutions after total hip and knee joint arthroplasty. J Bone Joint Surg Am. 2005; 87(Suppl 2):9-21.
2013
Which statement is TRUE of the lower trapezius muscle?
(a) It is innervated by the thoracodorsal nerve.
(b) It is innervated by the long thoracic nerve.
(c) Contraction of this muscle results in upward rotation of the scapula.
(d) Contraction of this muscle results in abduction of the scapula
Answer: (c)
Commentary: The lower trapezius, as well as the upper trapezius and the middle trapezius, is innervated by the spinal accessory nerve (11th cranial nerve) and possibly contributions from the ventral rami of C2, C3, and C4. Contraction of the lower trapezius results in scapular depression,
adduction, and upward rotation.
Reference: Killen SH, Miller JT. Shoulder and arm and upper back. In: Cutter NC, Kevorkian
CG, editors. Handbook of manual muscle testing. NewYork: McGraw-Hill; 1999. p 20-21.
2013
Which non-surgical treatment for carpal tunnel syndrome is shown to provide significant short term benefit?
(a) Magnet therapy
(b) Laser therapy
(c) Therapeutic exercise
(d) Therapeutic ultrasound
Answer: (d) Commentary: Patients suffering from carpal tunnel syndrome are often offered nonsurgical treatments. Current evidence shows significant benefit from therapeutic ultrasound treatments, splinting, yoga, and carpal bone mobilization. However, trials involving the use of magnet
therapy, laser therapy, therapeutic exercise, and chiropractics have not produced significant benefits compared to placebo or control treatments.
Reference: O’Connor D, Marshall SC, Massy-Westropp N, Pitt V. Non-surgical treatment (other than steroid injection) for carpal tunnel syndrome. Cochrane Database Syst Rev 2003;(1):1
2013
Of the muscles listed, the most distal muscle receiving innervation from the C5 root is
(a) brachioradialis.
(b) pronator quadratus.
(c) brachialis.
(d) biceps brachii.
Answer: (a)
Commentary: The brachioradialis is innervated by C5 and C6. The biceps and brachialis are more
proximal, and pronator quadratus typically receives no C5 innervation.
Reference: Dumitru, D, Zwarts, MJ. Radiculopathies. In: Dumitru D, Amato AA, Zwarts, MJ,
editors. Electrodiagnostic medicine. 2nd ed. Philadelphia: Hanley & Belfus; 2002. p 721
2013
A 22-year-old runner presents with acute onset of distal calf pain. She is diagnosed with Achilles
tendinitis and is referred to physical therapy. Which therapeutic modality is the LEAST
beneficial in treating an overuse injury of this sort?
(a) Therapeutic ultrasound
(b) Iontophoresis
(c) Ice massage
(d) Neuromuscular electrical stimulation
Answer :(d)
Commentary: With acute overuse injuries, modalities such as ultrasound, iontophoresis, and ice
massage may decrease pain and facilitate rehabilitation. Electrical stimulation with recruitment
of muscle fibers may be contraindicated in treating acute overuse injuries.
2011
Hamstring injuries occur most commonly
a) at the proximal attachment of the lateral hamstrings to the pelvis.
b) during concentric contraction of the medial hamstrings.
c) at the distal attachment of the medial hamstrings to the tibia.
d) during eccentric contraction of the lateral hamstrings.
Answer: (d)
Commentary: The majority of hamstring injuries occur from indirect forces during running and
sprinting activities. Most injuries occur at the myotendinous junction, not at the osseous
attachments, during eccentric contraction of the hamstring. The lateral hamstrings (biceps
femoris) are affected more than the medial hamstrings (semitendinous and semimembranosus).
2011
Comparing the functional outcomes at 1-year post treatment of 2 groups of patients with
nonspecific low back pain greater than 12-months’ duration and no prior history of lumbar fusion,
which finding regarding structured rehabilitation with cognitive behavioral therapy (CBT) versus
lumbar fusion is TRUE?
(a) Better functional outcomes in the surgical group versus the CBT group
(b) Improvements in both groups with similar functional outcomes
(c) Better functional outcomes in the CBT group versus the surgical group
(d) Poor functional outcomes in the CBT group, but no consistent outcome in the surgical
group
Answer: (b)
Commentary: Randomized trials for surgery are difficult to conduct, particularly those that
compare surgical to nonsurgical treatment. While available studies do not allow a general
statement regarding the efficacy of fusion over nonsurgical care for discogenic back pain, 4 trials
suggest any advantage of surgery over nonsurgical care is modest, on average near or below the
minimally important change in the disability score. Both groups demonstrated improvement
compared to baseline. Highly structured rehabilitation with a cognitive-behavioral component
seems nearly equivalent to surgery in efficacy at 1 year, with fewer complications.
2011
Which cancer related pathological fractures require surgical management?
(a) Humeral, if life expectancy is less than 3 months
(b) Radial, if pain resolves following radiation
(c) Femoral, if life expectancy is greater than 1 month
(d) Pelvic without acetabular involvement
Answer: (c)
Commentary: The indications for surgery for pathological fractures from cancer are life
expectancy of greater than 1 month with a fracture of a weight-bearing bone, and greater than 3
months for fracture of a non-weight-bearing bone. If pain persists following radiation, fractures
should be managed surgically. Healing rates are low following pathologic fractures, with 1
review of 123 patients reporting a 35% incidence of fracture healing. Fractures of the pelvis are generally treated conservatively, unless pain persists after radiation or unless they involve the
acetabulum.
2011
Of the muscles listed, the most distal muscle receiving innervation from the C5 root is
(a) brachioradialis.
(b) pronator quadratus.
(c) brachialis.
(d) biceps brachii.
Answer: (a)
Commentary: The brachioradialis is innervated by C5 and C6. The biceps and brachialis are more proximal, and pronator quadratus typically receives no C5 innervation.
Which statement is TRUE of the lower trapezius muscle?
(a) It is innervated by the thoracodorsal nerve.
(b) It is innervated by the long thoracic nerve.
(c) Contraction of this muscle results in upward rotation of the scapula.
(d) Contraction of this muscle results in abduction of the scapula
Answer: (c)
Commentary: The lower trapezius, as well as the upper trapezius and the middle trapezius, is innervated by the spinal accessory nerve (11th cranial nerve) and possibly contributions from the ventral rami of C2, C3, and C4. Contraction of the lower trapezius results in scapular depression, adduction, and upward rotation.
2013
Answer: (a)
Commentary: Gluteus medius weakness leads to a Trendelenburg gait. This woman’s lateral trunk lean is a compensated Trendelenburg gait. Gluteus medius or hip abductor weakness is common following total hip arthroplasty. In one study, 36 of 76 (47%) patients with total hip arthroplasty had hip abductor weakness. Of those 36 patients, all 36 had weakness in the gluteus medius, 28 had weakness in the gluteus minimus, and 4 had weakness in the tensor fascia latae
Answer: (b)
Commentary: This patient presents with an anterior-inferior labrum tear related to chronic anterior shoulder instability following a prior traumatic event (dislocation). Unidirectional instability refers to instability in only 1 direction, anterior direction being the most common. This type of instability is common after a traumatic event. Multidirectional instability refers to laxity in more than 1 direction and is associated with congenital laxity or chronic repetitive microtrauma. Anatomically, there is disruption in the anterior-inferior glenohumeral joint capsule and anterior-inferior labrum. Superior labral anterior to posterior (SLAP) lesions may occur, but
Page 16 of 23
that possibility is less likely in this patient, because of his history and a negative O’Brien compression test
2013
A 25-year-old man comes to your office for evaluation of low back pain. As part of the physical examination, you mark a point at the L5 vertebral body and another point midline 10 cm above. You ask him to flex forward maximally while keeping his knees extended and measure the distance between the two points. This distance is 13.5 cm. You suspect he may have what diagnosis?
(a) Lumbar spondylolisthesis
(b) Scheuermann disease
(c) Lumbar herniated disc
(d) Ankylosing spondylitis
Answer: (d)
Commentary: The Schober test is used to assess restricted range of motion seen in ankylosing spondylitis as the disease progresses. The distance between the 2 points with forward flexion exceeds 15 cm in normal individuals. This clinical test is not used for the assessment of lumbar spondylolisthesis, Scheuermann disease, or lumbar herniated discs.
2013
20-year-old football player reports anterior shoulder pain during a game. He completes the game,
but radiographs after the game revealed a type 2 acromioclavicular (AC) joint sprain. How is a
type 2 acromioclavicular (AC) joint injury defined?
(a) Acromioclavicular and coracoclavicular ligaments are both disrupted.
(b) Acromioclavicular and coracoclavicular ligaments are both intact.
(c) Acromioclavicular ligament is disrupted, but the coracoclavicular ligament is intact.
(d) Acromioclavicular ligament is intact, and the coracoclavicular ligament is disrupted
Answer: (c)
Commentary: Acromioclavicular joint injuries are classified into 6 types according Rockwood
classification. A type 1 injury describes a mild injury to the AC joint without disruption of either
the acromioclavicular or the coracoclavicular ligaments. A type 2 injury describes disruption of
the acromioclavicular ligament, but the coracoclavicular ligament remains intact. A type 3 injury
describes disruption of both ligaments whereas a type 4 injury entails complete disruption of both
ligaments with posterior displacement of the distal clavicle into the trapezius muscle.
2010
Which statement is TRUE regarding the rehabilitation of anterior cruciate ligament (ACL)
reconstruction/repair?
(a) Immediate postoperative weight bearing adversely affects subsequent knee function.
(b) A self-directed program is not as effective as regular physical therapy visits.
(c) Use of a continuous passive motion machine improves outcome.
(d) Postoperative functional bracing does not improve outcome.
Answer: (d)
Commentary: The use of postoperative functional bracing does not improve outcome. Immediate
postoperative weight bearing does not adversely affect subsequent knee function. A self-directed
program is as effective as regular physical therapy visits in a motivated patient. The use of a
continuous passive motion machine does not improve outcome.
2010
Compared to a younger individual, an older worker who suffers a musculoskeletal injury is more
likely to
(a) return to work sooner.
(b) have a recurrent injury.
(c) have the injury treated nonsurgically.
(d) sustain a less serious injury.
Answer: (b)
Commentary: Compared to a younger individual who suffers a musculoskeletal injury, an older
individual is more likely to have a recurrent injury, a decreased likelihood of returning to work
after the injury, increased time lost from the job as a result of the injury and a more serious injury.
Also, an older individual with a spine injury is more likely to have surgery than is a younger
individual.
2010
A 40-year-old woman reports left-sided facial pain for the past month along with difficulty in
moving her jaw. She hears a clicking noise with chewing along with constant tinnitus. Upon
examination, she has tenderness to palpation along her muscles of mastication on the left with
deviation of the mandible upon jaw opening. She would like to have pain relief. You suggest
(a) referral to an oral surgeon.
(b) that she perform jaw isometric exercises in a closed position with massage.
(c) a 2-week trial of an oral nonsteroidal anti-inflammatory medication.
(d) an ultrasound-guided intra-articular injection with steroids.
Answer: (c)
Commentary: This woman has a temporomandibular joint (TMJ) disorder most likely myofascial
in origin, which is the most common etiology. It is usually self-limited, and is managed
conservatively with relative rest (eg, avoiding jaw clenching, gum chewing), heat, and
nonsteroidal anti-inflammatory agents. Intra-articular steroid injections are not needed with a
myofascial origin of pain. She also does not need a referral to an oral surgeon at this time.
2010
An 87-year-old man on your inpatient rehabilitation unit was found on the therapy mat in much
pain after hearing a loud “cracking” noise when he transferred himself. What position of his right
lower limb would suggest hip fracture?
(a) Internal rotation and lengthened
(b) Internal rotation and shortened
(c) External rotation and lengthened
(d) External rotation and shortened
Answer: (d)
Commentary: In most cases, the lower limb of the fractured hip would be held in external rotation
(rotated outward) and would appear shortened relative to the unaffected lower limb.
2010
Which approach is shown to be efficacious in treating carpal tunnel syndrome?
(a) Oral corticosteroids
(b) Exercise therapy
(c) Vitamin B6
(d) Botulinum toxin injection
Answer: (a)
Commentary: Of the choices listed, only oral steroids have been shown to be efficacious in the
treatment of carpal tunnel syndrome. In addition to oral steroids, local injection of corticosteroids
and wrist splint are shown to be effective. Exercise therapy and botulinum toxin are ineffective
in the treatment of carpal tunnel syndrome.
2010
You are seeing a 79-year-old gentleman with chronic right shoulder pain. For the past several
years he has had limited shoulder movement and is diffusely tender around the shoulder.
Magnetic resonance imaging demonstrates a partial tear of the supraspinatus and infraspinatus
tendons with degenerative changes of the glenohumeral joint. You recommend
(a) rotator cuff repair.
(b) total shoulder arthroplasty.
(c) intra-articular viscosupplementation injection.
(d) flexibility and progressive strengthening exercises.
Answer: (d)
Commentary: The nonsurgical management of shoulder osteoarthritis (OA) with a chronic,
massive rotator cuff defect requires flexibility exercises and gentle progressive strengthening
exercises to increase shoulder function. Surgical repair involves humeral hemiarthroplasty.
Rotator cuff repair in partial thickness tears consists of surgical smoothing of the humeroscapular
motion interface with cuff curettage. Reverse total shoulder arthroplasty is used for
anterosuperior escape rotator cuff lesions. There is no role for shoulder viscosupplementation,
since it has not been shown to be beneficial.
2010
Which clinical scenario is most consistent with a L4-5 foraminal disc herniation?
(a) Weakness of the extensor hallicus longus, decreased sensation of the web space between
the first and second toes, absent hamstring reflex
(b) Weakness of the gastrocnemius, decreased sensation of lateral foot, absent Achilles reflex
(c) Weakness of the anterior tibialis, decreased sensation of the web space between the first
and second toes, absent hamstring reflex
(d) Weakness of quadriceps and anterior tibialis, decreased sensation of medial lower leg,
absent patellar reflex
Answer: (d)
Commentary: A foraminal disc herniation at L4-5 level would most likely affect the exiting L4
nerve root. A nerve root lesion could result in muscle weakness in the affected myotomes,
sensation loss in the affected dermatomes, and deep tendon reflex changes. The physical
examination findings most consistent with a lesion to the L4 nerve root would be weakness of
the quadriceps (L2-4), decreased sensation in L4 dermatomes, and decreased or absent patellar
deep tendon reflex (L4).
2010
Imaged with musculoskeletal ultrasound, normal tendon structure looks
a) hypoechoic, with hyperechoic septa.
b) hypoechoic , with fascicular pattern.
c) hyperechoic, with fibrillar echotexture.
d) hyperechoic, with posterior acoustic shadowing.
Answer:(c)
Commentary: Musculoskeletal ultrasound is an imaging modality that is able to identify and
characterize various soft tissue structures. Normal tendons appear as hyperechoic(bright echo)
structures with fibrillar or fiber-like pattern. Normal muscle appears as a hypoechoic(low echo)
structure with hyperechoic septa. Bone appears as a very hyperechoic structure with posterior
acoustic shadowing. Posterior acoustic shadowing is an artifact that refers to the anechoic
region(no echo) deep to the bone surface.
2012
A 20-year-old female soccer player presents to your office with chronic low back pain. Her computed tomography(CT) scan is seen in figure 1. What abnormality is seen on these CT images? Fig. 1 (a) Herniated disc (b) Facet degeneration (c) Pars interarticularis fracture (d) Tarlov cyst
Answer: (c)
Commentary: Spondylolysis is a defect in the pars interarticularis. These CT images(sagittal and
axial) show evidence of an L5 pars interarticularis fracture. Spondylolysis is common in the
athletic population, particularly among athletes who perform repetitive flexion-extension.
Herniated discs and Tarlov cysts are not seen in these images and are more readily evaluated on
MRI. Facet degeneration is often diagnosed by CT scan but is not seen on these images.
2012
A patient presents to your clinic with a 1-month history of mild hand numbness and clumsiness
without weakness. Electrodiagnosis confirms a primarily sensory median neuropathy at the wrist
without axon loss. Symptoms are not interfering with work. What is the most appropriate
treatment recommendation to provide short-term relief for this patient?
(a) Immediate referral to surgery for carpal tunnel release
(b) Neutral wrist splints to be worn at night
(c) Thumb spica splint
(d) Injection of platelet rich plasma into carpal tunnel
Answer (b)
Commentary: Wrist splints are shown to effectively decrease symptoms of carpal tunnel
syndrome in the short-term. Splints should be worn at night and during the day if possible. Brace
should place wrist in neutral (up to 5o of extension): note that many off-the-shelf carpal tunnel
braces place the wrist in excessive extensions. A thumb spica splint is not effective in treating
carpal tunnel syndrome. Conservative treatment is essential in mild to moderate cases of carpal
tunnel syndrome. Surgical referral should be considered for patients with weakness or worsening
symptoms not improved with conservative treatment. Platelet rich plasma injections are not an
effective treatment for carpal tunnel syndrome.
2012
Performing a seated leg extension exercise is an example of what type of kinetic chain exercise?
(a) Open
(b) Closed
(c) Static
(d) Mixed
Answer: A
Commentary:In open kinetic chain exercises the most distal segment moves around a fixed
proximal segment. In closed kinetic chain exercises the proximal segment moves around a fixed
distal segment. Static muscle contractions occur when the muscle is contracted but the proximal
and distal segments do not move. There are no mixed kinetic chain exercises.
2009
20-year-old college basketball player was seen in the training room after practice. He reports
“twisting” his ankle while attempting to rebound a missed shot. On further questioning, he
describes an inversion-type injury. He has swelling along the lateral aspect of the ankle. He is
tender to palpation over the anterior talofibular ligament and calcaneofibular ligament as well as
the 5th metatarsal base. He has no pain over the lateral or medial malleolus or proximally over the
fibular head. You obtain plain radiographs, which show a nondisplaced avulsion fracture of the
5th metatarsal base. What is the next step in treating this individual?
(a) Provide clearance for return to playing basketball without immobilization.
(b) Obtain a surgical consult for possible screw or pin fixation.
(c) Recommend immobilization with a postoperative shoe for 1-2 weeks.
(d) Prescribe non-weight bearing with crutches for 6-8 weeks or until radiographically
verified healing occurs
Answer: C
Commentary:Nondisplaced or minimally displaced avulsion fractures of the 5th metatarsal base
can occur with inversion ankle sprains. These generally are treated nonsurgically with a short
course of immobilization (1-2 weeks) with a postoperative shoe or a short walking boot.
Displaced fractures may require screw or pin fixation. It is important to differentiate an avulsion
fracture of the base from a fracture of the metaphyseal-diaphyseal junction (Jones fracture), since
treatment is different.
2009
After a lateral ankle injury, which ligament is most commonly ruptured?
a. tibiotalar ligament
b calcaneofibular ligament
c. tibiocalcaneal ligament
d anterior talofibular ligament
D
Though not all inversion ankle injuries result in the rupture of the ankle ligaments, when rupture does occur, isolated anterior talofibular ligament ruptures occur in 65% of the cases. Combined anterior talofibular ligament and calcaneofibular ligament ruptures occur in approximately 20% of cases. The tibiotalar and tibiocalcaneal ligaments are part of the deltoid ligament complex and are not involved in classic lateral ankle injuries.
2014
A 40-year-old painter presents to your office 2 weeks after falling off scaffolding at work. He complains of knee pain, swelling, occasional locking and give-way sensation, although he has not fallen since the accident. The case manager asks if the painter can return to work. Your recommendation includes:
A. return to sedentary work while diagnostic tests are done.
B. Return to work if the magnetic resonance image shows a normal anterior cruciate ligament
C Transfer to the emergency room to be assessed for septic knee
D return to light duty that includes ladder climbing.
A is correct
The painter’s history implies a meniscus tear. Because you know the painter must climb ladders, and stand and bend for long periods of time, further evaluation is in order to assess the best treatment options. The patient’s mechanism of injury and symptoms do not suggest an infectious etiology, making a septic joint unlikely. Return to a modified job may facilitate healing while still encouraging the patient to continue to work.
2014
A 40-year-old man with a history of severe asthma and alcohol abuse complains of progressive right groin pain and a decline in mobility for the past 5 years. Acetaminophen and nonsteroidal anti-inflammatory drugs are not helpful. He has also tried physical therapy and the use of a cane without improvement. On physical examination, he has an antalgic gait and limited right hip range of motion, especially with internal rotation. Which procedure would best help the patient’s pain and function?
a. Total hip replacement
b. Lumbar epidural steroid injection
c. Radiofrequency rhizotomy
d. Hip injection of platelet rich plasma
Option a is correct.
This patient has osteonecrosis or avascular necrosis of the femoral head. Risk factors include glucocorticoid, alcohol, and tobacco use. When pain limits mobility and conservative management has failed, total hip replacement is indicated. Platelet rich plasma is still experimental for its primary indications of lateral epicondylitis, patellar tendinopathy, and Achilles tendinopathy.
2014
Overuse syndromes resulting in tendinopathies are ideally treated differently in the progressive phases of recovery. Treatments for tendinopathies may appropriately be initiated in the following order:
A. relative rest, stretching, muscle activation, strengthening.
B massage, relative rest, strengthening, muscle activation.
C aggressive stretching, relative rest, muscle activation, strengthening.
D ice, strengthening, muscle activation, stretching.
Option a is correct.
The first goal is to reduce inflammation and irritation. Rest, nonsteroidal anti-inflammatory agents, and ice each help accomplish that first goal. Aggressive stretching of sore muscles does not accomplish the first goal of reducing inflammation and irritation. Strengthening should not begin until pain is controlled and stretching is tolerated without pain. Muscle activation refers to techniques designed to elicit specific muscles within a functional muscular complex that may not be efficiently contracting in response to neural excitation.
2014
Activating and strengthening which muscles may help solve iliotibial band syndrome problems?
A Hip adductors
B Quadriceps
C Tensor fascia lata
D Gluteus Maximus
Option d is correct.
The iliotibial band (ITB) is a fibrous band and increasing its tensile force increases compressive forces against the fat pad underneath the band. Biomechanical contributions to ITB syndrome include hip flexor imbalance, dynamic knee valgus, contralateral hip drop. Activating and strengthening gluteus maximus, the most powerful femoral external rotator, can help prevent dynamic knee valgus and prevent ITB syndrome. Using the rectus femoris instead of the iliopsoas to generate hip flexion may lead to compensatory tensor fascia lata (TFL) activity causing hypertonicity of the TFL and hip flexor imbalance. Although strengthening hip abductors is helpful, the abductors to be strengthened should be the gluteus minimus and medius, not the TFL. Strengthening hip adductors can increase dynamic knee valgus tendencies , exacerbating symptoms. Activating and strengthening gluteus medius, quadratus lumborum, and external obliques prevents contralateral pelvic drop.
2014
What is the predominant cause of long-term failure of total hip arthroplasty 10 years after surgery?
a. Aseptic loosening
b. Infection in the hip joint
c. Heterotopic ossification
d. Low bone density
Option a is correct.
Aseptic loosening is the most predominant cause of long-term failure of hip arthroplasty at 10 years or longer after surgery. Infection in the joint within a year of the operation is due to direct contamination at the time of surgery; afterwards it is due to hematogenous seeding. Heterotopic ossification, if it occurs, does not change after 6 to 12 weeks postoperatively even though the bone continues to mature. Low bone density does not happen as a result of hip arthroplasty.
2014
A gymnast is experiencing ulnar-sided wrist pain that is exacerbated by forearm rotation. Physical exam of the painful wrist suggests greater distal radius palmar-dorsal movement relative to the ulna compared to the other wrist, suggesting distal radioulnar joint laxity. You suspect she has
a. a scaphoid fracture.
b. De Quervain syndrome.
c. a pulley injury.
d. a triangular fibrocartilage complex (TFCC) tear.
Option d is correct.
The triangular fibrocartilage complex (TFCC) is a stabilizer of the distal radioulnar joint (DRUJ). Athletes who participate in repetitive loading of the wrist may be susceptible to degenerative changes, or a fall on an outstretched arm can cause acute injuries. Scaphoid fractures typically present with dull and aching pain in the anatomic snuffbox at the radial wrist. De Quervain syndrome refers to tenosynovitis of the abductor pollicis longus and extensor pollicis brevis, and it presents with pain over the radial styloid. It often occurs in racquet sport athletes. Pulley injuries most often occur in climbers, and presents with pain over the volar aspect of the phalanx
2014
The anterior interosseous nerve innervates which muscle?
a. Brachioradialis
b. Extensor indicis proprius
c. Extensor hallucis longus
d Pronator quadratus
Option d is correct.
The pronator quadratus, flexor pollicis longus, and the lateral half of flexor digitorum profundus are innervated by the anterior interosseous nerve. The brachioradialis is innervated by the radial nerve, the extensor indicis proprius by the posterior interosseous nerve, and the extensor hallucis longus by the deep peroneal nerve.
2014
More than ninety percent of lumbar disc herniations involve which 2 levels?
a. L4-L5 and L5-S1
b. L3-L4 and L4-L5
c. L3-L4 and L5-S1
d. L2-L3 and L5-S1
Option a is correct.
Disc herniations at L4-L5 and L5-S1 comprise 98% of all lumbar disc herniations. If radicular symptoms are present then the L5 and S1 nerve roots are most likely involved.
2014
A 50-year-old administrative assistant presents with low back pain. After taking her history,
performing a physical examination, and reviewing her imaging studies, you determine that her
pain is likely discogenic. She asks if there are any positions which would be better for her back
while at work. Which position exerts the most pressure on the lumbar discs?
(a) Standing erect
(b) Standing erect and flexed forward
(c) Seated in a chair
(d) Seated in a chair and flexed forward
Answer: D
Commentary:Nachemson measured the relative pressure changes within the third lumbar disc
with changes of position. Standing erect was the reference position and pressures decreased with
lying supine and increased in the seated position. Seated and flexed forward further increased disc
pressures. Several other positions were evaluated
2009
