MSK CC Questions

Question 1

Describe three features of mechanical back pain?

Answer 1

• Typically results from abnormal strain being placed on the supporting structures of the
spine including vertebral joints (e.g. ZA joints), discs, muscles and ligaments.
• Varies with time and activity
• Is rarely constant or severe at rest or nocturnally and
• The person is well with no red flags. (Definition NHS review, Prof Gordon Wardell).
• It is usually a deep ache of variable severity that can grab with movement.
• Often improves with therapy i.e. Drug and Physical therapy.
• Mechanical or somatic pain (not simple or nonspecific pain) 85-90% of presentations

Question 2

Describe three features of disc or radicular back pain?

Answer 2

• Varies less with time and activity compared to mechanical back pain
• Tends to be more constant, severe at rest and nocturnally.
• Radicular pain may be associated with limb numbness, paraesthesia and positive
neurological findings.
• The pain is usually a burning or stabbing pain and has poor response to simple drug
therapy and physical therapy. 5% of presentations are radicular. Incidence of
discogenic pain is unclear.
• Discogenic = arising from damaged/ degenerative intervertebral discs without nerve
root involvement, back pain with no leg pain.
• Radicular = disc injury with prolapse or marked inflammatory response causing
pressure on nerve root, leg pain +/- back pain (e.g. sciatica, foraminal stenosis, spinal
stenosis.)

Question 3

What vertebral level usually is at:

• Base of skull
• Vertebrae prominens
• Inferior angle of scapula
• Line of iliac crests
• Line of posterior superior iliac spines

Answer 3

• Base of skull – C2
• Vertebrae prominens – C7 (It is the vertebra to become most prominent with flexion.
N.B. that C6 vertebra disappears with extension but C7 remains palpable.)
• Inferior angle of scapula – T7 but varies with scapula movt
• Line of iliac crests -L4-5
• Line of posterior superior iliac spines – S2

Question 4

What are four red flag symptoms in the musculoskeletal history?

Answer 4

• >50 yrs old and <20 years old
• History of Osteoporosis (fracture with minimal trauma)
• Trauma significant for age (minor in elderly, severe in young)
• History of malignancy (possible metastatic bone pain)
• Pain that is constant and night pain severe enough to significantly disturb sleep
• Use of intravenous (IV) drugs
• Immunocompromised patient and steroid use

• Neurological compromise involving more than 1 level (e.g. MS)
• Constitutional symptoms: night sweats, associated fever (e.g. septic joint, myeloma,
osteomyelitis, spinal abscess), unintentional weight loss.
• Red, hot, painful, swollen joint with very limited ROM – think septic arthritis or acute
inflammatory arthropathy.

Question 5

What is iliotibial band (ITB) syndrome?

Answer 5

The ITB originates from fascia of the tensor fascia lata, gluteus maximus and medius. It
inserts in two layers predominantly to the lateral tubercle of tibia. It is a runner’s injury
with pain over the lateral femoral condyle and lateral tibia +/- a clicking sound with
running. Tenderness over lateral femoral condyle.

Question 6

Name two possible sources of referred knee pain?

Answer 6

• Knee pain can be referred from the spine e.g. disc prolapse with a radiculopathy.
• Hip pathology can refer pain to the knee and may or may not have anterolateral hip
and groin pain as well.

Question 7

Describe four possible non-traumatic intrinsic causes of knee pain.

Answer 7

• Osteoarthritis – Unusual before 50 y of age unless predisposing injury. Commoner in
women and obesity, previous knee trauma and occupations with stress to knee e.g.
heavy lifting.
• Septic Arthritis – Presents with severe, constant and nocturnal pain that is
aggravated by all movement and not relieved with rest (not mechanical). Patient is
unwell, often with fever and a hot, red, swollen joint. Risk factors: elderly, DM,
Rheumatoid arthritis, recent joint surgery/ prosthesis, recent steroid injection, recent
local trauma especially if penetrating injury to knee joint, immunosuppression.
• Synovial inflammation – Rheumatoid arthritis can present with monoarthritis in early
stages. Seronegative spondylarthropathy (reactive, psoriatic, IBD associated) can
present with knee arthropathy
• Crystal disorders - Gout (urate crystal precipitation) may present with severe
inflammation. Pseudogout (calcium pyrophosphate crystals) may present in a similar
way.

Question 8

Describe Ege’s test and explain which meniscus is being tested with the hips in external rotation and internal rotation.

Answer 8

• Squatting with the feet turned outward (hips in External Rotation) tests the medial
meniscus and feet turned inwards (hips in Internal Rotation) tests the lateral meniscus.
Ensure adequate exposure from quadriceps to bare feet (no shoes/ socks)
• Ask the patient if there was any pain and where it was located
• An easy way to remember this is that the feet point AWAY from the meniscus being
tested e.g. when the feet are pointed laterally (in external rotation) the medial meniscus
in the one being tested.

Question 9

Which of the effusion tests is best at picking up smaller effusions (5-10mL)?
Describe how it is done.

Answer 9

Swipe/Bulge Test (Small Effusion 5-10mL)
Empty suprapatellar bursa with 2-3 sweeping motions.
Firmly pressing with your full hand and sweeping from starting positing (near mid
anterior quadriceps) moving distally to superior border of patella.
Swipe along the sulcus lateral to the patella, while looking for a ‘wave’ filling the medial
sulcus (this theoretically works on both sulci, but waves are best seen on medial side)
Examine both legs, one at a time.

Question 10

Does the patella usually dislocate medially or laterally?

Answer 10

Lateral dislocation is much more common than medial dislocation of the patella.

Question 11

Why should you check for Sag Sign at the knee before doing the Anterior Draw
and Lachman’s test?

Answer 11

If Sag Sign is positive you will see that the tibial plateau on the affected side sags when
the knee is flexed at 90 degrees, suggesting that the posterior cruciate ligament (PCL)
is ruptured. As the tibia is posteriorly subluxed it may produce a false positive Anterior
Draw or Lachman’s test.

Question 12

Why is the Anterior Draw test not very useful in the acute setting? What other
test can assess the anterior cruciate ligament (ACL) and why might it be more
useful in the acute context?

Answer 12

• In an acute injury, the Anterior Draw test has low sensitivity and specificity probably
due to effusion, pain and secondary muscle spasm, especially of hamstrings, and
inability to draw an already tight knee due to haemarthrosis.
• Lachman’s Test, like the Anterior Draw test, assesses the ACL. The knee is held at
20-30 degrees flexion, which reduces any tension along the line of the tibial plateau, by
having the hamstring tendons nearly perpendicular to the direction of movement and
with minimal flexion is not affected as much by haemarthrosis as in the Anterior Draw
test. The tibia is again drawn forward in the line of joint. This is the most accurate test
for ACL injury in acute or chronic cases.

Question 13

What is the normal amount of movement in Lachman’s Test? What would you
expect with Grade 1-3 injuries?

Answer 13

• Normal: minimal movement. Firm end feel.
• Grade 1: 0-5mm, firm end feel. Low grade tear or stretch injury.
• Grade 2: 5-10mm, firm to loose end feel. Tear of variable degree.
• Grade 3: 10+mm, loose end feel. Rupture of the tendon.

Question 14

Explain the difference between the terms valgus and varus deformity at the knee
and give a clinical example.

Answer 14

• A valgus deformity is a condition in which the bone segment distal to a joint is angled
outward (or laterally) away from the midline. An example at the knee would be genu
valgum or “knock-knee”.
• A varus deformity is a condition in which the bone segment distal to a joint is angled
inwards (or medially) towards the midline. An example at the knee would be genu
varus or “bow-legged’.
• A useful way to remember this is vaLgus – segment distal to the joint moves Lateral to
the midline (note the L).

Question 15

When testing the medial and lateral collateral ligaments the knee is usually at
what angle? Why?

Answer 15

The knee is held in extension to start. You do not usually test in this position as the
knee is in the “screw home“ position and locked. 30 degrees of flexion is introduced.
Each ligament is tested. Do NOT flex more than 30 degrees or the knee is too loose to
clinically assess the ligaments.

Question 16

What would indicate a “positive” McMurray’s test? What is McMurray’s testing
for?

Answer 16

• Any “pop”, “click” or pain under the finger on the joint line while straightening the leg
during the McMurray’s test.
• McMurray’s Test is looking for problems with the medial or the lateral meniscus.

Question 17

Where does pain from the glenohumeral joint tend to refer?

Answer 17

• Pain from the glenohumeral joint tends to refer to the deltoid or biceps area and
occasionally the posterior shoulder. Pain in trapezius/ proximal shoulder may be from
cervical spine.
• Shoulder pain rarely goes below the elbow or to the neck. This suggests radicular
causes from cervical spine.

Question 18

Which shoulder pathologies are expected if there is pain in the 60-120 degree
range of abduction? What about if the pain occurred in abduction beyond 120
degrees?

Answer 18

• Watch for painful arc (60 ‐120 degrees), suggesting supraspinatus tendinitis and/or
impingement syndrome (Subacromial Pain Syndrome) • Watch for pain above 120 degrees, suggesting acromioclavicular pathology or referred
cervicothoracic pain.

Question 19

What can cause winging of the scapula?

Answer 19

This is caused by pathology of the Serratus Anterior Muscle, which is supplied by the
Long Thoracic Nerve (of Bell) - C5, C6 +/- C7. This nerve has a superficial course and
is particularly susceptible to sport-related trauma to the ribs, below an outstretched
arm.

Question 20

If you have reduced active range of motion (ROM) on abduction but reasonably
full passive ROM what kind of pathology might this suggest?

Answer 20

This may suggest a:
a. Supraspinatus tendon tear

b. Supraspinatus nerve injury or
c. Severe supraspinatus tendon Impingement.

Question 21

If both active and passive abduction are restricted what kind of pathology might
this suggest?

Answer 21

This might indicate glenohumeral (intra-articular) pathology, such as adhesive
capsulitis, severe osteoarthritis or rheumatoid arthritis.

Question 22

Which one of the “Full Can Test” or the “Empty Can Test” was described first
and is the more provocative test?

Answer 22

The Empty Can Test was first described by Jobe and Moynes, in 1982 and is the “more
provocative test” of the two. The Full Can Test was created later, with no internal
rotation and is a “less provocative” test, with lower rates of inducing muscle weakness,
secondary to pain.

Question 23

For the Empty Can Test and the Full Can Test how much abduction and forward
flexion should the arms be in?

Answer 23

The patients’ arm should be in 90 degrees of abduction and 30 degrees of forward
flexion.

Question 24

What is the main rotator cuff muscle being tested by the abduction strength
testing (i.e. the full and empty can tests?) Is this the only muscle being
activated?

Answer 24

Generally, we think of these tests assessing mainly supraspinatus, BUT It is difficult for
any test to “isolate” supraspinatus.

Question 25

What rotator cuff muscles does the External Rotation Strength Testing primarily
assess?

Answer 25

Infraspinatus and Teres Minor.

Question 26

What rotator cuff muscle does the Gerber’s Test (Lift-Off Test) assess?

Answer 26

Subscapularis as this test assesses internal rotation strength.

Question 27

Describe Shoulder Impingement Syndrome (also called Painful Arc Syndrome)

Answer 27

• Shoulder Impingement Syndrome (also called Painful Arc Syndrome) is a clinical
syndrome in which patients experience pain, weakness and a reduction in range of
movement of the shoulder, due to inflamed rotator cuff muscles in the subacromial
space. There is loss of the normal biomechanics of the glenohumeral joint complex with the glenohumeral head impinging into the Coraco-acromial arch complex.
• Remember that pain between 60- 120 degrees on abduction suggests impingement.

Question 28

What two tests are used for impingement testing?

Answer 28

• Neer’s test
• Hawkin’s-Kennedy Test

Question 29

What direction should the palm be facing for Neer’s test?

Answer 29

The palm should be facing down (pronation)

Question 30

Test At what forward flexion range would we expect to see pain or guarding in Neer’s

Answer 30

o Mild impingement – at 90+ degrees
o Moderate impingement – 60-90 degrees
o Severe impingement – 60 degrees or less

Question 31

In Hawkins-Kennedy Test how much passive internal rotation do you expect? If
you go beyond this range how do most patients try to compensate for this?

Answer 31

You would normally only expect 20-30 degrees of internal rotation at the shoulder and
if you force it further the patient is likely to try to compensate by raising the shoulder
up.

Question 32

What two tests assess the biceps tendon?

Answer 32

• Speed’s test
• Resisted elbow flexion test

Question 33

If there has been a rupture of the long head of the biceps tendon what will you
notice in the Resisted Elbow Flexion Test?

Answer 33

A muscle “lump” will appear over the anterior humerus (a “Popeye” bulge).

Question 34

What can cause neurogenic claudication and how can it present?

Answer 34

• Spinal canal stenosis with possible tethering of the spinal cord
• Walking or prolonged standing produces unilateral or bilateral leg pain most commonly
in the calves. Relieved by rest or flexion. You may see elderly people bending over
their shopping trolley while walking – may suggest spinal stenosis. There is little to find
on examination. Need to exclude vascular claudication – check pulses.

Question 35

What internal organs might be the cause of back pain and give some examples
of conditions that might present this way?

Answer 35

Dissecting Aortic Aneurysm, pancreatic inflammation and malignancy, posterior
perforating duodenal ulcer, renal calculi, pyelonephritis, pelvic pathology.

Question 36

What are you looking for in forward flexion to assess for scoliosis?

Answer 36

Scoliosis can give an uneven height in the left and right hemi thoraces (the domes
of each half of the thorax).

Question 37

Why do we ask the patient to sit on the bed when we assess rotation of the
spine?

Answer 37

To keep the hips in a fixed position so they don’t contribute to the rotational
movement.

Question 38

What is the Femoral Nerve Stretch Test Testing for? What nerve root level is the
Femoral nerve and where would the patient feel pain if the Femoral Nerve Stretch
Test is positive?

Answer 38

• It tests for impingement of the Femoral Nerve. Impingement of this nerve is likely to
be caused by intervertebral disc prolapse at L2-L3 or L3-L4, and less likely L4-L5. • Reproduction of the patient’s neuropathic pain (qualities include “burning, shooting,
tingling, numbness, electricity”) in the anterior thigh is positive for Femoral Nerve
Stretch.

Question 39

What does the Straight Leg Raise (SLR) test assess for? What nerve root level is
the Sciatic nerve and where would the patient feel pain if the SLR Test is
positive?

Answer 39

• SLR test for impingement of the Sciatic Nerve. Impingement of this nerve is likely to
be caused by intervertebral disc prolapse at L5 or S1.
• Reproduction of the patient’s neuropathic pain in the back of the leg, not the back
(qualities include “burning, shooting, tingling, numbness, electricity”) is positive.

Question 40

With the Fabre Test, if the patient describes the pain posteriorly what is the likely
origin of the pain? What if they describe anterior pain?

Answer 40

• Posterior pain suggests sacroiliac or lumbar origin. • Anterior pain: suggests joint pathology e.g. arthropathy, labral tears, loose body or
femoroacetabular impingement. It can also be positive in iliopsoas tendonitis/bursitis.