MSK SAEs Flashcards

Question

77. Which factor is associated with increased risk for occupational injury in an older individual? (a) White collar occupation (b) Female gender (c) Impaired hearing (d) Self employment

Answer 1

Answer: C Commentary: Predictors of increased injury risk in an older worker include male gender, less education, obesity, alcohol abuse, disability, self report of impaired hearing or sight, and several specific job requirements. Service workers, mechanics, machine operators, and laborers are at increased risk for occupational injury compared to people in white collar occupations. Individuals who are self-employed have a lower risk of injury.

Answer 2

Answer:D Commentary: This patient has radiographic evidence of femoroacetabular impingement. Two types have been described, cam impingement and pincer impingement. Cam impingement is described more commonly in active males and describes a non-spherical femoral head or osseous abnormalities of the femoral head-neck junction. These bony abnormalities have abnormal contact with the acetabulum in hip flexion, adduction, and internal rotation. Pincer impingement describes abnormal contact between the femur and the acetabulum due to overcoverage of the femoral head from an abnormally deep or retroverted acetabulum.

Answer 3

Answer: C Commentary: Patients undergoing single knee or hip replacement surgery who were treated at an IRF were more likely to be discharged home, less likely to require home care services upon discharge, and were able to ambulate farther distances compared to those treated in an SNF.

Answer 4

Answer: C Commentary: Corticosteroid injection for de Quervain tenosynovitis has been shown to be more effective treatment than splinting and anti-inflammatory medications.

Answer 5

Answer: B Commentary: If a publicly accessible office is present within a single family home, it is required to be accessible under the ADA, so long as the necessary modifications are readily achievable. Accessibility of commercial airplanes is covered under the Air Carrier Access Act, not the ADA. Access to houses of worship or strictly residential private apartments is not required under the ADA.

Answer 6

Answer: D Commentary: This patient sustained an injury to her triangular fibrocartilage complex. This structure is a stabilizer of the distal radioulnar joint and is composed of an avascular articular disc and radioulnar ligament complex. It is often injured with repetitive wrist activities or compressive loads. Tears to it are best imaged by MRI arthrogram. Injury to this complex would not be optimally evaluated on plain films, bone scan, or computed tomography scan.

Answer 7

Answer: B Commentary: Work hardening is a rehabilitation program designed to simulate the individual worker’s job. It can be performed at a center or at the worker’s jobsite. These programs are often recommended to be done 5 days a week. The worker performs an individualized program based on his/her specific job requirements. Physician follow-up is needed to determine if goals have been achieved. Work conditioning is a program used to enhance aerobic conditioning but does not attempt to replicate the tasks of a specific job.

Answer 8

Answer: C Commentary: The patient has a common peroneal nerve palsy which can occur after total knee arthroplasty. Weak quadriceps strength and inadequate knee flexion may cause difficulty with ambulation, but not the loss of ankle dorsiflexion. Tibialis anterior tendon tear will cause difficulty with ankle dorsiflexion, but is not a common complication after knee arthroplasty. Also, acute tendon tears present with sudden pain and palpatory defect.

Answer 9

nswer: C Commentary: Real time ultrasound is less costly than magnetic resonance imaging (MRI) and has similar sensitivity and specificity in diagnosing medial epicondylitis. Plain radiographs and electrodiagnostic studies will not help localize or confirm your diagnosis of medial epicondylitis, but may help with diagnosing a fracture or nerve injury, respectively.

Answer 10

Answer: A Commentary: The Americans with Disabilities Act defines disability as a physical or mental impairment that substantially limits 1 or more of a person’s major life activities. The person has a record of such impairment, or is regarded as having such impairment. Impairment is the actual physiologic, anatomic, or psychologic abnormality. Handicap refers to the barriers society places on an individual to perform function in the community. A permanent disability rating is used to determine financial compensation for an injury.

Answer 11

Answer: B Commentary: The validity of a functional outcome measurement tool is defined as the ability of the tool to measure what it is designed to measure. The ability to measure different outcomes simultaneously does not impact the validity of the instrument, but the validity of the tool would need to be established for each of the outcomes being measured. The ability of two different raters to obtain the same conclusion is referred to as inter-rater reliability. Freedom from random error is also related to the reliability of the instrument.

Answer 12

Answer: D Commentary: Patellofemoral arthralgia is thought to result from tracking problems of the patella within the trochlear groove. Several biomechanical issues, such as tight and inflexible quadriceps, pes planus, tight iliotibial band, weak and ineffective vastalis medialis, and weak hip abductors, may contribute to incorrect tracking of the patella. The Ober test assesses the tensor fascia lata and iliotibial band for contracture and inflexibility.

Answer 13

Answer: A Commentary: According to the AMA Code of Ethics Opinion, individual gifts of minimal value from pharmaceutical representatives to physicians are permissible, so long as the gifts are related to the physician's work. It is not acceptable for physicians to request free pharmaceuticals for personal use or use by family members. Subsidies to underwrite the costs of continuing medical education are permissible when they are accepted by the conference's sponsor and are not provided directly to the physician. It is acceptable for faculty at conferences to accept reasonable honoraria and reimbursement for travel, lodging, and meal expenses.

Answer 14

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.

Answer 15

Answer: D Commentary: Functional restoration programs produce a greater improvement in endurance, but no differences are noted between functional restoration programs and active individual therapy programs.

Answer 16

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.

Answer 17

(d) If a patient on a statin presents with muscle complaints, with or without creatine kinase (CK) elevations, other causes, including strenuous exercise or hypothyroidism, must be considered. If a patient initially has normal or only moderately elevated CK levels, the statin may be continued with close monitoring of symptoms and CK levels; however, if symptoms become intolerable or if the CK level is 10 times the upper limits of normal (ULN) or greater, the statin must be discontinued. If myositis is present or strongly suspected, the statin should be discontinued immediately. Early diagnosis and treatment of symptomatic CK elevations, including cessation of drug therapies potentially related to myopathy, can prevent progression to rhabdomyolysis. Symptoms and CK levels should resolve completely before reinitiating therapy, at a lower dose if possible. Asymptomatic elevation of CK at 10 times the ULN or greater should also prompt discontinuation of the statin. Consideration should also be given to discontinuation of statins before events that may exacerbate muscle injury, such as surgical procedures or extreme physical exertion.Needle electromyography abnormalities are uncommon in statin-induced myopathy. An EMG does not exclude statin-induced myopathy, because it primarily affects type 2 muscle fibers. Electromyography is not routinely performed or recommended unless the clinical presentation does not improve with statin discontinuation or if concern exists about other diagnoses.

Answer 18

(d) Return-to-work rates of 77% can be achieved with work hardening programs. Poor outcome was associated with an increased number of treatments before the program, an increased length of time off from work; the patient's having lower satisfaction with the program, and a lawyer being involved in the case.

Answer 19

(c) There is about a 50% chance of return to work when a worker who injures his low back on the job is off work for 6 months. The rate drops to 25% when the worker is off for 1 year, and is minimal is he is off for 2 years.

Answer 20

(b) Up to 33% of individuals with symptoms from whiplash-associated disorders have chronic symptoms. Symptoms associated with whiplash-associated disorders include neck pain, arm pain, paresthesias, temporomandibular joint dysfunction, headache, dizziness, visual disturbances, and difficulty with memory and concentration. Ref: Panagos A, Sable AW, Zuhosky JP, Irwin RW, Sullivan WJ, and Foye PM. Industrial medicine and acute musculoskeletal rehabilitation. 1. Diagnostic testing in industrial and acute musculoskeletal injuries. Arch Phys Med Rehabil 2007;88(3 Suppl):S5.

Answer 21

(d) Risk factors associated with a repetitive strain injury include obesity, cold temperature, older age, diabetes, smoking, pregnancy, rheumatoid arthritis, and psychologic stress. Ref: Panagos A, Sable AW, Zuhosky JP, Irwin RW, Sullivan WJ, Foye PM. Industrial medicine and acute musculoskeletal rehabilitation. 1. Diagnostic testing in industrial and acute musculoskeletal injuries. Arch Phys Med Rehabil 2007;88(3 Suppl):S5.

Answer 22

(d) With closed nerve injury as described, early active and passive range of motion (ROM) therapy of the affected joints is begun. The value of electrical stimulation is uncertain. The purpose of surgical repair is to improve peripheral nerve recovery and eventual function. Therefore, surgery is done when the patient has an incomplete loss of function but shows no improvement over several weeks, or no return of function at 2 months for peripheral nerve and 4 months for a brachial plexus injury. Findings at the time of surgery help establish a prognosis. However, the chances of successful surgical repair begin to decline by 6 months after the injury. By 18--24 months, the denervated muscles usually are replaced by fatty connective tissue, making functional recovery impossible.

Answer 23

(b) The lumbar medial branches of the dorsal rami supply the facet joints as well as the deep paraspinals, such as the rotators and multifidi. The sinuvertebral nerve, also termed the recurrent meningeal nerve is the primary source of nerve supply to the lumbar intervertebral disc. It is derived from portions of the ventral rami and grey rami communicantes (sympathetic input). Accordingly, the referral pattern seen with intrinsic disc pain is vague and diffuse.

Answer 24

(c) Computed tomography (CT) scans with thin cuts through the area of the pars interarticularis can identify the healing pattern of a pars stress fracture. Ref: Standaert CJ, Herring SA. Expert opinion and controversies in sports and musculoskeletal medicine: the diagnosis and treatment of spondylolysis in adolescent athletes. Arch Phys Med Rehabil. 2007. Apr;88(4):537-40.

Answer 25

(d) Risk factors for chronic whiplash-associated pain include presence of preexisting degenerative disc disease, preexisting loss of cervical lordosis, female gender, awkward head position at time of impact, presence of radiating pain into upper limbs, and prior history of headache. A famous Lithuanian study showed no incidence of long-term whiplash pain in a country that had no compensation system for whiplash. Ref: Seroussi RE, Ferrari R. Curve/countercurve: Whiplash. SpineLine 2001:12-9.

Answer 26

(a) A person who knowingly discloses individually identifiable health information in violation of HIPAA faces a fine of $50,000 and up to a 1-year imprisonment. The criminal penalties increase to $100,000 and up to 5 years imprisonment if the wrongful conduct involves false pretenses, and to $250,000 and up to 10 years imprisonment if the wrongful conduct involves the intent to sell, transfer, or use individually identifiable health information for commercial advantage, personal gain, or malicious harm.

Answer 27

(a) The subpedicular transforaminal route of epidural steroid delivery places the needle at the anterior portion of the intervertebral foramen. The retroneural route of delivery purposefully terminates needle placement at the posterior edge of the intervertebral foramen to avoid injuring radicular vasculature. The caudal and interlaminar approaches are of limited utility in delivering steroid anteriorly due to raphe within the epidural space. Ref: Irwin RW, Zuhosky JP, Sullivan WJ, et al. Interventional procedures for work-related lumbar spine conditions. Arch Phys Med Rehabil 2007;88(Suppl):S22-3.

Answer 28

(c) Protected Health Information includes individually identifiable health information. This is information, including demographic data, that relates to any of the following particulars: the individual’s past, present or future physical or mental health or condition; the provision of health care to the individual; or the past, present, or future payment for the provision of health care to the individual. It can also be information that identifies the individual or for which there is a reasonable basis to believe it can be used to identify the individual. Individually identifiable health information includes many common identifiers (e.g., name, address, birth date, Social Security Number).

Answer 29

(b) The natural history of spinal stenosis is generally benign. While decompressive surgery achieves satisfactory results in the great majority of individuals, the difference in outcomes with their nonsurgical cohorts becomes narrower with time.

Answer 30

(b) In fiscal year 2003, the number of admissions to an inpatient rehabilitation facility with the diagnosis related group unilateral joint replacement in a lower extremity was 124,754, stroke was 54,433, amputation for circulatory disorders except upper limb and toe was 7,200, and hip or pelvis fracture was 5,863. Ref: US Government Accountability Office. Medicare: more specific diagnoses needed to classify inpatient rehabilitation facilities. April 2005. Report GAO-05-366. Available at: http://www.gao.gov/new.items/d05366.pdf. Accessed July 4, 2007.

Answer 31

A telltale sign of cervical cord involvement is bilateral symptoms. In this case, the athlete should be treated as having a potential spinal cord injury and should have his cervical spine immobilized. The football helmet should not be removed, since the cervical spine may fall into extension in the act of removing the helmet. If the airway needs to be accessed, then the face guards should be removed using special equipment. If the athlete suffered and recovered from a temporary “stinger,” involving 1 limb, he may return to play as long as his neurologic examination is normal.

Answer 32

Returning the employee to modified duty that fits the impairment and avoids provocative activities is important from several aspects. One, behavioral management with the employee allows early goals to be set, so that the employee can work with restrictions. It also establishes that simply being off work until pain free is not always a logical goal. Second, the employer can fully understand the employee’s capabilities during recovery. This management approach hones in on the employer to comply with the restrictions. Third, starting with reasonable restrictions allows the physician to guide the employee back to the work place by making adjustments as the worker’s rehabilitation progresses.

Answer 33

(d) The paramedic has a high demand job. A functional capacity evaluation would best determine the employee’s ability to return to her job. If deficits are noted, work hardening over a period of weeks will best ensure return to work. Work hardening for 1 week may not be sufficient. Work conditioning enhances aerobic fitness and conditioning but is not job specific. The paramedic is at high risk for recurrent injury. Returning the employee to work without testing the her ability to perform her job duties may precipitate premature return and reinjury.

Answer 34

B Recurrent dislocations should be treated with surgery at some point if the athlete would like to return to contact sports. Various anterior shoulder dislocation techniques that can be applied to reduce the shoulder, most by external rotation of the shoulder or by using gravity.

Answer 35

(d) If a patient on a statin presents with muscle complaints, with or without creatine kinase (CK) elevations, other causes, including strenuous exercise or hypothyroidism, must be considered. If a patient initially has normal or only moderately elevated CK levels, the statin may be continued with close monitoring of symptoms and CK levels; however, if symptoms become intolerable or if the CK level is 10 times the upper limits of normal (ULN) or greater, the statin must be discontinued. If myositis is present or strongly suspected, the statin should be discontinued immediately. Early diagnosis and treatment of symptomatic CK elevations, including cessation of drug therapies potentially related to myopathy, can prevent progression to rhabdomyolysis. Symptoms and CK levels should resolve completely before reinitiating therapy, at a lower dose if possible. Asymptomatic elevation of CK at 10 times the ULN or greater should also prompt discontinuation of the statin. Consideration should also be given to discontinuation of statins before events that may exacerbate muscle injury, such as surgical procedures or extreme physical exertion. Needle electromyography (EMG) abnormalities are uncommon in statin-induced myopathy. An EMG does not exclude statin-induced myopathy, because it primarily affects type 2 muscle fibers. Electromyography is not routinely performed or recommended unless the clinical presentation does not improve with statin discontinuation or if concern exists about other diagnoses.

Answer 36

D The prospective payment system for inpatient rehabilitation facilities requires that all patients admitted for inpatient rehabilitation be assigned to an impairment group code category. Payment to the rehabilitation facility is further determined by the patient’s subclassification into a case-mix group. The FIM instrument motor score is used to help determine the case-mix group designation under the prospective payment system for inpatient rehabilitation facilities. None of the other options listed are used in this process.

Answer 37

A The interdisciplinary approach to patient care emphasizes common patient and team goals rather than discipline-specific goals. The patient and family members should be included in the goal setting process. All team members must work in a collaborative way to facilitate achievement of goals. Team members must have an appreciation for all the issues that affect the patient rather than focusing on an isolated problem. Team communication is essential at all points in the rehabilitation process, not just when problems occur.

Answer 38

B Case managers are shown to be beneficial liaisons between the physician and workers compensation carrier and their presence facilitates patient care. To be treated as a workers compensation case, the patient must give the carrier full access to his/her medical record. The employee treated under workers compensation cannot restrict the access of the case manager to the physician; however, discussions with the case manger should be done in the environment that the patient requests.

Answer 39

AThe purpose of the Health Insurance Portability and Accountability Act (HIPAA) is to ensure that a patient’s medical record remains private, but is available to health care providers as directed by the patient. A non-treating physician, lawyer, or insurance company may have access to the record with written authorization by the patient or guardian. There are no stipulations about a physician’s qualifications with regards to medical information access. (a) Office for Civil Rights-HIPAA Privacy. Incidental uses and disclosures. Revised April 2003. [cited 2006 July 13] Available from URL: http://www.hhs.gov/ocr/hipaa/guidelines/incidentalud.pdf

Answer 40

B Whole body-vibration is associated with increased frequency of low back pain. Some studies have found a correlation between increased frequency of disc protrusion and occupational driving. The exposure to vibration will likely facilitate continued symptoms in this worker, and relative rest is indicated during the initial stages of recovery. There is no predetermined length of physical therapy that is associated with recovery. Workers with low back pain and leg pain must learn to sit without increasing symptoms. Complete avoidance will not necessarily improve recovery and is not practical. The driver can likely perform some duties with restrictions. The employer has the responsibility to provide a job that meets the restrictions set by the physician. If the employer is unable to provide a job with these restrictions then the employee must remain off work.

Answer 41

D The transverse tarsal joint, namely the talonavicular and calcaneocuboid joints, must have their joint axes in parallel to allow for a flexible midfoot and pronation. If the axes intersect, the midfoot becomes rigid, which enables proper supination.

Answer 42

D With closed nerve injury as described, early active and passive range of motion exercise of affected joints is begun. The value of electrical stimulation is uncertain. Surgery is done when there is an incomplete loss of function but no improvement over several weeks or no return of function at 2 months for peripheral nerve and 4 months for a brachial plexus injury. The purpose of surgical repair is to improve peripheral nerve recovery and eventual function. Findings at the time of surgery help establish a prognosis. However, the chances of successful surgical repair begin to decline by 6 months after the injury. By 18 to 24 months, the denervated muscles usually are replaced by fatty connective tissue, making functional recovery impossible.

Answer 43

C Central sensitization is a complex set of activation dependent post-translational changes occurring at the dorsal horn, brainstem, and higher cerebral sites that sensitizes the central nervous system to further perception of pain. Wind-up is an amplified evoked response to repeated afferent inputs at the level of the dorsal horn.

Answer 44

C It is advisable to select the finest needle that will reach the area. The injection should be peritendinous with avoidance of the tendon to prevent rupture. The minimum interval between injections should be at least 6 weeks. Early postinjection local anesthesia is not a complication of steroids, but it will occur if local anesthetic is mixed with the steroid.

Answer 45

A The work by Marras and colleagues showed that increasing the horizontal distance from the trunk of an object being carried increased the risk of developing a low back disorder. This increase in distance increased the forces consistently on the anterior column of the spine. Although the other options can all place the worker at risk for a low back injury, only the increased carrying distance from the trunk has been shown to be the most predictive of a low back injury.

Answer 46

A Dependence is a maladaptive pattern of drug use marked by tolerance and a drug-class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood levels of drug, or administration of an antagonist. Tolerance is a state of adaptation in which exposure to a drug induces changes that result in diminution of 1 or more of the drug’s effects over time. Addiction is a chronic biopsychosocial disease characterized by impaired control over drug use, compulsive use, continued use despite harm, and craving.

Answer 47

B The medial branches of the dorsal rami supply innervation to the facet joints and the deep paraspinals, namely the segmental multifidi and rotators. The sacral multifidi are innervated by the sacral (rather than the lumbar) dorsal rami. Each lumbar medial branch innervates the facet joint at and below its derivation. The L4-5 facet joint is innervated by the L3 and L4 medial branches, derived from the L3 and L4 nerve roots.

Answer 48

D ) In order to appropriately follow Medicare regulations for teaching physicians, when caring for a patient with a resident physician, the attending physician must see the patient, review the medical record documentation of the resident, and personally document involvement in key aspects of the history, exam, and medical decision-making. Documentation from the resident alone does not confirm the level of attending physician involvement. The attending physician documentation combined with the resident documentation can be used to determine the level of care provided and the appropriate level of billing.

Answer 49

C he C6-7 and C7-T1 epidural levels have the greatest amount of space. Interlaminar epidural injections should be performed with caution in the spaces that have a smaller diameter, such as those at stenotic levels or high cervical levels. Practitioners should also be aware that the ligamentum flavum may have defects in a high percentage of individuals.

Answer 50

D The United States Department of Labor has determined that computer work is associated with a significant number of musculoskeletal disorders, many of which are considered cumulative trauma disorders. Examples include cervical and thoracic myofascial pain, rotator cuff tendonitis, medial and lateral epicondylitis, de Quervain tenosynovitis, and carpal tunnel syndrome.

Answer 51

A According to the Charter on Medical Professionalism, there are 3 fundamental principles of medical professionalism. They are (1) the primacy of patient welfare, (2) patient autonomy, and (3) social justice.

Answer 52

D All of the options listed are key aspects of practice-based learning and improvement, with the exception of the ability to advocate for quality patient care and assist patients in dealing with system complexities. This statement is a key aspect of systems-based practice as defined by the Accreditation Council of Graduate Medical Education.

Answer 53

A Wrist strengthening, acupuncture, and shock wave therapy all help in the treatment of epicondylitis. However, low intensity laser treatment is not proven beneficial.

Answer 54

C The Commission on Accreditation of Rehabilitation Facilities (CARF) provides accreditation status that signifies the rehabilitation facility holds itself to the highest standards in the field. CARF accreditation is voluntary and not all inpatient rehabilitation facilities participate. Accreditation by CARF does not confer any preferred status with payors, and CARF provides accreditation in general comprehensive inpatient rehabilitation as well as specialty programs such as spinal cord injury and traumatic brain injury.

Answer 55

(a) Occult cervical fractures are most often seen at the C1 and C7 levels. By adding computed tomography (CT) scanning to the evaluation of trauma patients, a significant number of occult cervical fractures can be diagnosed. Of spinal fractures, 5% to 30% are multiple and may appear at noncontiguous levels. Thus, radiographic evaluation of the entire spinal axis is necessary wheneverinjury at 1 region of the spine is detected

Answer 56

(d) Loisel, in1997, performed a randomized controlled trial that showed that the injured worker with low back pain returned to regular work activities 2.41 times faster if the worker received therapeutic functional rehabilitation and ergonomic intervention when compared to usual care.

Answer 57

(a) The Center for Medicare and Medicaid Services currently reimburses inpatient rehabilitation facilities (IRF) based on a prospective payment system (PPS) according to the patient’s severity of disability and his/her required use of resources. The rehabilitation impairment category is based on the primary rehabilitation diagnosis, and the case-mix group is determined in part by the patient’s co-morbid medical conditions

Answer 58

(b) This is a common clinical conundrum. Medial tibial stress syndrome (frequently and improperly referred to as shin splints) represents a range of pathology from posterior tibialis tendonitis to periostitis. Fredericson et al determined that stress fractures, which will require more aggressive treatment, have more focal pain and pain with percussion testing. Pain from a stress fracture worsens as run goes on and often hurts after a run. A magnetic resonance image or bone scan can make a definitive diagnosis.

Answer 59

(b) The indication for spinal instrumentation in neuromuscular scoliosis is that the primary curve exceeds 25° and forced vital capacity has not dropped below 35% of normal.

Answer 60

(a) A functional capacity evaluation (FCE) is the next best choice for this worker. An FCE will determine functional deficits the worker has by assessing work simulated activities. Work conditioning may be helpful because it includes aerobic conditioning but does not provide information and training regarding specific work tasks. His physical findings are minimal so additional physical therapy may not be recommended. These minimal physical exam findings in a 63-year-old man may indicate a nontraumatic incomplete cuff tear that may be a part of normal aging. In this setting, conservative management remains appropriate. Incomplete rotator cuff tears can be found in the asymptomatic population, especially over the age of 50.

Answer 61

(d) Medical error reporting systems are designed to encourage staff to report sentinel events, adverse events, and close calls without fear of punishment. If these issues are recognized, then further review and action can be initiated. Review may include a root cause analysis to determine the exact cause of the problem and strategies for prevention. When a medical error has occurred, staff are encouraged to recognize the issue and report the issue immediately.

Answer 62

(b) Case managers work as medical liaisons between the company and medical care team to facilitate communication of and approval for diagnostic tests and treatment. They have been shown to improve timeliness of care. It is important to ask the patient’s preference regarding the case manager’s presence and to ensure patient confidentiality. The physician is to determine if the patient can return to work based on objective and subjective evidence. It is not the case manager’s job to provide the treating physician with evidence regarding validity of the worker’s condition.

Answer 63

(c) While data on sacroiliac joint provocative tests have been equivocal in the literature, recent evidence has shown thigh thrust and pelvic distraction maneuvers to be helpful. The Thomas test is used to assess hip flexor contracture. The Gillet test is a sacroiliac joint motion test and not a provocation test. The FADIR maneuver is used to assess piriformis tightness and provocation.

Answer 64

(c) Return-to-work barriers proven to date include the following: lack of knowledge regarding modified work, negative attitudes of employees, difficulty changing the work tasks and organization of the work, and a mismatch between the employee’s education level and the requirements of the modified job.

Answer 65

(b) The ligamentum flavum forms the anterior border of the facet joint. Rents in the facet capsule allow contrast material to leak and therefore medication will also leak out of the intended area. Intra-articular injections into the facet joint performed for diagnostic purposes may lose specificity when this extravasation into the epidural space occurs, because other pain generating structures may also be blocked from receiving the medication.

Answer 66

(a) Deterioration in personal hygiene is the most likely warning sign of substance abuse in a resident colleague. Other warning signs of impairment secondary to substance abuse include increased rates of absenteeism, inability to meet deadlines, loss of concern about patient welfare, and wide fluctuations in mood and performance.

Answer 67

(c) The mouse should be placed at a distance that is easy to reach and allows comfortable flexion of the elbow approximately 40° to 90°. Chair height is not a preset determined height but is individualized so that the hips are at a 90° angle to the knees. The computer disk drive should be easily reached if used repetitively. Avoiding seated flexion would be a better recommendation. The computer screen height should allow a neutral neck position and minimize static flexion or extension.

Answer 68

(d) Once a physician is certified by the American Board of Physical Medicine and Rehabilitation, he or she must continue to fulfill certain requirements in order to maintain certification status. Publication of an article in a peer-reviewed journal every 10 years is not a requirement for maintenance of certification. All the other options listed are required.

Answer 69

(b) An anterior pelvic tilt is caused by one of several anatomic factors. These include tight hip flexors, weak lower abdominals, and weak gluteal muscles. Compensatory lumbar extension through lumbar lordosis results in individuals with excessive anterior pelvic tilt.

Answer 70

(b) A tight posterior capsule is a common phenomenon in overhead athletes. Often rotator cuff tendinopathy results from impingement and scapular dyskinesis. Glenohumeral internal rotation deficit (GIRD) defined as internal rotation less than 15° or a greater than 25° side to side difference, is due to tight posterior capsule, teres minor, and infraspinatus. Further, Matsen and Harriman showed that a tight posterior capsule drives the humeral head anteriorly when flexing the shoulder, thus predisposing to further impingement at the coracoacromial arch. Scapular dyskinesis, due to weak scapular stabilizer muscle weakness, is typically in a position of anterior tilting rather than posterior tilting.

Answer 71

(a) The purpose of the Health Insurance Portability and Accountability Act (HIPAA) is to ensure that a patient’s medical record remains private. A non-treating physician, lawyer, insurance company, etc. can have access so long as the patient directs it, with written authorization. There are no stipulations about a physician’s qualifications with regards to medical information access. Office for Civil Rights–HIPAA Privacy: incidental uses and disclosures. Revised April 2003. Available

Answer 72

(d) The quadruped push-up is a closed kinetic chain (CKC) exercise. CKC exercises are the least demanding of the rotator cuff exercises. The axial load with CKC exercises effectively reduces the weight of the arm (ie, load). CKC promote muscle co-activation needed for functional tasks.

Answer 73

(c) This patient has lateral epicondylitis or so-called tennis elbow. Weak scapular stabilizer muscle strength may cause decreased force production through the elbow, thus causing more force and load through the elbow. Leading with the elbow during the backhand stroke can cause an increased load on the wrist extensor muscles. Keyboards placed too high or too low may cause lateral epicondylitis. Racquet string tension should be adjusted to mild to moderate tension (52 to 55 pounds if stringing machine is properly calibrated) in a normal (non-oversized) racquet. A racquet strung to less than 30 pounds will require the tennis player to use more force. This may, in turn, cause increased grip pressures and wrist extensor overuse.

Answer 74

(b) Femoral neck stress fractures are serious injuries. Stress fractures may occur without a cortical break. Stress fractures of the medial side of the femoral neck, the “compression” side, can be treated with a weight-bearing restriction for 6 weeks or longer including no running or high impact activities. Stress fractures on the lateral side of the femoral neck, the “tension” side, warrants strong surgical consideration because of the poor healing capability at that location.

Answer 75

(c) Maximum medical improvement (MMI) is a term used by a physician to indicate that he/she has determined that no further significant recovery of a condition is anticipated to occur. Resolution of the condition may or may not occur. Determining MMI does not indicate that no treatment is indicated

Answer 76

(b) Guidelines for worker entry and treatment under workers’ compensation law are determined by each state. The published American Medical Association guidelines are useful tool in determining disability. Because each state determines which edition of the publication is used, its application is not uniform nationwide. Not all states require subspecialty certification required of a physician wishing to practice industrial medicine. In some states the employer chooses the physician to treat the injured worker.

Answer 77

(a) The most likely diagnosis in this case is lateral epicondylitis. In acute overuse injuries ice should be used first to reduce inflammation. Physical therapy may be used to facilitate a home exercise program for flexibility and strengthening exercises and to ensure appropriate posture adaptations. The computer set-up—including chair height and positioning of the monitor, keyboard, and mouse—will help resolve current complaints and reduce risk of re-injury. This ergonomic evaluation is multifactorial.

Answer 78

(a) Bigos's study of over 3,000 aircraft employees identified risk factors for low back injury that are outside of the physical factors. Workers who hardly ever enjoyed their job were 2.5 times more likely to report a back injury than those who “almost always” enjoyed their job. This study suggested that identifying factors outside of the physical and ergonomic model was important in determining risk of injury. No studies demonstrate that factory workers often have mental illness.

Answer 79

(d) The modified Thomas test is performed with the patient supine; with the tested leg in maximal passive hip extension and knee flexion and the contralateral knee to the chest. The test position causes the pelvis to be placed in posterior pelvic tilt and reduces any lumbar lordosis. Tightness of hip flexors is measured by the degrees of hip flexion from neutral. Tightness of the knee extensors is measured by the degrees of knee flexion from neutral. Tightness of the iliotibial band is measured by the degrees of hip and knee external rotation.

Answer 80

(c) Case managers reduce workers’ compensation costs by 23% and reduce the overall number of lost-time cases. Overall case management can help improve the quality of care, reduce cost, and decrease time loss in the worker’s compensation system. Studies show that case managers doe not interfere with the physician-patient relationship or the physician’s recommendations, and do not make proposals that favor the insurer.

Answer 81

(a) Narcotics and non-narcotic medications often may be necessary to manage pain in the injured worker. It is important to set expectations of how these medications will be used. Expected length of time of narcotic usage is especially important. The goal should be to return the worker to his/her job without medication. Simply cutting off medications may be inappropriate. As pain improves, and strength and function improve, medications should be tapered.

Answer 82

(a) The multifidi are local postural muscles of the lumbar spine. They are length transducers or position sensors of a spinal segment, by way of their rich composition of muscle spindles. The multifidi pass along 2 or 3 spinal levels. They are theorized to work as segmental stabilizers rather than producing gross trunk motion, since they do not have a large moment arm. Researchers have found atrophy of the multifidi in people with low-back pain.

Answer 83

(a) Modifying the activity that is causing the repetitive overload is necessary if treatment is to succeed. Treatment success is measured by reduced pain and return to function, in this case to an occupation that requires repetitive overhead activities. The healthcare provider must communicate with the employer to best understand the specific musculoskeletal job requirements and modify these activities during the recovery phase of rehabilitation. Taking the worker off work entirely engages disability behavior and may not serve a specific recovery function. Not making a work modification is also a mistake, because the overload to the upper quadrant will continue and that will impair rehabilitation.

Answer 84

(d) Epidural steroid injections (ESIs) are indicated for radicular rather than referred pain. While anectodotal descriptions of ESIs used for neurogenic claudication may present them as helpful, the efficacy of ESIs have yet to be established for this condition.

Answer 85

(d) Once an individual becomes board certified in the specialty of physical medicine and rehabilitation, he/she must continue to fulfill certain requirements in order to maintain their certification status. Publication of 1 article in a peer-reviewed journal every 10 years is not a requirement for maintenance of certification. All of the other options listed are required.

Answer 86

(d) Patients instructed to limit early morning flexion have shown reduced pain intensity, compared to controls. This finding is related to disc hydration that occurs during sleep. No studies have shown that all workers wearing lumbar corsets have reduction in injuries. Athletic activities outside of the work environment often help improve endurance, which is protective for low back pain. Sedentary

Answer 87

(c) In this patient with known herniated disc now with urinary incontinence the primary concern should be to evaluate for cauda equina syndrome. The MRI is necessary to determine if an extruded disc is causing the current symptoms. Surgery in the acute setting is essential to achieve neurologic recovery

Answer 88

(d) No specific lumbar spine strengthening program has been shown to prevent low back pain in the work place. Spine strength is not a predictor of reduced risk for onset of low back pain.

Answer 89

D | Descending stairs requires 110° knee flexion.

Answer 90

(b) The risk of intraneural injection is real, but in experienced hands this injection is safe. Anesthetics mixed with the corticosteroid can mask the pain associated with needle placement into the nerve and should not be used. Numbness is anticipated with this injection without use of anesthetics, and helps to confirm proper placement. Local tenderness and hematomas are common with this injection and do not represent a complication. Persistent or worsening pain or swelling lasting more than 48 hours are signs of nerve injection or neurotoxic injury

Answer 91

(a) Nonorganic physical signs in patients with low back pain was described by Gordon Waddell. His original paper describes the physical signs that correlated with psychological data and were distinguishable from standard clinical signs of physical pathology. Waddell’s signs should be used to determine if nonorganic issues may be contributing to the patient’s complaints. Not all patients with nonorganic physical signs are malingerers or require psychiatric evaluation. The signs are not indicators for therapeutic modalities.

Answer 92

b Work-hardening programs are most effective when essential job duties are simulated. Bonfilglio RP, LaBan MM, Taylor RS. Industrial rehabilitation medicine managemen

Answer 93

a The least water-soluble compound will have the longest half-life. Braddom RL, editor. Physical medicine and rehabilitatio

Answer 94

C (c) No imaging is necessary in this patient with no known medical risk factors. The low back pain can be managed initially without the expense of CT or MRI. Recommendations for obtaining x-rays for the patient with a first episode of low back pain for less than 7 weeks include: over age 65, history of osteoporosis, history of urinary tract dysfunction, persistent sensory loss, progressive pain despite treatment, night or rest pain, fever, chills, unexplained weight loss, history of trauma or repetitive overuse, recurrent pain with no x-rays in 2 years, previous surgery, or fracture.

Answer 95

(a) A magnetic resonance imaging (MRI) provides the most accurate and complete information during the initial assessment for lumbar disc pathology, stenosis, infection, tumor, or trauma. Because many patients who present with low back pain and lumbar radicular pain may have spontaneous improvement of symptoms, it is recommended to wait for approximately 7 weeks without improvement and with proper care before performing an MRI.

Answer 96

(d) External rotation and abduction increase risk of dislocation because of anterior instability.

Answer 97

(b) A functional capacity evaluation will determine if the worker can return to his work duties on a safe and dependable basis. A painter’s work responsibilities require significant repetitive upper extremity activities not necessarily challenged with therapeutic exercise. Although aerobic conditioning is important, simulation of work duties should be done before this patient returns to work.

Answer 98

(d) Patients with history of previous hip replacement and posterior approach are at greater risk for postoperative dislocation. Posterior surgical approach has a higher risk of dislocation than anterior approach.

Answer 99

(c) The functional capacity evaluation indicated he can lift up to 50 pounds safely but his job requires that he lift 75 pounds so further intervention before return to work is indicated. A work hardening program is an interdisciplinary program that will incorporate work-specific activities and conditioning to transition the worker from acute care to a safe return to work. Although gaining knee flexion may be beneficial, it is not the major focus for return to work.

Answer 100

(a) Loss of worker identity caused by depression and anxiety is associated with poor motivation during the rehabilitation process. Other associated factors include deteriorating financial status, change in family roles, loss of control regarding the future, and deteriorating employer relationships.

Answer 101

(c) This worker has sustained a significant injury and may likely have torn his anterior cruciate ligament. The most appropriate recommendations in the acute setting include ice, compression, elevation, and x-ray to rule out fracture. Work restrictions should allow the worker to remain with restricted weight bearing until improvement is noted or further testing is completed.

Answer 102

a) Financial barriers that are disincentives for return to work include that the worker receives a portion of his/her salary while not working and that the worker has potential for monetary gain through legal settlement.

Answer 103

(d) Reduced (not excessive) hip rotation, along with excessive supination or pronation of the foot, forefoot varus or valgus, and leg length inequality have all been implicated in those at risk for recurrent stress fractures.

Answer 104

(c) Aseptic loosening caused by polyethylene wear is is the most common reason for hip arthroplasty revision surgery.

Answer 105

(b) Several job characteristics are associated with delayed return to work. These characteristics include: low pay, low c

Answer 106

(b) Pain that awakens the worker at night may indicate a serious etiology including tumor or infection. Radicular pain, paresthesias, and weakness with fatigue may also present with serious as well as common causes such as disc herniations and spinal stenosis. The latter may help direct the diagnosis. However, pain worse at night should alert the treating physician to evaluate more serious etiology without delay.

Answer 107

(c) Several studies have found a strong relationship between attorney involvement and not returning to work. In workman’s compensation cases involving lawyers, 73% of injured workers did not return to work. In cases without lawyer involvement, 32% did not return to work. These factors are important for the physician to know initially to best understand the psychosocial barriers involved in treating the injured worker.

Answer 108

(d) Good treatment outcome is associated with a history of personal empathetic communication between the supervisor and injured employee. No data show improved outcomes in injured workers who have recently received a raise or have worked for the employer more than 5 years. Poor outcomes have been found in injured workers who have received a poor evaluation within the 6 months preceding the injury. The level of position within the workplace is irrelevant in a worker’s compensation outcome.

Answer 109

(c) Jobs that require lifting and material handling place the worker at increased risk for low back injury. Lifting frequency, load movement, trunk twisting and trunk sagittal angle predict medium and high-risk occupational low back pain. No risk correlation has been found for length of time sitting or standing. Although falls in the work place put the worker at risk for low back injury, the repetitive motion involved in lifting and material handling is thought to cause low back pain more frequently.

Answer 110

(c) This patient has suffered a fairly significant ankle inversion sprain. The lateral collateral ligaments are injured 85% of the time with this type of injury. This patient should be placed in an air stirrup for 2 weeks, weight bearing as tolerated, using crutches as needed. A cast or cast boot is acceptable for 2 weeks but usually is not required. Contrast baths are not indicated before 48 hours following injury.

Answer 111

(b) A functional capacity evaluation (FCE) is an assessment of a worker’s ability to perform workrelated activities. A functional capacity examination can be used to determine if a worker might benefit from work hardening or work conditioning, to determine whether a worker can return to his/her job, to determine if work restrictions are recommended or if job modifications are needed, and to document the worker’s activity capability. No absolute time line exists. An FCE can be used in the subacute, or maintenance phase of treatment. An FCE does not determine validity of injury but can reveal the effort a person expends to perform a task.

Answer 112

(b) The rhomboid major elevates, retracts and causes medial (downward) rotation of the scapula, but it does not depress the scapula. All the other muscles depress the scapula

Answer 113

(c) Intra-articular corticosteroid injections have enough systemic absorption that suppression of the adrenal hypopituitary axis may be seen with repeated injections. More localized deleterious effects include skin depigmentation, soft tissue atrophy, steroid arthropathy, postinjection flare, and tendon rupture.

Answer 114

(d) Work conditioning is the physical conditioning portion of work hardening. It has been referred to as an aerobic training program for patients with less complex and more chronic conditions. Often these patients are not being retrained to return to a specific job. In a work hardening program the injured worker is gradually strengthened and reconditioned to the functional capacity level required to perform a given job. Work hardening has also been referred to as work simulation, work readiness training, and work rehabilitation.

Answer 115

(d) This scenario is most likely retrocalcaneal bursitis. This condition is seen in middle aged to elderly persons, and may occur with overuse. A limp is common and pain is usually worse with first activity after rest. Swelling and local tenderness may be seen, and a “pump bump” may be present. This bump is a prominence created by inflammation associated with shoe wear. The local swelling is due to inflammation of the retrocalcaneal bursa. An acute Achilles tendon rupture is associated with a positive Thompson test, which consists of compressing the calf and causing the foot to plantarflex. If the tendon is ruptured, the foot will not plantarflex. The pain is not located in the bottom of the foot as would be seen with plantar fasciitis. Posterior calcaneal nerve entrapment would not cause swelling, nor would it be warm to touch.

Answer 116

b) The Waddell signs are nonorganic physical signs that are used for patients with low back pain. They are a simple screen that can be used to help identify patients who may require a more detailed psychological assessment. Three or more positive signs are a clinically significant finding. The signs include simulation, distraction, overreaction, regional disturbances and either superficial or nonanatomic tenderness

Answer 117

(d) Lumbar supports do not prophylactically prevent low back injuries or prevent recurrence of low back pain. One study showed a decrease in lost time at work when lumbar supports were utilized with a back injury educational program. No improvement in lifting capacity has been found with the use of bracing. Workers who use lumbar supports use them as a proprioceptive reminder to use proper mechanics with lifting and other work-related activities

Answer 118

(d) Following anterior shoulder dislocation, the most common neural injury is damage to the axillary nerve. Gentle pendular exercises (Codman exercises) are not allowed until weeks 2–3 postinjury. Early postreduction rehabilitation should avoid active external rotation past 45° for at least 3 weeks and usually up to 6 weeks. External rotation with abduction is not allowed until 8 weeks postinjury.

Answer 119

(a) The information provided by functional capacity evaluations (FCE) includes the worker’s capability to return to full or restricted duty, the need for work hardening, or the need for work conditioning. It can also define discrepancies between subjective complaints and objective findings. The FCE can also help determine if the worker has reached maximal medical improvement. Although general aerobic condition may be assessed, the FCE does not include formal aerobic capacity testing. The psychological assessment is important during the FCE but formal psychiatric diagnosis is not made during an FCE. Unfortunately, functional capacity evaluations are not standardized and cannot be compared. Such standardization has been proposed but currently does not exist.

Answer 120

(a) Occult cervical fractures are most often seen at the C1 and C7 levels. By adding computed tomography (CT) scanning to the evaluation of trauma patients, a significant number of occult cervical fractures can be diagnosed. Of spinal fractures, 5%–30% are multiple and may appear at noncontiguous levels. Thus, radiographic evaluation of the entire spinal axis is necessary whenever injury at 1 region of the spine is detected.

Answer 121

(d) Cumulative trauma disorders (CTDs) develop as a result of repetitive microtrauma to tissue in the setting of poor ergonomics. Any worker who performs a task requiring repetitive loading or motion is at risk. This includes keyboard operators but is not exclusive to them. The most common occupational hazard has not been determined. Often, implementing ergonomic recommendations can help reduce CTDs.

Answer 122

D | The Codman pendulum exercises are recommended to treat adhesive capsulitis (frozen shoulder).

Answer 123

(c) The first step would be to make sure the patient is neurovascularly intact. The next step would be to obtain bilateral shoulder films with the patient holding and not holding 10-pound weights to accentuate any laxity present. Bilateral films are necessary as the patient may have lax ligaments in both shoulders. A scapular Y view is used for shoulder dislocations. An axillary radiograph is used for shoulder dislocations and will also evaluate the glenoid.

Answer 124

(b) During civil litigation, the physiatrist may be asked to comment on causality of an injury. The determination that 1 condition caused another condition should be determined on a “reasonable degree of medical certainty.” In this setting “probable” indicates that the physician believes there is a greater than 50% chance that condition A caused condition B. The term “possible” indicates that the physician believes there is a less than 50% chance that 1 event caused another condition.

Answer 125

(c) This patient has lateral epicondylitis or “tennis elbow,” a condition brought on by repetitive flexionextension or pronation-supination of the forearm. The pain will be increased by resisted wrist extension with the elbow at 180°. The reflexes will not be affected, nor will atrophy be noted. This is not a neurologic condition, but a myofascial one.

Answer 126

(c) Maximum medical improvement is defined as the time when no improvement is likely to further be achieved after a work-related injury. This definition is exclusive of the amount of time spent in physical therapy, the worker’s subjective complaints, or whether or not the worker is able to return to his/her previous job. A worker may reach maximum medical improvement and continue to have impairments that prevent return to his/her former job.

Answer 127

(a) A worker may have 2 financial disincentives to return to work. First, employees usually receive a portion of their salary while unable to work, if the injury occurred while the worker was performing his/her job. Second, the worker may not want to return to work if monetary gain is being sought through pending litigation.

Answer 128

(a) Factors associated with permanent institutionalization after hip fractures are age greater than 80 years, lack of involvement by family members, insufficient physical therapy at a skilled nursing facility, and pre-existing dementia.

Answer 129

(b) Plantar fasciitis is classically most painful upon arising first thing in the morning, and is aggravated by overuse or change in footwear. An S1 radiculopathy often presents with numbness and tingling and has associated reflex changes and possibly weakness in the plantar flexors. Tarsal tunnel syndrome is caused by compression of the posterior tibial nerve inferior to the medial malleolus. A Morton’s neuroma causes plantar pain in the forefoot and is aggravated by wearing tight, restrictive shoes.

Answer 130

(b) Alhough, house painters may be at risk for injury, machine operators, truck drivers, and nurses have the greatest incidence in compensated low back pain injuries

Answer 131

(b) This patient has a grade 3 acromioclavicular separation. Grade 1 or 2 separations would not have a visible deformity and would require weighted bilateral shoulder films. A grade 3 separation may have good results with conservative care, but a young manual laborer should be referred for surgical repair to ensure good results. Grade 4-6 separations should be surgically repaired. Patients should only be placed in a sling for a few days until the pain subsides. This will decrease the possibility of losing shoulder range of motion. The shoulder should be given a few days rest, and physical therapy referral is not appropriate at this time. A corticosteroid injection is not the treatment of choice and will not repair the separation.

Answer 132

(d) Workers who participated in a cardiovascular training program were compared to a control group. Those in the training program reported 51% fewer sick days than controls despite no change in their maximum oxygen consumption (VO2max).

Answer 133

c) Nonsteroidal medications, education in lumbar positions of comfort, and physical therapy constitute the standard of care in conservative management of lumbar radiculopathy. Ten days of bedrest is no longer recommended, since the effects of immobilization can further impair recovery. Limited or relative rest can help relieve repetitive trauma while acute pain management interventions are underway. A lumbar corset may help with pain in the first few days but immediate return to work while relying on a lumbar corset does aid in recovery. Jackhammer operators are exposed to a great deal of vibration, which increases an individual’s risk of disc injury. When a disc injury is suspected in this population, return to a modified work description avoiding lifting, bending, twisting, and vibration should be recommended. Lumbar discography should be reserved for individuals

Answer 134

(c) Spondylolisthesis in the lumbar spine is a common finding, occurring 70% of the time at L5-S1 and 25% at L4-5. It is caused by a defect or fracture in the pars interarticularis and is graded 0-4 on the basis of the amount of slippage of one body on the other. It may indeed lead to spinal stenosis and compromise of the cauda equina. A spinal orthosis will not be effective in stabilizing this defect but can be useful in reducing lumbar lordosis, decreasing pain, and reducing gravitational forces on the slippage.

Answer 135

(a) A functional capacity evaluation (FCE) is a comprehensive test with some objective data that tests a person’s ability to perform work-related tasks. An FCE helps determine what the worker can do at work on a safe and dependable basis. Testing is usually performed work after the initial rehabilitation program has been completed.

Answer 136

c) This patient has lateral epicondylitis or “tennis elbow,” a condition brought on by repetitive flexionextension or pronation-supination of the forearm. The pain will be increased by resisted wrist extension with the elbow at 180°. The reflexes will not be affected, nor will atrophy be noted. This is not a neurologic condition, but a myofascial one. No audible click will be heard. This might occur if the radial head is subluxing, but not in lateral epicondylitis.

Answer 137

(a) Arthritis and other rheumatic conditions are the leading cause of disability in the United States, imparting an aggregate cost of about 1.1% of the gross national product.

Answer 138

(a) Appropriate management for acute knee injuries include, ice, elevation, non-steroidal antiinflammatory drugs, protection, weight bearing as tolerated and activity modification. X-rays initially rule out bony injury. magnetic resonance imaging should be reserved for cases where the diagnosis is in question or a surgical procedure is planned. A careful examination to fully exclude ligament or cartilage injury cannot be completed until the effusion has resolved enough to allow for an appropriate examination. Therefore, in the case of an acute knee injury with effusion, the patient should be reexamined within a 1- to 2-week interval in order to narrow the diagnosis and progress treatment.

Answer 139

(b) Suspicion of a compartment syndrome should lead the physician to get pressure measurements immediately, since delays may result in permanent muscle or nerve damage. Usual pressures are less than 30mmHg. Pressures from 30 to 50mmHg are equivocal, but pressures greater than 50mmHg constitute a surgical emergency. The leg should NOT be elevated, because this will lower arterial perfusion pressure and will further compromise vascular supply. An external circumferential force will increase pressure. An x-ray and bone scan are not indicated in this patient.

Answer 140

(b) Impairment is defined as an alteration of a person’s health status, a deviation from normal in a body part or any organ system (any loss or abnormality of psychologic, physiologic, or anatomic structure or function).

Answer 141

(d) Patients with diabetes mellitus are at risk for serious infection and for systemic effects of absorbed corticosteroids. Injection into an infected joint, tendon or bursa is contraindicated. Multiple injections should not be performed unless clear improvement has been demonstrated. More than 3 steroid injections are rarely indicated. There is a risk of tendon rupture in patients who return to usual activity too rapidly. Plantar fasciitis and lateral epicondylitis respond well to steroid injection.

Answer 142

(d) The patient’s symptoms and the physical exam findings are consistent with an ulnar neuropathy at the elbow.

Answer 143

(d) Postural changes can produce muscle imbalances that can cause pain syndromes. Changing posture and re-education of muscles through appropriate strengthening programs is appropriate management. The ergonomics at her work site have a lot to do with her pain complaints. Time away from work may temporarily reduce symptoms but will likely have no long-term effect. The use of pain management interventions such as ice and anti-inflammatory medications is appropriate but should not be expected to correct the long term problem.

Answer 144

(b) This patient most likely has suffered a grade I or II ulnar collateral ligament injury. This injury is called a “gamekeeper’s or skier’s thumb.” A complete (grade III) tear is diagnosed by a difference of 15° or more of lateral laxity compared to the uninjured side or an absolute laxity of 35°. This is not a grade III injury, and will likely heal with nonsurgical treatment consisting of immobilization in a thumb spica cast or splint for 2 to 4 weeks. This patient may be returned to ski with a thumb spica or cast in place. A steroid injection is not indicated. Ice may help with the pain and swelling, but immobilization is required for this patient. Nonsteroidal anti-inflammatory drugs may be given for pain control.

Answer 145

(b) If job requirements cannot be modified, an injured worker may not be able to return to his/her job. The employee’s age or the length of time that has elapsed since the injury does not by definition exclude the worker from returning to work. Whether the worker was responsible for the injury does not exclude him/her from returning to work.

Answer 146

c) Repetitive injuries from keyboard occupations are well recognized and require active rehabilitation for restorative function. Eccentric exercises will increase repetitive stress to the injured site and should not be used in the initial treatment recommendations. The prescription of biweekly steroid injections is excessive and may promote musculotendon atrophy and susceptibility to further injury. Moving the mouse further away from the keyboard will likely increase symptoms and dysfunctions. Wrist splints can be used during the initial treatment program to provide relative rest, reduce inflammation, and to provide comfort.

Answer 147

(b) The Gaenslen sign is a test to determine sacroiliac pathology. This test is performed by having the patient lie supine. One buttock is extended over the table’s edge while the other remains on the table. The ipsilateral leg is allowed to drop below the edge of the table, with the other leg remaining in a flexed position. Pain in the area of the sacroiliac joint on the side of the extended leg represents a positive test. The Thomas test is a test to measure hip flexion contracture. The Ober test is used to identify contracture of the iliotibial band or the tensor fascia lata. The Lasegue sign is the straight leg test, a nerve root stretch test to identify radicular pain.

Answer 148

(d) This patient describes classic neurogenic claudication due to spinal stenosis. He has a non-focal examination and should be managed conservatively initially with flexion based exercises. Epidural steroid injections may be warranted if the patient does not respond to initial therapeutic exercise.

Answer 149

(a) The breaststroke has an associated “whip kick” which puts stress on the medial knee. For proper propulsion, the knee must be in a significant valgus position during leg extension. This can lead to overuse of the adductors and the quadriceps and a condition known as “breaststroker’s knee.” Individuals who have patellar tracking problems or a high Q angle (greater than 18° in men) with the knee extended will be prone to patellofemoral pain. You should prescribe that this young man work on stretching and strengthening of his adductors and quadriceps. The quadriceps strengthening should focus on the last 30° of knee extension, which selectively strengthens the vastus medialis. This patient has negative tests for internal derangement, such as anterior cruciate ligament tear or meniscus tear. No laxity was noted, and referral for arthroscopy is not indicated.

Answer 150

(b) Anterior knee pain syndrome is associated with atrophy of the quadriceps, a large (more than 15°) Q angle, tight lateral thigh structures, positive posterior drawer, and lateral patellar tilt. McConnell J, Fulkerson J. The knee:patellofemoral and soft tissue injuries. In: Zachazewski JE, editor.

Answer 151

(b) Anesthetics mixed with corticosteroid can mask the pain associated with needle placement into the nerve and should not be used. The risk of intraneural injection is real, but in experienced hands this injection is safe. Numbness is anticipated with this injection without use of anesthetics, and helps to confirm proper placement. Local tenderness and hematomas are common with this injection and do not represent a complication. Persistent or worsening pain, or swelling lasting more than 48 hours, are signs of nerve injection or neurotoxic injury. Severe carpal tunnel syndrome with axonal loss is not reversed with this procedure.

Answer 152

(a) The amount of lost time is a major determinant of return to the work place. Although more extensive injuries may more easily deter the employee from returning to work, the extent or type of injury has not been found to be the major determinant in all worker’s compensation cases. Neither the type of job or the type of treatment required, such as surgery, are major determinants of successful return to work. Several studies have shown that the longer the worker is out of work related to the injury, the more unlikely it is that he/she will return to work successfully.

Answer 153

(d) This patient's symptoms are most consistent with plantar fasciitis. Classically, this syndrome is most painful first thing in the morning upon arising and is aggravated by overuse or change in footwear. Stretching the plantar fascia, often before getting out of bed in the morning, and use of a heel cup or medial longitudinal arch orthotic are the initial treatments for this condition. Corticosteroid injection may be indicated at the insertion of the fascia into the plantar aspect of the calcaneus; however, this is usually not required on a repeated basis. Relative rest from the aggravating activity may be useful, but bed rest is not indicated. A walking cast would not allow stretch of the plantar fascia.

Answer 154

(d) The difficulty in using proper posture and body mechanics and the forces required for pulling patients up in bed are believed to be the reasons that this task most often causes back pain among nurses.

Answer 155

(c) Functional recovery programs should focus on restoring functional ability, including return to work

Answer 156

(d) The onset and length of symptomatic relief after steroid injection are related to the preparation used. Dexamethasone sodium phosphate has an intermediate solubility and a fairly long biologic half-life (36-72 hours). Methylprednisolone and triamcinolone have biologic half-lives of 12-26 hours. Hydrocortisone phosphate is not recommended for intraarticular use.

Answer 157

(c) Other than a history of previous back injury, psychologic factors were found to be more important than physical factors in predicting injuries.

Answer 158

(d) Cervical spine degenerative changes in males over 60 are commonly seen in asymptomatic patients.

Answer 159

(c) Patients treated with continuous passive motion obtain greater early knee flexion (and thus experience fewer hospital days and manipulations). These devices might exacerbate flexion contractures and extension lags. Their use has no effect on rates of infection or deep vein thrombosis.

Answer 160

(a) Prognostic factors associated with good surgical outcome following surgical decompression include pronounced constriction of the spinal canal (<6mm anteroposterior diameter), prominent leg rather than back symptoms, symptom duration of less than 4 years, and absence of concomitant disease affecting walking ability.

Answer 161

(d) Upper limb cumulative trauma disorders, especially those involving the hand and wrist, most often result from repetitive forceful exertions.

Answer 162

(a) These symptoms are consistent with stenosing tenosynovitis, commonly referred to as de Quervain's tenosynovitis. The patient should have tenderness over the common tendon sheath for the abductor pollicis longus and the extensor pollicis brevis. Finkelstein's test is confirmative of this diagnosis. It consists of flexing the thumb under cupped fingers and flexing the wrist in an ulnar direction, stretching the thumb tendons. This condition usually responds to conservative management of steroid injection and placement in a splint. Severe refractory cases may require surgical release, but not until at least a month of conservative therapy has been tried.

Answer 163

(d) Impairment ratings are based on physical examination findings such as joint limitations and muscle atrophy and function loss.

Answer 164

(b) This condition can be treated with the use of ice after activity and ultrasound to the inflamed area at the lateral epicondyle. Steroid and local anesthetic injection into the tendinous insertion can be useful for temporary relief. A lateral epicondyle counterforce brace ("tennis elbow" band) can provide relative rest for the inflamed extensor tendons. Exercise using light weights to strengthen the wrist extensors is useful. This should be done with the elbow flexed and in full extension. If surgical release is indicated, lateral extensor release is considered to be the procedure of choice.

Answer 165

(c) Of the choices provided, electromyogram/nerve conduction velocity testing would provide the most objective documentation of radiculopathy. Magnetic resonance imaging is an anatomic test. Straight leg raising and findings of manual strength of 4/5 provide more subjective information.

Answer 166

(c) This patient has been performing excessive, unaccustomed, intense exercise. He is at risk for a compartment syndrome, which occurs when perfusion of muscle and nerve tissues decreases to a level inadequate to sustain the viability of the tissues. The intracompartmental pressure increases and produces venous obstruction. This in turn increases the intracompartmental pressures even more, and necrosis of muscle and nerve tissue may ensue in as little as 4-8 hours.

Answer 167

(c) Magnetic resonance imaging can identify a large percentage of tears on the rotator cuff of asymptomatic persons. These tears may be partial or complete. The overall prevalence of asymptomatic tears of the rotator cuff in all groups was 34%. Fifty-four percent of persons over age 60 had a tear of the rotator cuff (28% full thickness, 26% partial thickness).

Answer 168

(d) Rupture of the long head of the biceps most often occurs in persons over 40 years of age with longstanding shoulder pain due to rotator cuff pathology. It may result in approximately 10% loss of supination in turning the forearm. It does result in a cosmetic deformity with a bulge in the lower arm, but most patients regain full range of motion and normal elbow flexion strength with a conservative therapy program. Usually only heavy laborers under age 40 need surgical intervention to provide the extra strength for lifting.

Answer 169

(b) When expected improvement on functional gains has occurred, a patient has reached maximum medical improvement.

Answer 170

(d) Intradiscal pressure is lowest when a person lies prone and is much higher when standing, running, sitting, or bending.