Musculoskeletal Flashcards
When applying cryotherapy in the treatment of musculoskeletal disorders, which of the following
events is NOT a contraindication to its use?
(a) Paroxysmal cold hemoglobinuria
(b) Impaired sensation
(c) Arterial insufficiency
(d) Spasticity
Answer : (d)
Commentary: Contraindications for the use of cryotherapy include paroxysmal cold hemoglobinuria, impaired sensation and arterial insufficiency. Other contraindications are cold hypersensitivity, cryopathies, cold intolerance, cryotherapy-induced neurapraxia, and Raynaud disease. Spasticity is one of the general uses of cryotherapy in addition to musculoskeletal injuries and pain syndromes, postoperative conditions and emergency treatment of minor burns.
Reference: Weber DC, Hoppe KM. Physical agent modalities. In: Braddom RL, editor. Physical
medicine and rehabilitation. 4th ed. Philadelphia: Elsevier-Saunders; 2011. p 458.
Imaged with musculoskeletal ultrasound, normal tendon structure looks
a) hypoechoic, with hyperechoic septa.
b) hypoechoic , with fascicular pattern.
c) hyperechoic, with fibrillar echotexture.
d) hyperechoic, with posterior acoustic shadowing.
Answer:(c)
Commentary: Musculoskeletal ultrasound is an imaging modality that is able to identify and characterize various soft tissue structures. Normal tendons appear as hyperechoic(bright echo) structures with fibrillar or fiber-like pattern. Normal muscle appears as a hypoechoic(low echo) structure with hyperechoic septa. Bone appears as a very hyperechoic structure with posterior acoustic shadowing. Posterior acoustic shadowing is an artifact that refers to the anechoic
region(no echo) deep to the bone surface.
Reference: Jacobson J. Fundamentals of musculoskeletal ultrasound. Philadelphia: Saunders-
Elsevier; 2007. p 4.
- The third occipital nerve innervates which structure?
(a) C2-3 zygapophysial joint
(b) C2-3 intervertebral disc
(c) C3-4 zygapophysial joint
(d) C3-4 intervertebral disc
Answer:(a)
Commentary: The third occipital nerve(TON) innervates the C2-3 zygapophysial joint. The C3-4 zyagpophysial joint is innervated by the C3 and C4 medial branches. Innervation to the cervical discs involves the sinuvertebral nerve, vertebral nerve and sympathetic trunk.
Reference: Bogduk N. Practical guidelines: Spinal diagnostic and treatment procedures. San
Francisco: International Spine Intervention Society; 2004. p 126.
A 20-year-old female soccer player presents to your office with chronic low back pain. Her computed tomography(CT) scan is seen in figure 1. What abnormality is seen on these CT
images?
(a) Herniated disc
(b) Facet degeneration
(c) Pars interarticularis fracture
(d) Tarlov cyst
Answer: (c)
Commentary: Spondylolysis is a defect in the pars interarticularis. These CT images(sagittal and axial) show evidence of an L5 pars interarticularis fracture. Spondylolysis is common in the athletic population, particularly among athletes who perform repetitive flexion-extension Herniated discs and Tarlov cysts are not seen in these images and are more readily evaluated on MRI. Facet degeneration is often diagnosed by CT scan but is not seen on these images.
Reference: Spinelli J, Rainville J. Lumbar spondylolysis and spondylolisthesis. In: Frontera WR, Silver JK, Rizzo TD, editors. Essentials of physical medicine and rehabilitation. 2nd ed. Philadelphia: Saunders-Elsevier; 2008. p 253-258.
A high school athlete sustains a suspected concussion during a football game. The player should be
(a) removed from play, evaluated and, if asymptomatic, be allowed to return to the game on the same day.
(b) able to continue playing if he or she is able to perform.
(c) immediately transported to the local emergency department for evaluation.
(d) evaluated on the sideline and should not return to play that same day.
Answer:(d)
Commentary: When an athlete sustains a concussion in a game or during practice, he or she should not return to play on the same day of the injury. The athlete should be removed from play and be evaluated on the sidelines. Standard emergency medical management principles should be
applied when appropriate; serial monitoring should be performed and the athlete’s disposition should be determined. The athlete should follow up with an appropriate healthcare provider before he or she is returned to play.
Reference: McCrory P, Meeuwisse W, Johnston K, Dvorak J, Aubry M, Molloy M, et al. Consensus statement on concussion in sport. 3rd international conference on concussion in sport; November 2008; Zurich, Switzerland; Clin J Sport Med 2009;19(3):185-195.
A 22-year-old runner presents with acute onset of distal calf pain. She is diagnosed with Achilles
tendinitis and is referred to physical therapy. Which therapeutic modality is the LEAST
beneficial in treating an overuse injury of this sort?
(a) Therapeutic ultrasound
(b) Iontophoresis
(c) Ice massage
(d) Neuromuscular electrical stimulation
Answer :(d)
Commentary: With acute overuse injuries, modalities such as ultrasound, iontophoresis, and ice massage may decrease pain and facilitate rehabilitation. Electrical stimulation with recruitment of muscle fibers may be contraindicated in treating acute overuse injuries.
Reference: Stretanski MF. Achilles tendinitis. Frontera WR, Silver JK, Rizzo TD, editors. In: Essentials of physical medicine and rehabilitation. 2nd ed. Philadelphia: Saunders-Elsevier;
2008. p 407-10.
A 55-year-old overweight man presents to clinic with complaints of numbness in his left leg. He reports that he does not exercise and has an office job. He is diagnosed with meralgia paresthetica. Which of the following is consistent with this diagnosis?
a) Peroneal motor F-wave study is abnormal.
b) Sensory nerve conduction studies reveal decreased amplitude on the affected side.
c) Electromyography findings show denervation in the vastus lateralis.
d) Exam reveals decreased sensation in the medial thigh.
Answer: (b)
Commentary:
Meralgia paresthetica presents with paresthesias in the lateral thigh. Sensory nerve conduction studies of the lateral femoral cutaneous nerve may show a drop in the sensory nerve action potential (SNAP) amplitude on the affected side compared to the asymptomatic, contralateral study. Symptoms are confined to below the inguinal ligament and above the knee. Peroneal motor nerve conduction studies and F waves should be normal and needle electromyography should not show acute or chronic axonal motor loss, because the lateral femoral cutaneous nerve is purely sensory.
Reference: Craig EJ, Clinchot DM. Lateral femoral cutaneous neuropathy. In: Frontera WR,
Silver JK, Rizzo TD, editors. Essentials of physical medicine and rehabilitation. 2nd ed.
Philadelphia: Saunders-Elsevier; 2008. p 283-9.
In athletes, the etiology of thoracic outlet syndrome is most likely due to
a) clavicle fractures.
b) anatomic variations.
c) repetitive overhead activity.
d) hyperextension injuries of the neck.
Answer: (c)
Commentary: The most common etiology of thoracic outlet syndrome(TOS) in sports is likely related to repetitive overhead motion. Hypertrophy of sport-specific musculature may predispose to TOS. The role of anatomic variations is uncertain in TOS and may be common in patients with and without this disorder. Fractures of the clavicle and hyperextension injuries of the neck may be
causes of TOS in the setting of trauma.
Reference: Laker S, Sullivan WJ, Whitehill TA. Thoracic outlet syndrome. In: Akuthota V, Herring SA, editors. Nerve and vascular injuries in sports medicine. New York: Springer; 2009. p 113-26.
A 22-year-old man who is right hand-dominant presents to your office with acute onset of right shoulder pain. He is a former college tennis player without a previous history of shoulder pathology. Which test would you perform to evaluate for pathology involving the labrum of the
shoulder?
a) Hawkin test
b) Bowstring sign
c) O’Brien active compression test
d) Apley scratch test
Answer: (c)
Commentary: The O’Brien active compression test is used to evaluate and differentiate labral tears (superior labrum anterior posterior – SLAP tears) from acromioclavicular joint pathology and pain. The Hawkin test is an impingement test of the shoulder and is not intended to evaluate tears of glenoid labrum. The bowstring sign is used to identify lumbar nerve root compression. The Apley scratch test is used to assess the range of motion of the shoulder.
Reference: Bowen J, Malanga GA, Pappoe T, McFarland E. Physical examination of the shoulder. In: Malanga GA, Nadler SF, editors. Musculoskeletal physical examination. Philadelphia: Elsevier-Mosby; 2006. p 59-118.
A 30-year-old woman began running 2 weeks ago. She runs 4 miles a day, twice a week. She began experiencing bilateral lower leg pain. On physical examination, she reports diffuse pain along the medial tibia at the start of her run with improvement during the run. The most likely
diagnosis is
a) stress fracture.
b) medial tibial stress syndrome.
c) anterior tibialis tendinitis.
d) tarsal tunnel syndrome.
Answer: (b)
Commentary: This woman presents with symptoms most consistent with medial tibial stress syndrome (MTSS) or what has been termed “shin splints.”Pain from MTSS occurs along the lower third of the posteromedial border of the tibia. A stress fracture is unlikely in this low mileage runner who has had only 2 weeks of running activity. Stress fractures generally have a focal area of pain and are not relieved with further running. Anterior tibialis tendinitis presents
with anterolateral pain along the dorsal aspect of the ankle. Tarsal tunnel syndrome is associated
with numbness and tingling in the foot.
Reference: Hoch AZ, Pepper M, Akuthota V. Stress fractures and knee injuries in runners. In: Akuthota V, Harrast MA, Kraft GH, editors. Physical medicine and rehabilitation clinics of North America. Philadelphia: Saunders; 2005. p 749-77.
