OCS McGee

Question 1

1. What is the most common location associated with Gout?
   a. 1st MCP joint
   b. Patellofemoral joint
   c. 5th TMT joint
   d. 1st MTP joint

Answer 1

d. Correct

Question 2

A 22 year old sedentary male presents to your clinic with an insidious onset of low back pain for three weeks. The patient reports his pain is increased with rest and decreased with activity. The pain is localized to his lower lumbar and upper SIJ region. Radiographs have not been taken and NSAID’s have helped reduce the pain.

1. Based on the above information, the patient’s signs and symptoms are most closely associated with
   a. Ankylosing Spondylitis
   b. Herniated Nucleus Pulposus
   c. Mechanical low back pain
   d. Spondylolisthesis

Answer 2

a. Correct
b. Incorrect. This is typically associated with a flexion + rotation mechanism with symptoms extending distal into the buttocks and lower extremities
c. Incorrect. This is typically associated with trauma or microtrauma (not insidious onset) and is typified by pain decreased with rest and increased with activity
d. Incorrect. This is typically associated with trauma or overuse from gymnastics or activities involving extremes of lumbar extension

Question 3

A 22 year old sedentary male presents to your clinic with an insidious onset of low back pain for three weeks. The patient reports his pain is increased with rest and decreased with activity. The pain is localized to his lower lumbar and upper SIJ region. Radiographs have not been taken and NSAID’s have helped reduce the pain.

2. This patient would most likely benefit from which of the following physical therapy interventions?
   a. Bedrest for 48 hours and education about staying as active as possible and continuing to take his NSAID’s
   b. Flexion exercises and education about sleeping with a pillow under his knees
   c. Extension exercises and education about discontinuing usage of a pillow under his head while sleeping
   d. Mechanical lumbar traction

Answer 3

a. Incorrect. This is standard medical management for mechanical low back pain
b. Incorrect. This is a typical intervention for spondylolisthesis as it decreases the extension moments at the lower lumbar spine
c. Correct: Extension exercises assist in maintaining mobility and the discontinuation of using a pillow under his head assists in decreasing a kyphotic spine
d. Incorrect. This is indicated for HNP.

Question 4

What is the “classic triad” associated with Reiter’s Syndrome?

a. Arthritis, laryngitis, ptosis
b. Arthritis, conjunctivitis, laryngitis
c. Arthritis, ptosis, urethritis
d. Arthritis, conjunctivitis, urethritis

Answer 4

d. Correct. Arthritis occurs most commonly in the weightbearing joints with an asymmetric presentation. There is a mild redness, tearing and burning of the eyes which lasts for a few days. There is an increased frequency and burning associated with urination (typically the first symptom). Reiter’s syndrome is a self-limiting disease that typically resolves in 3-4 months

Question 5

4. Reiter’s Syndrome has two forms, each associated with a different pathology. These two pathologies are:
   a. Flu & Meningitis
   b. Malaria & Ringworm
   c. Typhoid & Yellow Fever
   d. Venereal Disease & Dysentery

Answer 5

d. Correct. The two forms of Reiter’s Syndrome are associated with dysentery and venereal infection

Question 6

A series of chronic relapses of Reiter’s Syndrome typically causes which of the following?

a. Pain at the PIP’s and DIP’s of the hands and a decrease in depth perception
b. Upper cervical spine hypermobility and kidney infection
c. Lumbar/SIJ deformity and chronic Plantar Fasciitis and Achilles tendonitis
d. Pannus formation at the wrist and PIP’s of the hand

Answer 6

a. Incorrect
b. Incorrect
c. Correct: Lumbar and SIJ deformity (assess by radiograph) is common. Chronic Achilles tendonitis and Plantar Fasciitis occurs because the disease process makes inflammation at tendinous insertions common.
d. Incorrect. This is common in Rheumatoid Arthritis

Question 7

Fibromyalgia is most appropriately defined as a

a. Muscle endurance disorder
b. Myofascial pain disorder
c. Sleep disorder
d. Psychosomatic disorder

Answer 7

a. Correct. Fibromyalgia is a muscle endurance disorder resulting in muscle fibers becoming taut, fibrous bands that place a stretch on tendinous insertions and fascia. These painful sites are commonly known as “tender points”.
b. Incorrect. Myofascial pain syndrome is typified by one or two trigger points within a single muscle with a characteristic pain referral pattern.
c. Incorrect. 70-90% of all Fibromyalgia patients suffer from an inability to attain stage 4 sleep. However, poor sleep is only a symptom and a contributing cause of Fibromyalgia.
d. Incorrect. Although once thought to be a suspect diagnosis, Fibromyalgia has very specific diagnostic criteria.

Question 8

A 48 year old homemaker presents to your clinic with a four month history of bilateral neck and shoulder pain of insidious onset. She complains of poor sleep, lack of endurance, and an onset of symptoms with using her upper extremities for greater than 15 minutes. Her pain is severely impacting her quality of life. Upon physical examination, you discover tenderness to palpation at the bilateral Suboccipital muscles, bilateral upper Trapezius, the medial portion of the supraspinatus muscles bilaterally, and the intertransverse spaces of C6-7 bilaterally. You also discover tenderness along her right elbow at the lateral epicondyle and at her bilateral paraspinals of L4/5. When palpating, you are careful to use only enough pressure to cause the nailbed of your finger to blanche. You have performed special tests that have ruled out all other cervical and shoulder pathology. Based solely on the above information, would you diagnosis this patient with Fibromyalgia?

a. Yes
b. No

Answer 8

a. Incorrect. This patient has several criteria that fit the diagnosis of Fibromyalgia to include pain for greater than 3 months and poor sleep. She also has 11 tender points that are tender to palpation and the examiner used the appropriate amount of force (enough to turn the nailbed white, approximately 4kg of force). However, the diagnostic criteria of Fibromyalgia require that 11 of 18 specific tenderpoints be tender. The paraspinals of the lumbar spine are not among those tenderpoints. Also, the patient must complain of “widespread” pain that is bilateral, above and below the waist, and include the axial and appendicular skeletal pain.
b. Correct

Question 9

A 17 year old female soccer player presents to your clinic 24 hours after sustaining a Grade 2 contusion to her right quadriceps. She is leaving for a soccer road trip that very afternoon and asks your advice as to whether put heat or ice on her leg while traveling on the team bus. She states that she has been icing for the past 24 hours, however, she has heard conflicting advice regarding the use of ice or heat after the first 24 hours of the injury. You instruct her to do which of the following?

a. Use ice
b. Use heat
c. Use ice for the next 24 hours, then switch to heat
d. Neither. If she is OK to play soccer this weekend, she doesn’t need to worry about the bruise.

Answer 9

a. Correct. Cold modalities are indicated for acute contusions
b. Incorrect. Muscle contusions often have deep bruising associated with them. By applying heat, an increase in temperature can result in an increased bleeding which has been shown to result in Myositis Ossificans.
c. Incorrect.
d. Incorrect.

Question 10

9. A 68 year old retired metal worker is 9 weeks status post right TKA. The patient has been on a fishing vacation for the past two weeks. When he returns for physical therapy, you notice he has a flexion contracture at his right knee that is preventing him from attaining the last 15 degrees of knee extension. He was able to attain terminal knee extension prior to leaving for vacation. He reports that he was not adherent to his home exercises while on vacation and that he is beginning to develop some low back pain. Which of the following interventions would you choose to perform in the clinic in order to restore this patient’s range of motion as rapidly as possible?

a. Contract/Relax stretches to his hamstrings
b. Static stretch to his hamstrings
c. Ultrasound to his distal hamstrings followed by Contract/Relax stretches to his hamstrings
d. Ultrasound to his distal hamstrings followed by static stretch to his hamstrings

Answer 10

a. Correct. Contract/Relax stretches will increase range of motion more rapidly than static stretches. While static stretches are effective, the patient can perform static stretches at home.
b. Incorrect. The patient can perform static stretches at home. Doing these in the clinic is not the most effective use of time.
c. Incorrect. Ultrasound is contraindicated over plastic implants and joint cement.
d. Incorrect. Ultrasound is contraindicated over plastic implants and joint cement.

Question 11

10. A 43 year old male recreational basketball player presents to your clinic with acute patella tendonitis. You decide to utilize iontophoresis using dexamethasone to treat the inflammation and ask a technician to set-up the treatment. Once the patient is ready, you stop by to ensure the parameters are correct before beginning the iontophoresis treatment. The technician comments that there was only 1.25cc of dexamethasone left in the medicine dispenser and that he used a 1.5cc pad. You check to ensure that no dexamethasone has leaked from under the pad. It hasn’t. You notice that the technician has placed the dispersive pad on the patient’s distal quadriceps. The active pad is placed over the patella tendon with pre-wrap covering the pad along the edges to keep it in place. The negative electrode is attached to the active pad. The generator is set to 40mA-min. Based on this information, what is most likely to cause a burn during this treatment?

a. Intensity: 40mA-min is too high of a setting for dexamethasone
b. Pre-wrap covering the active pad
c. Too little medication on the active pad
d. Wrong polarity: dexamethasone should be pushed from the positive electrode

Answer 11

a. Incorrect. 40mA-min is an ideal intensity for iontophoresis
b. Incorrect. The pre-wrap is only covering the edges of the pad. Risk of burns increase when something is placed directly over the electrode, thus compressing it against the skin.
c. Correct. One of the most common causes of burns associated with iontophoresis is an under-filled pad.
d. Incorrect. Dexamethasone is negatively charged.

Question 12

11. A 27 year old female presents to physical therapy to reduce scar-tissue adhesions to her right forearm 3 months after a radial shaft fracture was surgically repaired with open reduction/internal fixation. You elect to combine iontophoresis and transverse friction massage in order to break up the scar tissue. What agent will you “push” with the iontophoresis?
    a. Acetic acid
    b. Dexamethasone
    c. Dexamethasone combined with Lidocaine
    d. Iodine

Answer 12

a. Incorrect. Acetic acid is used to treat calcific tendonitis
b. Incorrect. Dexamethasone is used to treat inflammation
c. Incorrect. Dexamethasone combined with Lidocaine is used to treat inflammation and pain.
d. Correct. Iodine is used as an anti-sclerotic agent.

Question 13

Your clinic performed a research study to determine the efficacy of lumbar manipulation in patients with acute low back pain. Ten subjects were included in the study and were equally divided into two groups. The experimental group received lumbar manipulation twice a week for two weeks. The control group received moist heat and TENS for twenty minutes, twice a week for two weeks. The outcome measure was the Oswestry Disability Index which patients were asked to complete before their initial treatment and after their last treatment. A two-tailed t-test was performed with a significance set at p<0.05.

12. Based on the above information, what was the independent variable of this study?
    a. Manipulation
    b. Moist heat and TENS
    c. Oswestry Disability Index
    d. T-test

Answer 13

a. Correct. Manipulation was the variable or intervention being studied
b. Incorrect. This was the control treatment
c. Incorrect. This was the dependent variable
d. Incorrect. This was the statistical test

Question 14

Your clinic performed a research study to determine the efficacy of lumbar manipulation in patients with acute low back pain. Ten subjects were included in the study and were equally divided into two groups. The experimental group received lumbar manipulation twice a week for two weeks. The control group received moist heat and TENS for twenty minutes, twice a week for two weeks. The outcome measure was the Oswestry Disability Index which patients were asked to complete before their initial treatment and after their last treatment. A two-tailed t-test was performed with a significance set at p<0.05.

13. In order for the Oswestry Disability Index to be an appropriate outcome measure for this study, it must have:
    a. Construct validity
    b. Content validity
    c. Concurrent validity
    d. Predictive validity

Answer 14

a. Correct. Construct validity pertains to the extent to which a tool measures what it claims to measure. In this example, the Oswestry Disability Index should have high construct validity for assessing disability in patients with low back pain.
b. Incorrect. Content validity pertains to whether the test samples the behavior that is being studied. For example, if you were writing an anatomy final examination, you would want to ensure the test had good content validity. This means that the final examination measured all parts of human anatomy equally. For example, equal parts of gross anatomy and microanatomy.
c. Incorrect. Concurrent validity pertains to the relationship between test scores of what is being measured (test #1) and what it is being compared to (test #2). For example, if a researcher wants to validate a new back assessment questionnaire (Acme Back Index), she will want to compare it to a questionnaire that represents the “gold standard” (the Oswestry for example). She would have the subjects take both questionnaires at the same time and compare the Acme (test #1) to the Oswestry (test #2).
d. Incorrect. Predictive validity measures the extent to which a future prediction can be made based on a measure made today.

Question 15

The researchers involved in this study were particularly worried about a Type 2 Error occurring when they performed their statistical tests. A Type 2 Error is:

a. Stating there is a difference between two treatments when there is not one
b. Stating there is no difference between two treatments when there is one
c. The generalization from the sample being studied to the population
d. The probability of reaching a correct decision

Answer 15

a. Incorrect. This is the definition of a Type 1 Error. It means the researchers are afraid of “backing a loser”.
b. Correct. This typically occurs with a small sample size. It means “missing a winner”.
c. Incorrect. This is the definition of External Validity
d. Incorrect. This is the definition of the Power of a Statistical Test

Question 16

15. A 33 year old male recreational tennis player reports that he heard a “pop” and felt immediate pain when performing a serve three days ago. His shoulder hurts when he attempts to elevate his arm greater than 90°. You suspect a labral injury. You immediately perform the anterior apprehension test (for SLAP lesions) as described by Mimori. The test is negative. You feel confident that the patient does not have a SLAP lesion because the test has a reported high degree of:
    a. Power
    b. Precision
    c. Sensitivity
    d. Specificity

Answer 16

a. Incorrect. Power relates to the probability of reaching a correct decision with a statistical test
b. Incorrect.
c. Correct. Sensitivity pertains to the True Negatives of a test. A simple trick in remembering this is SnNOut: Sn sensitivity N when negative Out rules out the pathology
d. Incorrect. Specificity pertains to the True Positives of a test. A simple trick in remembering this is SpPIn: Sp specificity P when positive In rules in the pathology

Question 17

A 30 year old left-hand dominant female sustained a compression injury to her left arm approximately 2cm proximal to the medial epicondyle. The injury occurred three weeks prior and is beginning to show signs of improvement. Physical examination revealed decreased pinch and grip strength, compromised thumb stability with manual resistance, and flexion contractures or “clawing” of the 4th and 5th fingers.

If this patient had a negative Tinel’s sign at the elbow, what is the most likely classification of her nerve injury?

a. Axonotmesis
b. Neurapraxia
c. Neurotmesis
d. Wallerian Degeneration

Answer 17

a. Incorrect. This is a second-degree injury and would produce a (+) Tinel’s sign.
b. Correct. This is a first-degree injury (least severe). Due to the local demyelination, Tinel’s sign would be negative.
c. Incorrect. This is a fifth-degree injury caused by a complete transaction of the nerve. Tinel’s sign would be positive.
d. Incorrect. This is a component of an axonotmesis.

Question 18

A 30 year old left-hand dominant female sustained a compression injury to her left arm approximately 2cm proximal to the medial epicondyle. The injury occurred three weeks prior and is beginning to show signs of improvement. Physical examination revealed decreased pinch and grip strength, compromised thumb stability with manual resistance, and flexion contractures or “clawing” of the 4th and 5th fingers.

If this patient had a positive Tinel’s sign at the elbow, what is the most likely classification of her nerve injury?

a. Axonotmesis
b. Neurapraxia
c. Neurotmesis
d. Wallerian Degeneration

Answer 18

a. Correct. Axonotmesis would produce a (+) Tinel’s sign. Since the mechanism of injury was compression, we are not concerned with a total transaction of the nerve (Neurotmesis) which would also elicit a (+) Tinel’s sign but would not be showing signs of improvement.
b. Incorrect. This would cause Tinel’s sign to be negative
c. Incorrect. While we would expect a positive Tinel’s sign with this injury, the nerve would have been totally transected – unlikely with a compression injury – and thus would not be showing signs of improvement.
d. Incorrect. While Wallerian degeneration is a component of an Axonotmesis injury, it is not a classification of a nerve injury in and of itself.

Question 19

Assuming that this patient had an Axonotmesis, what would be her predicted rate of nerve recovery?

a. ½ inch per week
b. 1 inch per week
c. 1 inch per month
d. No recovery

Answer 19

c. Correct. The proper prognosis for nerve recovery following an Axonotmesis is approximately 1 inch per month.

Question 20

19. Assuming that this patient had an Axonotmesis, what would be her expected prognosis?
    a. 100% recovery
    b. 50-75% recovery
    c. <50% recovery
    d. No recovery

Answer 20

a. Correct. The prognosis for axonotmesis (and neuropraxia) is complete recovery
b. Incorrect.
c. Incorrect.
d. Incorrect. Fourth degree (neuroma incontinuity) and fifth-degree (Neurotmesis) injuries will not recover.

Question 21

20. Which of the following tissues has the ability to regenerate itself instead of repairing with scar tissue?
    a. Bone
    b. Ligament
    c. Muscle
    d. Tendon

Answer 21

a. Correct. Bone can regenerate via osteoblastic activity.
b. Incorrect.
c. Incorrect.
d. Incorrect.

Question 22

Which of the following is an example of the pathology attributed to Rheumatoid Arthritis?

a. Chronic thickening and edema of the synovial lining
b. Thinning and breakdown of hyaline cartilage
c. Inability to weightbear on the MTP’s of the feet
d. Inability to flex the DIP’s of the hand

Answer 22

a. Correct
b. Incorrect. This is a pathology associated with Osteoarthritis
c. Incorrect. This is an impairment typically associated with OA
d. Incorrect. This is an impairment typically associated with OA

Question 23

What are the most common locations associated with Rheumatoid Arthritis?

A.) DIP’s, hips, knees, feet
B.) DIP’s, wrists, hips, feet
C.) PIP’s, wrists, knees, feet
D.) Shoulders, PIP’s, hips, knees

Answer 23

C

Question 24

What is the “telltale” radiographic sign of Ankylosing Spondylitis?
A) Bamboo Spine
B) Degenerative Disc Disease
C) Schmoral’s nodes
D) Scotty Dog

Answer 24

A) Correct
B) This is a normal sign of aging
C) This is a sign of compression fractures
D) This is a sign of spondylolisthesis

Question 25

A 24 year old male presents to your clinic following a traumatic injury that occurred to his right shoulder 2 days prior while playing basketball. The patient stated that an opposing player struck his right forearm while he was attempting to catch a pass. He immediately felt pain and a “pop” at the time of injury. After further questioning, you determine his arm was in a position of approximately 100° abduction, 90° of external rotation, and slight extension at the time of injury and that the opposing player’s force was directed from anterior to posterior. The patient is very hesitant to move his arm and presents with his arm in glenohumeral neutral and slight adduction. Based upon the information above, you suspect the patient most likely has what type of injury? a. Anterior glenohumeral instability b. Acromioclavicular sprain c. Posterior glenohumeral instability d. SLAP lesion

Answer 25

a. Correct. The most common mechanism for anterior glenohumeral subluxation/dislocation is an indirect trauma with the arm abducted, externally rotated, and extended. b. Incorrect. This is typically seen with a direct trauma to the superior shoulder c. Incorrect. The most common mechanism for posterior glenohumeral subluxation/dislocation is an axial load with the shoulder in adduction, flexion, and internal rotation d. Incorrect. The most common mechanism is a traction injury to the long head of the biceps or FOOSH.

Question 26

A 24 year old male presents to your clinic following a traumatic injury that occurred to his right shoulder 2 days prior while playing basketball. The patient stated that an opposing player struck his right forearm while he was attempting to catch a pass. He immediately felt pain and a “pop” at the time of injury. After further questioning, you determine his arm was in a position of approximately 100° abduction, 90° of external rotation, and slight extension at the time of injury and that the opposing player’s force was directed from anterior to posterior. The patient is very hesitant to move his arm and presents with his arm in glenohumeral neutral and slight adduction Based on the mechanism of injury, what structures are most likely to be compromised? a. Inferior Glenohumeral Ligament Complex & Biceps Brachii b. Coracoclavicular ligament c. Posterior Glenohumeral capsule d. Anterior labrum and long head of the Biceps tendon

Answer 26

a. Correct. With the glenohumeral joint in 90°/90° Abd and ER, the primary restraints to anterior humeral translation are the Inferior Glenohumeral Ligament Complex & Biceps Brachii b. Incorrect. This would be injured with a AC sprain c. Incorrect. This would be injured with posterior instability d. Incorrect. This would be injured with an anterior SLAP injury

Question 27

A fifteen year old female soccer player presents to your clinic 1 week after traumatic anterior dislocation of her right shoulder. She states her athletic trainer had to reduce her injury on the sideline. Since the time of injury, she has been treated in her training room with ice and TENS and has been wearing a sling. Upon physical examination, you find the following: Positive Anterior Apprehension/Relocation test, negative Feagin’s sign, and negative sulcus sign. Radiographs reveal no fractures of the Humerus or Glenoid. ## Footnote Based on the above information, this patient would most likely fit into which surgical diagnostic category? a. AMBRI b. Inferior Instability c. SLAP Type 1 d. TUBS

Answer 27

a. Incorrect. AMBRI stands for ATRAUMATIC MULTIDIRECTIONAL BILATERAL REHABILITATION (as appropriate) and rarely INFERIOR capsular shift surgery. This patient’s injury was traumatic and there was no multidirectional instability as demonstrated by the negative Feagin's and Sulcus signs. These injuries typically respond well to physical therapy and surgery is typically not recommended. b. Incorrect. This patient had negative Feagin’s and Sulcus signs – both assess for inferior instability of the shoulder. c. Incorrect. A Type 1 SLAP is associated with degenerative fraying of the superior labrum. d. Correct. TUBS stands for TRAUMATIC UNILATERAL anterior with a BANKART lesion responding to SURGERY.

Question 28

A fifteen year old female soccer player presents to your clinic 1 week after traumatic anterior dislocation of her right shoulder. She states her athletic trainer had to reduce her injury on the sideline. Since the time of injury, she has been treated in her training room with ice and TENS and has been wearing a sling. Upon physical examination, you find the following: Positive Anterior Apprehension/Relocation test, negative Feagin’s sign, and negative sulcus sign. Radiographs reveal no fractures of the Humerus or Glenoid. When assessing this patient on the field, her athletic trainer would want to assess for possible injury to what nerve. a. Axillary b. Dorsal Scapular c. Radial d. Suprascapular

Answer 28

a. Correct. Traumatic dislocations are often associated with Axially nerve injuries b. Incorrect. The Dorsal Scapular nerve comes off of the superior trunk of the brachial plexus and is not near the site of injury. c. Incorrect. Proximal Radial nerve injuries are typically associated with Humeral shaft fractures. Radiographs showed no fractures with this patient. d. Incorrect. The Suprascapular nerve comes off of the superior trunk of the brachial plexus. It is often associated with injuries involving excessive protraction of the shoulder.

Question 29

A 27 year old female postal worker tore her right rotator cuff. The patient elected to have surgery for her right shoulder. What type of repair would allow for the fastest post-operative rehabilitation? a. Arthroscopic b. Open c. Mini-Open

Answer 29

a. Incorrect. While arthroscopic repairs were originally thought to be able to be progressed faster, research has shown that they must be progressed slowly due to the weaker fixation of the repair. Recurrence rates for arthroscopic repairs are high, between 8-17% b. Incorrect. Open repairs require the deltoid muscle to be released/detached from the clavicle or acromion. The patient cannot initiate AROM of the deltoid for 6-8 weeks. Recurrence rates for open procedures is 5%. c. Correct. Mini-open repairs require a small, vertical incision be made between the anterior and middle deltoid fibers. This allows for early initiation of deltoid AROM and a faster course of rehabilitation.

Question 30

6. What type of SLAP repair is typically associated with a bucket-handle tear of the superior labrum with an intact biceps tendon and biceps anchor? a. Type 1 SLAP b. Type 2 SLAP c. Type 3 SLAP d. Type 4 SLAP

Answer 30

a. Incorrect. This is associated with a degenerative fraying of the superior labrum b. Incorrect. This is associated with the biceps anchor being pulled away from the glenoid c. Correct. d. Incorrect. This is associated with a bucket-handle tear with a torn biceps tendon and the labrum being displaced into the joint

Question 31

You are rehabilitating a patient who is one week status post left rotator cuff repair. The surgical report stated the orthopedic surgeon performed a mini-open repair and that the patient had a “small” tear. ## Footnote 7. When is it safe to D/C the sling for this patient? a. 7-10 days b. 2 weeks c. 3 weeks d. 4 weeks

Answer 31

a. Correct. After a mini-open repair for a “small” tear, it is safe to D/C the sling in 7-10 days b. Incorrect. A “medium” tear would require the sling to be kept until 2-3 weeks post-op c. Incorrect. A “large” tear would require the sling be kept until 2-3 weeks post-op d. Incorrect.

Question 32

8. How large is a “small” tear? a. \<1cm b. 1.5 – 2cm c. 2-3cm d. 5cm

Answer 32

a. Correct. A “small” tear is considered \<1cm b. Incorrect. A “medium” tear is 2-4 cm c. Incorrect. A “medium” tear is 2-4 cm d. Incorrect. A “large” tear is \>5cm

Question 33

One of your PT technicians comes to work Monday morning complaining of excruciating right shoulder pain. She tells you that the pain came about Saturday morning and was of insidious onset and that she had not performed any strenuous activity Friday. The pain is in her lateral upper arm that has not been relieved by rest or changes in position and that forward flexion exacerbates the pain. She also reports she has tenderness along the distal acromion near the middle deltoid insertion. Based on this information alone, which of the following diagnoses is most likely correct? a. AC joint sprain b. Calcific tendonitis c. Deltoid tendonitis d. Impingement syndrome

Answer 33

a. Incorrect. AC joint pathology is associated with trauma to the superior shoulder. It can be associated with unremitting pain during the acute stages, however, this individual reported no trauma. b. Correct. Calcific tendonitis is typified by an insidious onset of pain that is not relieved by position changes in the acute stages. Pain is typically in the lateral upper arm. Forward elevation often exacerbates this condition. It is a self-limiting condition that usually resolves within one week of onset c. Incorrect. Deltoid tendonitis is usually associated with overuse and a decrease in symptoms with position changes. d. Incorrect. Impingement syndrome is associated with overuse and decreased symptoms with position changes.

Question 34

What muscles comprise the lower scapular force couple? a. Rhomboids, Middle Trapezius, Lower Trapezius b. Rhomboids, Lower Trapezius, Serratus Anterior c. Levator Scapula, Middle Trapezius, Lower Trapezius d. Middle Trapezius, Lower Trapezius, Serratus Anterior

Answer 34

d. Correct

Question 35

A 40 year old male salesman presents to your clinic complaining of a 6 week history of right shoulder pain. The patient complains of pain at the anterior shoulder that is primarily exacerbated with elevation of his right arm. Physical examination reveals the following: • Subacromial pain/tenderness • (+) Painful arc • (+) Neer test • MMT ABD & ER 4+/5 with pain • Motion limited in a capsular pattern Which of Neer’s Stages of Impingement does this patient most likely fall into. a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4

Answer 35

a. Incorrect. This is typically associated with younger patients (\<25 years). While the physical examination would be very similar, no capsular pattern would be present. b. Correct. Stage 2 is commonly associated with people ages 25-40 years old with the clinical presentation described above. c. Incorrect. This is typically associated with people over 40 years of age. In addition, MMT of ABD and ER is typically weak with pain and there is often a “squaring” of the acromion (associated with deltoid and RC atrophy) d. Incorrect. This is typically associated with people \>60 years of age with a clinical presentation similar to Stage 3 (see C above).

Question 36

A 40 year old male salesman presents to your clinic complaining of a 6 week history of right shoulder pain. The patient complains of pain at the anterior shoulder that is primarily exacerbated with elevation of his right arm. Physical examination reveals the following: • Subacromial pain/tenderness • (+) Painful arc • (+) Neer test • MMT ABD & ER 4+/5 with pain • Motion limited in a capsular pattern What pathology is most likely associated with this patient’s condition? a. Bone spur, tendon disruption b. Chronic rotator cuff tear c. Edema d. Fibrosis, tendonitis/bursitis

Answer 36

a. Incorrect. This is typically associated with Stage 3 Impingement b. Incorrect. This is commonly associated with Stage 4 Impingement c. Incorrect. This is typically associated with Stage 1 Impingement d. Correct.

Question 37

If this patient’s clinical presentation were changed to the following: • Subacromial pain/tenderness • (+) Painful arc; (+) Neer test • MMT ABD & ER 4-/5 with pain • Motion limited in a capsular pattern • Noted “squaring” of the acromion Which of Neer’s Stages of Impingement would he then fall into? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4

Answer 37

a. Incorrect. This is typically associated with younger patients (\<25 years). While the physical examination would be very similar, no capsular pattern would be present and MMT would be strong with pain. b. Incorrect. Stage 2 is commonly associated with people ages 25-40 years old with the clinical presentation as originally described. c. Correct. This is typically associated with people over 40 years of age. In addition, MMT of ABD and ER is typically weak with pain and there is often a “squaring” of the acromion (associated with deltoid and RC atrophy) d. Incorrect. This is typically associated with people \>60 years of age with a clinical presentation similar to Stage 3 (see C above).

Question 38

14. Which is the most likely anatomical rationale for shoulder impingement? a. Greater tubercle and associated rotator cuff tendons compress against the coracoacromial ligament during shoulder elevation and internal rotation b. Lesser tubercle and associated rotator cuff tendons compress against the coracoacromial ligament during shoulder elevation and internal rotation c. Greater tubercle and associated rotator cuff tendons compress against the coracoclavicular ligament during shoulder elevation and internal rotation d. Lesser tubercle and associated rotator cuff tendons compress against the coracoclavicular ligament during shoulder elevation and internal rotation

Answer 38

a. Correct. The coracoacromial ligament acts as the “roof” of the subacromial space. Flexion and internal rotation brings the supraspinatus, infraspinatus, and teres minor tendons into contact with the coracoacromial ligament (during abnormal arthrokinematics). Repeated trauma leads to pathology. b. Incorrect. The lesser tubercle is medial to the greater tubercle and is the attachment for the subscapularis tendon only. During internal rotation, the lesser tubercle does not make contact with the coracoacromial ligament. c. Incorrect. The coracoclavicular ligament is typically not thought to be involved with impingement. d. Incorrect. The coracoclavicular ligament and lesser tubercle are typically not thought to be involved with impingement.

Question 39

A 19 year old right-handed male collegiate baseball pitcher presents to your clinic complaining of right shoulder pain. His pain has increased gradually over the past two weeks. He reports that he has had right shoulder pain since his junior year in high school that typically occurs during mid-season, but that is resolved by cessation of throwing activities at the end of each season. His pain began approximately 2 weeks ago and he is currently in the middle of baseball season. The patient only has pain with throwing a baseball. He is able to sleep on his affected side without pain. ## Footnote You decide to perform an Anterior Load/Shift test on this patient and note a feeling of the humeral head overriding the glenoid rim, but spontaneously reducing. Based on this information, how would you grade the amount of anterior glenohumeral translation? a. Normal b. Grade 1 c. Grade 2 d. Grade 3

Answer 39

a. Incorrect. Normal laxity would produce minimal translation b. Incorrect. Grade 1 laxity produces a feeling of the humeral head riding up to, but not over, the glenoid rim c. Correct. d. Incorrect. Grade 3 laxity produces a feeling of the humeral head overriding the glenoid rim and remaining dislocated.

Question 40

A 19 year old right-handed male collegiate baseball pitcher presents to your clinic complaining of right shoulder pain. His pain has increased gradually over the past two weeks. He reports that he has had right shoulder pain since his junior year in high school that typically occurs during mid-season, but that is resolved by cessation of throwing activities at the end of each season. His pain began approximately 2 weeks ago and he is currently in the middle of baseball season. The patient only has pain with throwing a baseball. He is able to sleep on his affected side without pain. Further examination reveals positive Neer and Hawkins-Kennedy impingement tests. The Anterior Slide test and Compression Rotation test are negative. ROM is within normal limits and MMT of the rotator cuff are strong (4+/5) with pain. Posterior capsule mobility is within normal limits and there is no evidence of scapular dyskinesia. Based on all the data, this patient would most likely be diagnosed with: a. Primary impingement b. Secondary impingement c. Posterior (Internal) impingement d. SLAP lesion

Answer 40

a. Incorrect. This is typically due to an abnormal mechanical relationship between the rotator cuff and the coracoacromial arch that results in a narrowing of the arch. Patients are typically \>40 years old, have decreased ROM and strength, and are unable to sleep on their involved shoulder. b. Incorrect. This is common in younger populations and is often associated with overhead athletes and anterior instability. However, scapular dyskinesia and hypomobility of the posterior capsule are hallmark signs. c. Correct. Posterior or Internal impingement is common in overhead athletes. It is caused by excessive external rotation (as often seen in pitchers). Abduction and external rotation (cocking phase of throwing) cause the supraspinatus and infraspinatus tendons to become pinched at the superior/posterior glenoid. This occurs on the undersurface (instead of the bursa surface) of the tendon. It is commonly associated with anterior instability. d. Incorrect. This patient had negative Anterior Slide and Compression Rotation tests – both test for labral pathology.

Question 41

17. How is the Hawkins-Kennedy impingement test performed? a. The patient’s arm is passively elevated into maximal forward flexion b. The patient’s arm is flexed to 90° and then passively internally rotated to end-range. c. The patient’s arm is maximally horizontally adducted across their body d. The dorsum of the patient’s hand is placed at their back pocket. The patient then lifts their hand away from their back.

Answer 41

a. Incorrect. This is the Neer test b. Correct. c. Incorrect. This is the Cross-Over test d. Incorrect. This is the Lift-Off test.

Question 42

18. What anatomic structure(s) does the Neer impingement test assess? a. Supraspinatus only b. Supraspinatus and Long Head of Biceps c. Supraspinatus and Infraspinatus d. Subscapularis

Answer 42

a. Incorrect. The Hawkins-Kennedy assesses the supraspinatus by compressing the greater tubercle against the anterior coracoacromial ligament b. Correct. The Neer test compresses the supraspinatus and long head of biceps tendons between the greater tubercle and the anterior acromion c. Incorrect. These can be assessed with the Painful Arc test d. Incorrect. The Lift-Off test assesses the subscapularis tendons

Question 43

A 34 year old female presents to your clinic complaining of elbow pain and numbness and paresthesias in the fingers of her left upper extremity. She could not recall which fingers specifically. The patient has (+) Wartenberg’s Sign, and (+) Froment’s sign. Resisted thumb flexion, and forearm supination and pronation are strong and without pain. No deformities are noted at the IP joints. ## Footnote 1. Based on the above information, which peripheral nerve is most likely injured? a. Anterior Interosseous Nerve b. Posterior Interosseous Nerve c. Radial Nerve d. Ulnar Nerve

Answer 43

a. Incorrect. Compression of the AIN would cause weakness of the Flexor Pollicus Longus and the lateral half of the Flexor Digitorum Profundus. This would result in an extension deformity of the IP of the thumb and the DIP of the index finger. b. Incorrect. Compression to the PIN would cause pain in the proximal extensors and pain with resisted supination. c. Incorrect. Radial nerve compression would cause pain at the proximal extensor muscles at the lateral elbow, but would not result in (+) Wartenberg’s and Froment’s signs. d. Correct. Compression of the Ulnar nerve

Question 44

A 34 year old female presents to your clinic complaining of elbow pain and numbness and paresthesias in the fingers of her left upper extremity. She could not recall which fingers specifically. The patient has (+) Wartenberg’s Sign, and (+) Froment’s sign. Resisted thumb flexion, and forearm supination and pronation are strong and without pain. No deformities are noted at the IP joints. 2. What does Wartenberg’s sign assess? a. Ability to adduct the 5th digit b. Abductor Pollicus weakness c. Ulnar nerve regeneration distal to the Cubital Tunnel of the elbow d. Pinch deformity at IP of thumb and DIP of index finger

Answer 44

a. Correct. The patient places their hand on a table and the examiner passively spreads the fingers apart. The patient is then asked to bring the fingers together. Inability to adduct the 5th digit is positive for ulnar nerve injury b. Incorrect. Abductor Pollicus weakness can be assess by Froment’s sign c. Incorrect. This is assessed by Tinel’s sign at the Cubital Tunnel d. Incorrect. Pinch deformity is a sign of Anterior Interosseous nerve injury due to weakness/paralysis of the Flexor Pollicus Longus and Flexor Digitorum Profundus.

Question 45

A 34 year old female presents to your clinic complaining of elbow pain and numbness and paresthesias in the fingers of her left upper extremity. She could not recall which fingers specifically. The patient has (+) Wartenberg’s Sign, and (+) Froment’s sign. Resisted thumb flexion, and forearm supination and pronation are strong and without pain. No deformities are noted at the IP joints. What does Froment’s sign assess? a. Ability to adduct the 5th digit b. Adductor Pollicus weakness c. Ulnar nerve regeneration distal to the Cubital Tunnel of the elbow d. Pinch deformity at IP of thumb and DIP of index finger

Answer 45

a. Incorrect. This is assessed by Wartenberg’s sign. b. Correct. The patient grasps a piece of paper between their thumb and index finger and the examiner attempts to pull the paper away. (+) for weakness of Abductor Pollicus. c. Incorrect. This is assessed by Tinel’s sign at the Cubital Tunnel d. Incorrect. Pinch deformity is a sign of Anterior Interosseous nerve injury due to weakness/paralysis of the Flexor Pollicus Longus and Flexor Digitorum Profundus.

Question 46

4. Which muscle assists the Supinator in all activities requiring rapid forearm supination? a. Biceps Brachii b. Brachialis c. Brachioradialis d. Extensor Carpi Radialis Brevis

Answer 46

a. Correct.

Question 47

A 56 year old male right-hand dominant carpenter presents to your clinic with a 3 week history of proximal right anterior forearm pain and paresthesias in his 1st-3rd digits. These symptoms are exacerbated by activity. Examination reveals weakness with 1st–3rd digit flexion and wrist flexion. He exhibits tenderness to palpation along the proximal anterior forearm. Manual muscle tests of biceps brachii and of 3rd digit PIP flexion are both strong but with a reproduction of his paresthesias. Resisted pronation with the elbow flexed to 90° is weak with pain. However, resisted pronation with the elbow extended is strong and without pain. ## Footnote 5. Based on the information above, what is the most likely diagnosis? a. Anterior Interosseous nerve entrapment b. Bicepital tendonitis c. Posterior Interosseous nerve entrapment d. Pronator Teres syndrome

Answer 47

a. Incorrect. This is very similar to Pronator Teres syndrome but the distinguishing feature of AIN entrapment is a lack of sensory loss/symptoms. This patient had paresthesias extending down into his 1st-3rd fingers therefore this is not AIN entrapment. AIN entrapment will have weakness/paralysis of Flexor Pollicus Longus, Flexor Digitorum Profundus (lateral half), and the Pronator Quadratus (often). b. Incorrect. The patient has motor loss and paresthesias in a Median nerve distribution. MMT of biceps brachii was strong with a reproduction of symptoms. This is caused by the bicepital aponeurosis compressing the median nerve during resisted biceps activity. Patients with bicepital tendonitis would typically present with decreased strength due to pain. This patient’s biceps MMT was strong. c. Incorrect. The PIN comes off of the Radial nerve. This patient did not have any symptoms in a Radial nerve distribution. d. Correct. The median nerve is compressed between the two heads of the Pronator Teres muscle with weakness of muscles innervated by the median nerve BELOW the Pronator Teres. This was differentiated by assessing resisted pronation with the elbow flexed to 90° (in which the pronator teres has a minimal contribution to pronation) and with the elbow extended (in which pronator teres is the primary force producer). Also, the difference between Pronator Teres syndrome and AIN entrapment is Pronator Teres syndrome has a sensory component (exacerbated by activity) whereas AIN entrapment does not. The patient had reproduction of symptoms with resisted 3d digit PIP flexion because the Flexor Digitorum Superficialis compresses the median nerve during this maneuver).

Question 48

A 56 year old male right-hand dominant carpenter presents to your clinic with a 3 week history of proximal right anterior forearm pain and paresthesias in his 1st-3rd digits. These symptoms are exacerbated by activity. Examination reveals weakness with 1st–3rd digit flexion and wrist flexion. He exhibits tenderness to palpation along the proximal anterior forearm. Manual muscle tests of biceps brachii and of 3rd digit PIP flexion are both strong but with a reproduction of his paresthesias. Resisted pronation with the elbow flexed to 90° is weak with pain. However, resisted pronation with the elbow extended is strong and without pain. Why would this patient have a reproduction of symptoms (paresthesias in 1st-3rd digits with resisted 3rd digit PIP flexion? a. Flexor Carpi Ulnaris compresses the posterior interosseous nerve b. Flexor Digitorum Profundus compresses the anterior interosseous nerve c. Flexor Digitorum Superficialis compresses the median nerve d. Palmaris Longus compresses the radial nerve

Answer 48

c. Correct

Question 49

Which of the following groups of muscles are innervated by the Anterior Interosseous nerve? a. Flexor Pollicus Longus, Abductor Pollicus Longus, Flexor Digitorum Profundus (lateral half) b. Flexor Carpi Ulnaris, Pronator Quadratus, Flexor Digitorum Profundus (lateral half) c. Pronator Teres, Pronator Quadratus, Flexor Digitorum Profundus (lateral half) d. Thenar eminence, lateral two lumbricals, Flexor Digitorum Profundus (lateral half)

Answer 49

a. Incorrect. Abductor Pollicus Longus is innervated by the Radial nerve b. Incorrect. Flexor Carpi Ulnaris is innervated by the Ulnar nerve c. Incorrect. Pronator Teres is innervated by the Median nerve d. Correct.

Question 50

1. What is the only proximal carpal that has a tendon attachment? a. Lunate b. Pisiform c. Scaphoid d. Triquetrial

Answer 50

a. Incorrect b. Correct. The Flexor Carpi Ulnaris attaches at the Pisiform. c. Incorrect d. Incorrect

Question 51

2. What percentage of maximal grip strength can be produced with the wrist in full flexion? a. 15% b. 25% c. 40% d. 55%

Answer 51

a. Incorrect b. Correct c. Incorrect d. Incorrect

Question 52

3. Which two flexor pulleys are the most important for the mechanical function of the finger? a. A1 & A2 b. A2 & A4 c. C1 & C2 d. C1 & A1

Answer 52

a. Incorrect b. Correct c. Incorrect d. Incorrect

Question 53

4. Which flexor tendon zone goes from the middle phalanx to the distal palmar crease a. Zone 1 b. Zone 2 c. Zone 3 d. Zone 4

Answer 53

a. Incorrect. Zone 1 goes from the insertion of the FDP at the distal phalanx to the mid-portion of the middle phalanx. b. Correct. This is also known as Bunnell’s no man’s land. c. Incorrect. Zone 3 goes from the A1 pulley to the distal transverse carpal ligament. d. Incorrect. Zone 4 is the area covered by the transverse carpal ligament.

Question 54

A 33 year old nurse underwent a delayed primary tendon repair in Zone 2 of her left hand. She is 4 weeks post-op and has had no post-operative complications. ## Footnote 5. When is it safe to begin PROM extension of the wrist and fingers? a. Post-op week 4 b. Post-op week 6 c. Post-op week 8 d. Post-op week 10

Answer 54

a. Incorrect. At week 4, you may begin AROM wrist extension to neutral only b. Correct. c. Incorrect. At week 8, gentle resistive flexion exercises may begin d. Incorrect. At week 10, the patient is beginning to have the full use of her hand in all activities

Question 55

A 33 year old nurse underwent a delayed primary tendon repair in Zone 2 of her left hand. She is 4 weeks post-op and has had no post-operative complications. 6. When is it safe to D/C this patient’s Dorsal Blocking Splint? a. Post-op week 4 b. Post-op week 4.5 c. Post-op week 5 d. Post-op week 5.5

Answer 55

a. Incorrect b. Incorrect c. Incorrect d. Correct. The DBS is worn constantly thru week 5.5. It holds the wrist in 20° flexion, MCP’s 50° flexion, and PIP/DIP’s in full extension.

Question 56

7. When is the most appropriate time to allow a patient to allow full extension exercises at the DIP following Zone 1 or 2 central slip tenotomy (Fowler)? a. 1-3 weeks b. 2-4 weeks c. 3-5 weeks d. 4-6 weeks

Answer 56

a. Incorrect. During the first two weeks, the post-op dressing maintains the PIP in 45° flexion and DIP in full extension b. Correct. At 2-4 weeks, the PIP can be moved from 45° flexion to full extension c. Incorrect. After 4 weeks, it is safe to begin full finger motion d. Incorrect. After 4 weeks, it is safe to begin full finger motion

Question 57

8. Dorsal ganglion cysts commonly compress into which soft-tissues at the wrist? a. Abductor Pollicus Longus, Extensor Pollicus Brevis b. Extensor Carpi Ulnaris, Extensor Digiti Minimi c. Extensor Digit Minimi, Extensor Digitorum d. Extensor Pollicus Longus, Extensor Digitorum

Answer 57

a. Incorrect. These tendons are in the first compartment of the wrist and as such are too far radial. They are superficial to the Scaphoid. b. Incorrect. These tendons are in the 6th and 5th compartments and are to ulnar. They are superficial to the Triquetrium c. Incorrect. These tendons are in the 5th and 4th compartments d. Correct. Dorsal ganglion cysts typically occur at the scapholunate interval. Therefore, they would compress into the tendons running through the 3rd and 4th compartments

Question 58

9. A 27 year old sales clerk slipped on the ice and fractured her scaphoid. It was repaired via open reduction/internal fixation. Fracture union must be verified by which diagnostic test prior to initiating active-assistive and active exercises? a. CT scan b. MRI c. Ultrasound d. X-Ray

Answer 58

a. Correct. CT scan is the imaging technique of choice for verifying scaphoid fracture union. This is typically done at 8 weeks post-op.

Question 59

A 47 year old male presents to your clinic with right wrist pain x 2 weeks. He reports he made a bad golf swing in which his club struck the ground and he has had pain ever since. His pain is exacerbated with attempting to ride his bicycle and while driving his car (primarily using his right hand to turn the wheel to the left). His primary care physician ordered AP and lateral x-rays that revealed no pathology at the wrist and hand. Physical examination reveals tenderness to palpation approximately 1-2cm distal and radial to the pisiform. He also has pain with resisted 4th and 5th DIP flexion and ulnar deviation. ## Footnote 10. What is the most likely diagnosis? a. Ganglion cyst b. Hook of Hamate fracture c. Trapezium fracture d. 5th CMC sprain

Answer 59

a. Incorrect. Ganglion cysts typically occur at the scapholunate interspace. This patient has tenderness to palpation distal to this region. Also, Ganglion cysts are of an insidious nature, whereas this patient had a definite mechanism of injury b. Correct. The hook of the Hamate is located 1-2cm distal and radial to the pisiform bone and is commonly injured during indirect trauma involving holding a racket or a club. Pain with gripping (riding a bike, steering his car) is a common exacerbating symptom. Pain with resisted 4th and 5th digit DIP flexion occurs because the Flexor Digitorum Profundus tendon lies superficial to the Hamate. Pain with ulnar deviation occurs because the Flexor Carpi Ulnaris muscle attaches to the hook of the Hamate (as well as the pisiform and the base of the 5th metacarpal). Traumatic fractures to his area have a high non-union rate c. Incorrect. The Trapezium is located on the radial aspect of the wrist. d. Incorrect. A sprain of the 5th CMC joint would not cause pain with resisted 4th digit DIP flexion.

Question 60

A 47 year old male presents to your clinic with right wrist pain x 2 weeks. He reports he made a bad golf swing in which his club struck the ground and he has had pain ever since. His pain is exacerbated with attempting to ride his bicycle and while driving his car (primarily using his right hand to turn the wheel to the left). His primary care physician ordered AP and lateral x-rays that revealed no pathology at the wrist and hand. Physical examination reveals tenderness to palpation approximately 1-2cm distal and radial to the pisiform. He also has pain with resisted 4th and 5th DIP flexion and ulnar deviation. 11. Why were the x-rays negative for wrist and hand pathology in this particular case? a. Ganglion cysts are unlikely to show up on AP and lateral radiographs b. Hook of Hamate fractures are unlikely to show up on AP and lateral radiographs c. Trapezium fractures are unlikely to show up on AP and lateral radiographs d. Ligamentous injuries do not show up on radiographs

Answer 60

a. Incorrect. Radiographs will reveal ganglion cysts b. Correct. AP and lateral radiographs have very poor diagnostic value for detecting hook of Hamate fractures. Radiographs taken with a carpal tunnel view have higher specificity, however, CT scans are the gold standard for this pathology c. Incorrect. Fractures to the Trapezium will show up on AP and lateral radiographs d. Incorrect. While it is true that injuries to ligaments are not revealed on radiographs, this patient did not have a 5th CMC sprain

Question 61

A 28-year-old mechanic presents to your clinic with right ulnar sided wrist pain. He reports he was competing in a martial arts competition 4 weeks ago when an opponent grabbed his wrist and pulled him into a position of radial deviation. Since then he has had ulnar sided wrist pain with using a screwdriver, a wrench, and when hand-tightening a screw or bolt. This has caused him to miss at least 2 days from work a week. The patient he can produce pain and a click by flexing and extending his wrist while it is in a position of ulnar deviation. He demonstrates this for you. Physical examination reveals tenderness along the distal ulna/proximal carpals and a no symptoms with manual compression and shearing of the lunate and triquetrium. Resisted ulnar deviation is strong with pain and the patient demonstrates a (+) Press Test. ## Footnote 12. Based on this information, what is the most likely diagnosis? a. Extensor Carpi Ulnaris tendon subluxation b. Lunotriquetrial pathology c. Scaphoid instability d. Triangular Fibrocartilage Complex (TFCC) tear

Answer 61

a. Incorrect. The mechanism of injury (forced radial deviation) is consistent with this injury. However, the patient had tests positive for TFCC pathology. b. Incorrect. Lunotriquetrial shearing was negative. However, the examiner must always rule-out Lunotriquetrial pathology with trauma to the ulnar side of the wrist. c. Incorrect. The scaphoid is located on the radial side of the wrist. d. Correct. TFCC tears commonly occur with FOOSH, repetitive axial loading, and with distraction forces at the ulnar wrist (forced radial deviation). Exacerbating factors include gripping (holding screwdriver and wrench), forearm rotation (using a screwdriver or wrench) and ulnar deviation (hand-tightening a bolt or screw). The patient’s ability to reproduce his pain and a click with wrist flexion and extension while maintaining the wrist in ulnar deviation is synonymous with the TFCC Grind test. The Press Test is also diagnostic of TFCC pathology. Patients will also have tenderness in the area of the TFCC (distal Ulnocarpal joint)

Question 62

13. Which is the proper technique for performing the Press Test? a. Patient places their palms together and maximally presses them together. Ulnar sided wrist pain is a positive sign b. Examiner passively positions the patient into supination and ulnar deviation and then has the patient resist radial deviation. Ulnar sided wrist pain and visible/palpable subluxation is a positive sign c. Patient sits in a chair and grasps the sides of the seat with each hand and pushes themselves up off the chair. Ulnar sided wrist pain is a positive sign d. Patient performs AROM wrist radial & ulnar deviation. A clunk and pain at a point just beyond neutral as the wrist moves into ulna deviation is a positive sign.

Answer 62

a. Incorrect. This is Phalen’s test b. Incorrect. This is a test for ECU subluxation instability c. Correct. d. Incorrect. This is the Catch Up Clunk test for CIND (carpal instability non-dissociative)

Question 63

14. What is the proper classification of a Colles’ fracture? a. Extra-articular distal radius fracture with dorsal angulation, displacement, and shortening of the fracture b. Extra-articular distal radius fracture with volar displacement and angulation of the fracture. c. Intra-articular shear fracture of the distal radius with dorsal displacement of the fracture d. Intra-articular shear fracture of the distal radius with volar displacement of the fracture ## Footnote

Answer 63

a. Correct. b. Incorrect. This is a Smith’s fracture – also known as a Reverse Colles’ fracture c. Incorrect. This is a Barton’s fracture d. Incorrect. This is also a Barton’s fracture. They can be displaced either dorsally or volarly

Question 64

A 21 year old male college student presents to your clinic complaining of a two week history of dorsal hand pain over the area of the 4th metacarpal. The patient reports he inadvertently punched his dorm room door two weeks ago when he lost his key and couldn’t get in his room and has had pain since. The patient has decreased AROM extension at the 4th PIP and MCP. Grip strength is also diminished and painful. When the patient makes a fist, you observe the head of the 4th metacarpal is more proximal than the 3rd and 5th metacarpal heads. The patient is tender to palpation over the distal shaft of the 4th metacarpal. ## Footnote 15. Based on this information, what is the most likely diagnosis for this patient? a. Base of 4th proximal phalanx fracture b. Boxer’s fracture c. Distal MCP contusion d. Distal MCP dislocation

Answer 64

a. Incorrect. The patient would have tenderness over the base of the 4th phalanx, not the metacarpal. Also, there would be no decrease in 4th metacarpal height b. Correct. Boxer’s fractures are common “punching” injuries that involved dorsal swelling of the hand over the fracture site, loss of PIP and MCP extension, and diminished grip strength (this is because the majority of grip strength comes from the ulnar side of the hand). Decreased metacarpal height is also a common finding. Prognosis for conservative treatment is \>90% success rate. c. Incorrect. There would be no decreased metacarpal height and ROM and grip strength would be near normal. This is an important differential diagnosis for a Boxer’s fracture d. Incorrect. The tenderness would not be over the distal shaft of the 4th metacarpal and their would be a loss of motion at the MCP in both flexion and extension.

Question 65

A 21 year old male college student presents to your clinic complaining of a two week history of dorsal hand pain over the area of the 4th metacarpal. The patient reports he inadvertently punched his dorm room door two weeks ago when he lost his key and couldn’t get in his room and has had pain since. The patient has decreased AROM extension at the 4th PIP and MCP. Grip strength is also diminished and painful. When the patient makes a fist, you observe the head of the 4th metacarpal is more proximal than the 3rd and 5th metacarpal heads. The patient is tender to palpation over the distal shaft of the 4th metacarpal. 16. Further examination with the patient making a fist reveals a rotational misalignment of the injury. What was your most likely observation when you made this conclusion? a. Distal aspect of the digit was pointed toward the scaphoid b. Distal aspect of the digit was pointed away from the scaphoid c. Distal aspect of the digit (DIP) was unable to completely extend d. Distal aspect of the digit (DIP) was hyperextended

Answer 65

a. Incorrect. This is the normal orientation of the digits b. Correct. This is indicative of a rotational misalignment. This is even more severe is the distal digit overlaps with the adjacent finger. Every 1.5cm of overlap equals 5° of rotational deformity. Rotational misalignments require immediate orthopedic consultation. c. Incorrect. d. Incorrect.

Question 66

A 50 year old female data entry specialist presents to your clinic with a 2 month history of pain in the palmar aspect of her right hand and the 2nd and 3rd fingers. In addition, she complains of numbness and tingling at night. She finds relief by “shaking” or massaging her hand. She reports that her husband sustained a spinal cord injury at C6/7 and came home from the hospital 3 months ago. She is his sole caregiver. Her employer allowed her to work at home, and bought her a notebook computer for home use so she wouldn’t have to make room for her desktop model computer at home. The patient has no history of diabetes, hypothyroidism, and does not drink alcohol. You note the following on physical examination. Cervical AROM left sidebending and right rotation produces pain at the right cervical region. Spurling’s test is negative. Roos test is negative. Tinel’s sign is positive at the wrist and she also has a positive Phalen’s test. 17. Based on this information, what is the most probable diagnosis? a. Carpal tunnel syndrome b. Cervical radiculopathy c. Radial tunnel syndrome d. Thoracic outlet syndrome

Answer 66

a. Correct. Carpal tunnel syndrome is the most common peripheral neuropathy, affecting 1% of the general population. 83% of patients are \>40 years old (as this patient is) and it is twice as common in females as it is in males. Common clinical presentations include hand and finger pain, numbness, and/or paresthesias in a median nerve distribution that is often relieved by “shaking” or massaging the hand. Symptoms often occur at night. Phalen’s test and Tinel’s sign are positive. Furthermore, this patient recently (one month prior to symptoms onset) began using a laptop computer at home instead of her desktop model at work. Changes in ergonomics typically go hand in hand (pardon the pun) with carpal tunnel syndrome. b. Incorrect. This patient has a negative Spurling’s test and had not symptoms at the neck (other than some upper trapezius pain: the upper trapezius is stretched with sidebending away and rotation towards). Also, cervical radiculopathy typically presents with pain at the neck, shoulder and upper arm and paresthesias in the lower arm and hand. c. Incorrect. This would present with pain in the proximal forearm near the common extensor tendon d. Incorrect. Patient had a negative Roos test and would have presented with symptoms proximal to the wrist as well.

Question 67

A 50 year old female data entry specialist presents to your clinic with a 2 month history of pain in the palmar aspect of her right hand and the 2nd and 3rd fingers. In addition, she complains of numbness and tingling at night. She finds relief by “shaking” or massaging her hand. She reports that her husband sustained a spinal cord injury at C6/7 and came home from the hospital 3 months ago. She is his sole caregiver. Her employer allowed her to work at home, and bought her a notebook computer for home use so she wouldn’t have to make room for her desktop model computer at home. The patient has no history of diabetes, hypothyroidism, and does not drink alcohol. You note the following on physical examination. Cervical AROM left sidebending and right rotation produces pain at the right cervical region. Spurling’s test is negative. Roos test is negative. Tinel’s sign is positive at the wrist and she also has a positive Phalen’s test. Would you request an EMG study to confirm your diagnosis? a. Yes b. No

Answer 67

a. Incorrect. EMG studies are typically not required for carpal tunnel syndrome unless the patient’s clinical presentation is ambiguous or the examiner suspects other neuropathies. In this case, the presence of other neuropathies is not suspect as the patient reported she did not have diabetes, hypothyroidism, and is not an alcoholic (Patients with these co-morbidities are more predisposed to peripheral neuropathies) b. Correct. The patient’s clinical presentation is straightforward so no EMG would be required.

Question 68

19. A 28 year old female presents to your clinic with the following finger deformity: DIP hyperextended, PIP flexed. What is the name of this deformity and its most probably intervention? a. Boutonniere deformity & splinting/exercise b. Boutonniere deformity & surgical intervention c. Swan-neck deformity & splinting/exercise d. Swan-neck deformity & surgical intervention

Answer 68

a. Correct. This deformity typically respond well to splinting and exercise b. Incorrect. Boutonniere deformities rarely require surgical intervention c. Incorrect. Swan-neck deformities present with the DIP flexed, PIP hyperextended. These do not typically respond well to splinting and exercise. d. Incorrect.

Question 69

1. Which structure is the only direct, dynamic check of anterior shear forces at the L5/S1 facets? a. Deep Erector Spinae b. Gluteus Maximus c. Iliolumbar ligament d. Quadratus Lumborum

Answer 69

a. Correct. This muscle comes off of the ilia just anterior to the PSIS and attaches to the posterior aspect of the transverse processes. b. Incorrect. This muscle’s actions act as an indirect check of anterior shear forces c. Incorrect. This is a static check of anterior shear at the facts of L5/S1 d. Incorrect. This muscle does not attach to the lumbar spine.

Question 70

2. Which muscles place tension across the Thoracolumbar Fascia? a. Deep Erector Spinae, External Obliques, Iliopsoas, Superficial Erector Spinae b. Deep Erector Spinae, Gluteus Maximus, Multifidus, Transverse Abdominis c. External Obliques, Latissimus Dorsi, Multifidus, Quadratus Lumborum d. Quadratus Lumborum, Latissimus Dorsi, Superficial Erector Spinae, Transverse Abdominis

Answer 70

a. Incorrect. External Obliques and Iliopsoas are incorrect. b. Correct. Deep Erector Spinae and Multifidus push against the fascia and the Gluteus Maximus and Transverse Abdominis pull on the fascia c. Incorrect. External Obliques and Quadratus Lumborum are incorrect. d. Incorrect. Quadratus Lumborum is incorrect.

Question 71

3. The laws of spinal motion state that when the lumbar spine is in a neutral position, vertebral rotation and sidebending occur in opposite directions. Which law states this? a. Type 1 spinal mechanics b. Type 2 spinal mechanics c. Type 3 spinal mechanics

Answer 71

a. Correct. Type 1 spinal mechanics is also known as “neutral mechanics”. b. Incorrect. Type 2 spinal mechanics is also known as “non-neutral mechanics”. It states that when the lumbar spine is in flexion or extension, vertebral rotation and sidebending occur to the same side. c. Incorrect. Type 3 spinal mechanics states that when motion is introduced into a spinal motion segment from one plane, the amount of motion you can introduce from other planes is limited.

Question 72

4. Which type of hamstring contraction is most important for the stability of the SI Joint during which part of the gait cycle? a. Concentric contraction during Late-stance phase b. Concentric contraction during Midstance phase c. Eccentric contraction during Initial Contact phase d. Eccentric contraction during Midswing phase

Answer 72

a. Incorrect. b. Incorrect. c. Correct. The hamstrings are eccentrically contracting during the mid/late swing phase of gait and are therefore active during initial contact. The proximal attachment of the biceps femoris is the ischial tuberosity. By being maximally active during initial contact, the hamstrings are able to stabilize the SI Joint against the ground reaction force that occurs during initial contact. d. Incorrect.

Question 73

5. A 58 year old male patient presents to your clinic with a complaint of midline spinal pain at the thoracolumbar junction. The pain occurred insidiously 6 weeks ago and has not improved since. The patient has had no relief of symptoms with over-the-counter Tylenol and Motrin. The patient cannot relate any aggravating or relieving factors. Physical examination of the thoracolumbar spine is without noted deficit and does not reproduce any of the patient’s symptoms. You decide the patient’s pain may be coming from a non-musculoskeletal source. Which of the following is the most likely differential diagnosis? a. Cholecystitis b. Pancreatitis c. Penetrating duodenal ulcer d. Liver pathology

Answer 73

a. Incorrect. This refers to the right lower thoracic/lower lumbar region. This patient’s symptoms were midline (left and right) thoracolumbar junction. b. Incorrect. This refers to the left posterior shoulder and upper trapezius region c. Correct. Midline thoracolumbar junction is where penetrating duodenal ulcers refer pain to. This should not be confused with perforated duodenal ulcers which refer to the right posterior shoulder, upper trapezius, and midline cervical region. d. Incorrect. This refers to the right anterior shoulder and upper trapezius

Question 74

6. What is the Dermatome, Myotome, and Reflex for the S2 nerve root? a. 3rd toe, Extensor Hallicus Longus, Extensor Digitorum Brevis b. 4th & 5th toes, Gastrocnemeus, Achilles Tendon c. Great toe, Tibialis Anterior, Patellar d. Posterior thigh & plantar calcaneus, Hamstrings, Lateral Hamstrings

Answer 74

a. Incorrect. This is for L5 b. Incorrect. This is for S1 c. Incorrect. This is for L4 d. Correct.

Question 75

7. What is the Dermatome, Myotome, and Reflex for the C6 nerve root? a. 2-4 digits, Triceps, Triceps b. Medial forearm, none, none c. Middle Deltoid, Biceps, Biceps d. Thumb, Wrist Extensors, Brachioradialis

Answer 75

a. Incorrect. This is for C7 b. Incorrect. This is for C8 c. Incorrect. This is for C5 d. Correct.

Question 76

8. A 48 year old female presents to your clinic with an 8 week history of low back pain of insidious onset. The patient cannot relate any aggravating or relieving factors, however, she reports she is often awakened at night by her pain and this is often accompanied by sweats. Her pain is not relieved by changing positions. Physical examination does not produce any deficits or symptoms. Further questioning reveals the patient has had fluxuations in her appetite. When asked if she has lost any weight in the past month, she responds that she has gone from 135 pounds to 118 pounds in the last 4 weeks. She reports she has not been dieting. Based on this information, you suspect this patient’s symptoms are most likely coming from: a. Appendicitis b. Cancer c. Gastric ulcer d. Urogenital infection

Answer 76

a. Incorrect. This is not associated with low back/spinal pain b. Correct. There were several key elements to this patient’s history that would raise an immediate Red Flag for cancer. The patient’s pain was of insidious onset, it awakens her at night, she suffers from night sweats, she has had changes in her appetite, and she has lost 10% of her body weight in 4 weeks without dieting/fasting. Moreover, she has not been able to relieve her symptoms with position changes and the physical examination was not able to reproduce her symptoms. c. Incorrect. This typically refers pain to the right shoulder. d. Incorrect. This is hallmarked by symptoms associated with urination.

Question 77

9. What is the most likely mechanism that makes the Straight Leg Raise test positive? a. Compression at the intervertebral foramina b. Inflammation at the nerve c. Tear in the dural sleeve d. Tension placed on the nerve by the test

Answer 77

a. Incorrect. Nerve root compressions do not have radicular pain, paresthesias, or numbness. They involve sensory, motor, and MSR deficits. b. Correct. Nerves are designed to take tensile forces, so the act of stretching a nerve with the SLR (or other Neural Tension tests) is not the mechanism that reproduces the pain. However, when the tensile load is applied to a nerve that is inflamed or in the area of an inflammatory process, the load elicits a pain response. c. Incorrect. While this may cause inflammation and a positive sign, it is not the mechanism that makes the test positive. d. Incorrect. See response B.

Question 78

A 15 year old female gymnast complains of an insidious three month history of mid to low back pain. She reports pain when extending from a forward bent position, while wearing her backpack at school, and while sitting in one position for a period greater then 30 minutes. Physical exam reveals a step deformity with tenderness in area of L2 – L3. Pain is elicited with spinal extension but spinal motion in general is hypermobile. Gross lower quarter screen demonstrates no significant findings.. 10. What is the likely diagnosis? a. Herniated nucleus pulposus b. Muscle strain c. Osteoarthritis d. Spinal Stenosis e. Spondylolisthesis

Answer 78

a. Incorrect. This is typically not observed in such a young patient. Also, these patients generally have more pain with flexion type movements. b. Incorrect. Muscle strains will normally have a mechanism of injury c. Incorrect. Again, normally seen with a much older patient. d. Incorrect. Not expected in this age group. e. Correct. This would be a definite concern given the age of this patient. The fact that she has pain in extension, and a step deformity is noted raises further suspicion.

Question 79

A 15 year old female gymnast complains of an insidious three month history of mid to low back pain. She reports pain when extending from a forward bent position, while wearing her backpack at school, and while sitting in one position for a period greater then 30 minutes. Physical exam reveals a step deformity with tenderness in area of L2 – L3. Pain is elicited with spinal extension but spinal motion in general is hypermobile. Gross lower quarter screen demonstrates no significant findings 11. Which of the following would be the best treatment for this patient? a. Extension based exercises b. Lumbar stabilization exercises c. Lumbar Traction d. Quick thrust manipulative therapy e. William’s flexion exercises

Answer 79

a. Incorrect. These would likely increase the patient’s pain and possibly promote instability to the affected area. b. Correct. Provided the segment is stable, these would be the safest and would help promote stability to the area over time. c. Incorrect. No radicular symptoms are noted. Also, you would not want to traction a segment that is potentially unstable. d. Incorrect. While some manual therapy may be of benefit, direct quick thrust manipulative therapy to the area may not be the safest choice initially. e. Incorrect. While these may help maintain mobility, these would not be as effective in terms of helping to stabilize the fracture.

Question 80

12. What part of the spine does this condition affect? a. Intervertebral disc b. Pars Interarticularis c. Spinous Process d. Vertebral Body e. Zygapophyseal Joint

Answer 80

b. Correct. A spondylolisthesis is a congenital defect or fracture of the pars Interarticularis

Question 81

13. Which of the following is considered a frontal plane deformity? a. Kyphosis b. Lordosis c. Scoliosis d. Spondylosis

Answer 81

a. Incorrect. This is a sagittal plane deformity of the thoracic spine b. Incorrect. This is a sagittal plane deformity of the lumbar spine c. Correct. This is a frontal plane or lateral deformity of the spine d. Incorrect. This is not a planar deformity

Question 82

Ankylosing Spondylitis would typically be associated with this type of deformity? a. Kyphosis b. Lordosis c. Pectus Excavatum d. Scoliosis

Answer 82

A. Correct. This is a rheumatoid condition whereby the patient will generally present with a flattening of the chest and increased thoracic or thoracolumbar kyphosis.

Question 83

15. Bracing for scoliosis is required at: a. \> 5 degrees b. \>10 degrees c. \> 15 degrees d. \> 20 degrees e. \> 30 degrees

Answer 83

Correct. Curves greater then 30 degrees should definitely be braced. Those beyond 20 degrees and progressing 5 degrees or more over a 12 month period should also be considered for bracing.

Question 84

16. A 30 year old male computer programmer presents to your clinic complaining of diffuse, proximal lumbar/distal thoracic pain “centered over the spine.” The patient reports a mechanism of injury of bending forward to retrieve his 7 month old son from the floor with immediate pain at end range of forward flexion. Further questioning reveals he had his knees straight when bending forward and no spinal rotation occurred. Past medical history is insignificant. Active range of motion of the lumbar spine reveals reproduction of symptoms with forward bending. Lumbar spring tests are negative and the patient does not present with any pelvic asymmetry. Based on this information, which tissue is most likely injured? a. Intervertebral disc b. Multifidus c. Quadratus Lumborum d. Superficial Erector Spinae

Answer 84

a. Incorrect. The patient has pain in the lumbar spine only and he is not complaining of radicular signs. Furthermore, there was no rotational component to this injury (the intervertebral disc is most often injured in positions combining flexion with rotation). b. Incorrect. The patient complains of pain with forward flexion, not returning to a neutral position during forward flexion. The multifidus muscle extends and rotates the lumbar spine. It has a poor anatomic line of pull to eccentrically control forward bending. c. Incorrect. The Quadratus Lumborum controls sidebending – this patient only had reproduction of symptoms with flexion. Also, the Quadratus Lumborum is located lateral to where this patient is complaining of pain . d. Correct. The Superficial Erector Spinae muscle comes off of its aponeurosis at the mid-lumbar level and attaches on the ribs and transverse processes of the thoracic spine. This muscles primary actions are to maintain thoracic kyphosis and to eccentrically control forward flexion. This patient most likely has a strain of this muscle that is exacerbated with going into forward flexion.

Question 85

17. A 25 year old female complains of neck and shoulder pain 1 week status post MVA, when she was hit from behind at a stop sign. Prior medical history is insignificant. A/P and lateral X-rays taken in the ER were negative for fracture. Pt reports occasional tingling in area of R second through fourth fingers. There is associated R paraspinal and upper trapezius muscle spasm. ROM is significantly limited in R side-bending and R rotation. Overpressure in flexion produces considerable pain. Upper quarter screen is otherwise insignificant. Alar ligament testing demonstrated increased laxity. ## Footnote What would be your next course of action? a. Begin cervical traction to decrease radicular symptoms b. Consider having patent follow-up for an open mouth x-ray c. Consider having patient follow-up for an EMG/NCV d. Initiate electric stimulation to decrease muscle spasm

Answer 85

a. Incorrect. This would be contraindicated until alar ligament instability is resolved. This could further exacerbate the symptoms consider there was a stretch mechanism involved. b. Correct. Alar ligament instability could be a potential life threatening situation. An open mouth x-ray was not performed in the ER initially. This should be cleared before beginning any form of physical therapy treatment. c. Incorrect. Radicular findings are often commonly associated with whip lash trauma. The acuity of the injury would not warrant this at this time. d. Incorrect. While palitive treatment may help decrease some of the initial spasm, any type of instability should be cleared before beginning therapy.

Question 86

You are evaluating a 72 year old male patient who complains of bilateral lower extremity pain that is increased with walking, and improves over time after rest. Pain also decreases when walking uphill. Lumbar range of motion testing produces pain in extension and relief in flexion. Resting pulses are normal. What do you suspect is the likely diagnosis? a. Herniated Nucleus Pulposus b. Peripheral Neuropathy c. Spinal Stenosis d. Vascular Claudication

Answer 86

a. Incorrect. Pain would likely be increased in flexion here, and this is an older patient b. Incorrect. Specific movement patterns change the patients symptoms making this seem more musculoskeletal in origin c. Correct. This case has all the classic symptoms to include pain relief after prolonged rest, and relief from walking uphill d. Incorrect. This is very similar to spinal stenosis except relief would likely occur more immediately with rest after activity. Also, pain would likely worsen with uphill walking.

Question 87

You are evaluating a 72 year old male patient who complains of bilateral lower extremity pain that is increased with walking, and improves over time after rest. Pain also decreases when walking uphill. Lumbar range of motion testing produces pain in extension and relief in flexion. Resting pulses are normal. . Of the following, what would be the best treatment for this patient? a. Aquatherapy b. Balance and proprioception training c. Extension based home exercise program d. Walking conditioning program

Answer 87

a. Correct. The buoyancy effect of the water decreases compression on the nerve roots while allowing one to perform stabilization and conditioning exercises that enable them to better manage their symptoms. b. Incorrect. No balance or coordination deficits where mentioned in the vignette. c. Incorrect. This would surely increase the patient’s symptoms d. Incorrect. The patient would not likely have the tolerance to engage in a land based conditioning program at this time.

Question 88

What is the sequence of the meninges from the outermost layer to the innermost layer? a. arachnoid mater, dura mater, and pia mater b. arachnoid mater, pia mater, dura mater c. dura mater, arachnoid mater, pia mater d. dura mater, pia mater, arachnoid mater

Answer 88

c. Correct.

Question 89

While attempting to make a tackle, a 19 year old college football player had his right shoulder forced into depression, while his C-spine was forced into extension and L sidebending. You are evaluating him two days later. He continues to have general right anterior forearm and hand numbness. Brachioradialis reflexes are slightly diminished, and he continues to have diffuse cervical and upper trapezius pain. The patient also has pain with cervical extension and L sidebending / rotation. What is the most likely diagnosis? a. C3 –C4 nerve root injury b. Brachial plexus injury c. Median nerve injury d. Radial nerve injury

Answer 89

a. Incorrect. The symptoms are beyond this dermatome region b. Correct. This is the prime mechanism for a brachial plexus injury, and the symptoms are not isolated to one particular segmental or peripheral pattern c. and d. Incorrect. Symptoms are not isolated to a particular peripheral nerve domain.

Question 90

While attempting to make a tackle, a 19 year old college football player had his right shoulder forced into depression, while his C-spine was forced into extension and L sidebending. You are evaluating him two days later. He continues to have general right anterior forearm and hand numbness. Brachioradialis reflexes are slightly diminished, and he continues to have diffuse cervical and upper trapezius pain. The patient also has pain with cervical extension and L sidebending / rotation. Would traction be indicated to decrease this patients radicular symptoms? a. True b. False

Answer 90

B. Correct. This injury is the result of a stretch mechanism, therefore further distraction along its course would not be advisable.

Question 91

What body position increases intervertebral disc pressure the most? a. Lying prone b. Lying supine c. Sitting d. Standing

Answer 91

c. Correct. Intervertebral disc pressures are greater is sitting versus standing as the larger lower extremity musculature is not able to absorb the gravitational forces.

Question 92

A 23 year old female presents to your clinic with an 8 week history of occipital headaches of an insidious onset. Her physician has referred her to physical therapy for treatment of cervical strain/sprain. The patient’s medical history is significant for left shoulder surgery 6 years prior (Bankart repair) and she currently complains of tinnitus and impacted wisdom teeth on the right. Physical examination reveals active range of motion WNL. Spurling’s test is negative and there is no reproduction of headache with PROM or isometric muscle testing. AP, PA, and lateral joint mobilizations are without deficit or pain provocation and the patient has negative cervical distraction and compression tests. There is no tenderness to palpation along the cervical spine, suboccipital muscles, or scalenes. Based on your lack of physical findings, you determine the patient is experiencing referred pain. Which is the most likely source of this patient’s symptoms? ## Footnote a. Tectorial membrane b. Levator Scapulae c. TMJ d. Wisdom teeth

Answer 92

a. Incorrect. The tectorial membrane does originate on the occiput and becomes continuous with the posterior longitudinal ligament. However, if this were the source of pain, we would expect flexion to place a stress on this tissue and reproduce the patient’s pain. b. Incorrect. The levator scapulae typically refers pain along the superior and medial borders of the scapula c. Correct. The TMJ refers pain to the entire head and neck via the Trigeminocervical Nucleus. This nucleus is comprised of the nucleus of CN V and the dorsal horns of C1-3. The key element to this patient’s presentation is the presence of tinnitus. The aurculotemporal nerve (which branches off of CN V) innervates the posterolateral TMJ region as well as the tympanic membrane, external auditory meatus, and the lateral surface of the superior auricle. Thus, any symptom affecting the aurculotemporal nerve can cause an earache or tinnitus. d. Incorrect. The teeth refer pain to the TMJ.

Question 93

A 34 year old female presents to your clinic with a prescription from her family practice physician to evaluate and treat a hypomobile right TMJ. The patient reports she has been having pain in her TMJ for the past 6 months without relief. Physical examination reveals the following data: • S-curve with jaw opening • 25mm of jaw opening • Auditory and palpable “click” with opening and closing the jaw • Pain is decreased by having the patient bite down with a cotton roll between their molars ## Footnote 25. What is the most likely cause of this patient’s TMJ disorder? e. Anterior dislocation of the disc with relocation f. Capsular (TMJ) restriction g. Muscle imbalance h. Posterior subluxation of the TMJ

Answer 93

a. Correct. An S-curve with jaw opening is indicative of either a muscle imbalance or a displacement of the disc (the S-curve occurs because the condyle “walks around” the joint. To differentiate between a muscle imbalance vs. disc pathology, the patient was asked to bite down on a cotton roll at their molars. This decreased the patient’s pain because of the reduced pressure on the disc due to gapping the TMJ. If this test had increased the patient’s pain it would point to a muscular or ligamentous cause. Anterior dislocations with relocation are associated with a click with opening and closing the jaw. b. Incorrect. We would have expected to have seen a C-type curve with opening the jaw c. Incorrect. We would have expected pain to increase when biting the cotton roll d. Incorrect. We wold have expected approximately 30mm of jaw opening and double clicks with jaw opening and closing.

Question 94

A 34 year old female presents to your clinic with a prescription from her family practice physician to evaluate and treat a hypomobile right TMJ. The patient reports she has been having pain in her TMJ for the past 6 months without relief. Physical examination reveals the following data: • S-curve with jaw opening • 25mm of jaw opening • Auditory and palpable “click” with opening and closing the jaw • Pain is decreased by having the patient bite down with a cotton roll between their molars Assume instead that this patient had a straight-line deviation to the left with jaw opening (instead of an S-curve) that occurred late during the jaw opening phase. The patient had no clicking associated with opening or closing the jaw and biting on the cotton roll increased her symptoms. What would her diagnosis most likely be? a. Anterior dislocation of the disc without relocation b. Capsular (TMJ) restriction c. Muscle imbalance d. Posterior subluxation of the TMJ

Answer 94

a. Incorrect. This would be associated with a decrease in pain with biting the cotton roll and a clicking during jaw opening. b. Correct. Straight-line deviations that occur late during the jaw opening phase are associated with capsulitis. This was confirmed when the patient’s pain increased with biting on the cotton roll (indicating muscle or ligamentous involvement) c. Incorrect. This would have been associated with a straight-line deviation early in the jaw opening phase. d. This would have been associated with double clicks on opening and closing the jaw.

Question 95

Based on this patient’s straight-line deviation to the left with jaw opening (occurring late in the opening phase), what is the most likely impairment at the TMJ(s)? a. Bilateral TMJ hypermobility b. Bilateral TMJ hypomobility c. Left TMJ hypermobile, right TMJ hypomobile d. Left TMJ hypomobile, right TMJ hypermobile

Answer 95

D Correct.

Question 96

. The TMJ is innervated by branches of which cranial nerve? e. Facial f. Glossopharyngeal g. Hypoglossal h. Trigeminal

Answer 96

a. Incorrect. The facial nerve (CN VII) innervates the muscles of facial expression, taste, and salivation. b. Incorrect. The glossopharyngeal nerve (CN IX) controls the gag reflex, swallowing, taste, and salivation c. Incorrect. The hypoglossal nerve (CN XII) controls the tongue d. Correct. The trigeminal nerve’s (CN V) mandibular division gives off three nerves that innervate the TMJ: auriculotemporal, deep temporal, and masseteric nerves.

Question 97

Postero-medial shin splints are more likely correlated with a. excessive forefoot supination b. excessive forefoot pronation c. excessive forefoot rigidity d. excessive internal tibial torsion

Answer 97

a. Incorrect. This would most likely cause anterior lateral shin splints. b. Correct. This is mostly correlated with postero-medial shin splints c. Incorrect. This would be more likely associated with a supinated foot d. Incorrect. This may be present, but the increased pronation forces increases the shear on the postero-medial tendons

Question 98

A 21 year old male runner complains of a three month history of anterior-lateral shin pain after reaching a certain threshold of activity. Having being treated with rest, stretching, NSAIDS, and extrinsic strengthening for suspected shin splints, the patient fails to demonstrate improvement. As the patient returns to his running endeavors, the pain readily returns, and this time is associated with decreased sensation in area of the first web space. The dorsalis pedis and anterior tibial pulses are present. ## Footnote 2. What may be the likely etiology for this patient? a. acute exercise induced compartment syndrome b. knee plical syndrome c. lumbar nerve root compression d. stress fracture

Answer 98

a. Correct. This is activity level dependent, and typically a presentation of decreased sensation is a more pronounced finding indicating the syndrome has progressed. b. Incorrect. This would not be associated with neural findings, and more commonly is painful with the first few steps of walking c. Incorrect. There would likely be other symptoms associated down the extremity, and other lumbar movements may be provocative d. Incorrect. This would not likely be associated with sensory findings

Question 99

A 21 year old male runner complains of a three month history of anterior-lateral shin pain after reaching a certain threshold of activity. Having being treated with rest, stretching, NSAIDS, and extrinsic strengthening for suspected shin splints, the patient fails to demonstrate improvement. As the patient returns to his running endeavors, the pain readily returns, and this time is associated with decreased sensation in area of the first web space. The dorsalis pedis and anterior tibial pulses are present. What would be the best treatment decision for this patient? a. request that the patient’s physician consider an x-ray to rule out bony pathology b. advising the patient to seek emergent care to possibly include wick catheter measurements c. consider lumbar traction to help decrease any suspected radicular findings d. advising the patient to request a bone scan from family physician as the x-ray may not fully demonstrate a fracture

Answer 99

a. Incorrect. This would not be appropriate since a fracture is not expected b. Correct. Since these findings suggest more of an advance in condition, it is imperative to get the patient to the emergency room to have the pressures measured in his compartment. Otherwise the patient may risk permanent structural and functional damage. This is typically done with a Wick catheter pressure reading device. c. Incorrect. Wasting time here and treating the wrong diagnosis would cause tissue damage per above. d. Incorrect. Again not the appropriate test. A fracture is not likely

Question 100

A 42 year old female complains of a six month history of medial heel and medial longitudinal arch pain primarily with walking and at night. Visual inspection reveals increased forefoot pronation. Symptoms are elicited with palpation just posterior to the medial malleolus. What would be the most likely diagnosis? a. Achilles Tendonitis b. Metatarsalgia c. Plantar Fasciitis d. Tarsal Tunnel Syndrome

Answer 100

a. Incorrect. There would not likely be arch pain associated with this b. Incorrect. This would result more from a drop in the 2nd and 3rd rays. Also, the pain would be more localized to the metatarsal heads c. Incorrect. This is commonly mistaken for tarsal tunnel syndrome. The patient does not report the classic morning pain associated with plantar Fasciitis. d. Correct. In this case the pain was reproduced with palpation posterior to the medial malleolus where the tarsal tunnel in usually compromised.

Question 101

What would be the best treatment choice for a patient with a Morton’s neuroma? a. Achilles and hamstring stretching b. Joint mobilizations to the metatarsals to promote improved mobility c. Neural tension stretching d. Supporting the transverse metatarsal arch with an appliance

Answer 101

a. Incorrect. This would not alleviate the mechanical causes of the dysfunction b. Incorrect. This would probably increase the symptoms because of the increased shearing of the inflamed nerve between the metatarsals. c. Incorrect. Again does not best address the mechanical source of dysfunction d. Correct. Supporting the transverse metatarsal arch increases the space between the metatarsals, thus taking compression away from the inflamed digital nerve.

Question 102

The most common mechanism for an ankle sprain is: a. calcaneal eversion, plantar flexion, and forefoot adduction b. calcaneal eversion, plantar flexion, and forefoot abduction c. calcaneal inversion, plantar flexion, and forefoot adduction d. calcaneal inversion, plantar flexion, and forefoot abduction

Answer 102

a. Incorrect. Calcaneal eversion would stress the medial structures and lateral ankle sprains are by far the most common. b. Incorrect. Same explanation as a. c. Correct. Most ankle sprains occur as a result of plantar flexion and calcaneal inversion. Typically the forefoot continues to get forced in forefoot adduction d. Incorrect. Forefoot abduction is typically not coupled with the other two force mechanisms

Question 103

The most commonly injured ligament in the ankle is the: a. anterior talofibular ligament b. anterior tibiofibular ligament c. calcaneofibular ligament d. deltoid ligament

Answer 103

a. Correct. This is the most commonly sprained ankle ligament b. Incorrect. This would likely compliment an anterior talofibular ligament injury c. Incorrect. This would be associated with an inversion, dorsi flexion mechanism of injury. In question 6, we established that plantar flexion and inversion, along with forefoot adduction is the most common mechanism of injury. d. Incorrect. This would result from an eversion mechanism which is much less common

Question 104

A 38 year old male was playing basketball with friends next door to your clinic. It just so happens your were having a free walk-in Saturday morning clinic to expand your sports-medicine and orthopedic expertise to the community. His friends carry him in and laid him on a plinth as he was unable to bear weight. He reported that while running, “it felt like someone kicked me in the back of my leg”. His calf is obviously deformed, and he is unable to actively plantar flex his foot Based on these findings, what is the most likely diagnosis. a. Achilles tendon rupture b. Flexor hallicus longus strain c. Peroneus longus strain d. Posterior tibialis rupture

Answer 104

a. Correct. The patient described the classic feeling of being kicked from behind. His calf is also deformed indicating the tendon may have retracted superiorly, and he cannot plantar flex the foot because of the loss of integrity of the Achilles tendon. b. Incorrect. Not a common injury. Usually this is pretty protected from trauma. More likely would occur from forcing the big toe into hyperextension, thus the capsule would probably be injured first. c. Incorrect. The patient reported pain posteriorly, not laterally. Likely he would be unable to evert his foot without difficulty. d. Incorrect. This would result in a collapsed medial longitudinal arch, and occurs more over time versus a direct trauma

Question 105

A 38 year old male was playing basketball with friends next door to your clinic. It just so happens your were having a free walk-in Saturday morning clinic to expand your sports-medicine and orthopedic expertise to the community. His friends carry him in and laid him on a plinth as he was unable to bear weight. He reported that while running, “it felt like someone kicked me in the back of my leg”. His calf is obviously deformed, and he is unable to actively plantar flex his foot. Which special test would best test the integrity of this structure a. Anterior drawer test b. Hoffa’s test c. Homans’ sign d. Thompson’s test

Answer 105

a. Incorrect. This would check the integrity of the anterior talofibular ligament b. Incorrect. This would test for a suspected calcaneal fracture c. Incorrect. This would test for a possible deep vein thromboplebitis d. Correct. By squeezing the calf and watching to see in plantar flexion of the foot is elicited, you are testing the integrity of the Achilles tendon

Question 106

A 38 year old male was playing basketball with friends next door to your clinic. It just so happens your were having a free walk-in Saturday morning clinic to expand your sports-medicine and orthopedic expertise to the community. His friends carry him in and laid him on a plinth as he was unable to bear weight. He reported that while running, “it felt like someone kicked me in the back of my leg”. His calf is obviously deformed, and he is unable to actively plantar flex his foot. Based on your findings, this patient was referred to orthopedics and a surgical repair of the involved tissue was done within 24 hours. At would point in his post-operative rehab would you consider isotonic strength training and proprioception for the repaired area? a. Three weeks b. Five weeks c. Seven weeks d. Nine weeks

Answer 106

a. Incorrect. Too early for any active motion to begin. Stretching may be initiated at this time however. b. Correct. The specified time to begin active shortening is four to six weeks c. Incorrect. Too long of a delay could promote adhesions, and decrease tensile strength of repair. d. Incorrect. Same explanation as c.

Question 107

What would be a good objective test to measure for a pes planus deformity? a. Buerger’s Test b. Duchenne’s Test c. Feiss Line Test d. Morton’s Test

Answer 107

a. Incorrect. This test is used to test for arterial insufficiency to the lower limb. b. Incorrect. This test is used to test for a lesion of the superficial peroneal nerve c. Correct. This test measures the degree of a fallen medial longitudinal arch d. Incorrect. This test is used to determine if a Morton’s neuroma is present.

Question 108

Which palpable structure would be the main point of reference for this test? a. 1st Cuneiform b. Cuboid tuberosity c. Head of talus d. Navicular tuberosity e. Sustentaculum tali

Answer 108

D. Correct. During this test, the examiner marks the apex of the medial malleolus, and the plantar aspect of the first metatarsophalangeal while non-weight bearing. A line is made between the two points. Then the examiner palpates the navicular tuberosity, noting where it is relative to the line previously drawn. The patient is then asked to stand and if the navicular tuberosity appears to fall towards the floor, this determines the degree of pes planus one may have.

Question 109

You are treating a 22 year old African American female, currently on birth control, and smokes. She is 2 days status post, right anterior cruciate repair and has been complaining of moderate posterior calf pain on the surgical side. Furthermore, she is significantly tender to gentle palpation in that area. What do these findings most likely suggest? a. Baker’s cyst b. Deep vein thromboplebitis c. Posterior compartment syndrome d. Stiffness secondary to immobilization

Answer 109

a. Incorrect. This would probably not be tender to light palpation. Also, this is usually more of a complication resulting from an injury such as a meniscus injury versus surgery. b. Correct. This gal has some pervasive risk factors. She is post-op, and any chance of DVT should be taken seriously here. Some extravasing of blood may occur here, but commonly the patient is not sensitive to light touch. c. Incorrect. Not a typical susceptible compartment for compression syndromes. It is usually more pliable then the anterior compartment. d. Incorrect. Do not brush this off as general extremity stiffness. The symptoms are too obtrusive and she is only two days post-op.

Question 110

You are treating a 22 year old African American female, currently on birth control, and smokes. She is 2 days status post, right anterior cruciate repair and has been complaining of moderate posterior calf pain on the surgical side. Furthermore, she is significantly tender to gentle palpation in that area. What would be an appropriate special test to use for this? a. Compression Test b. Homan’s Sign c. Morton’s Test d. Thompson Test

Answer 110

a. Incorrect. There is no such test. Do not mistake for the squeeze test for fracture or syndesmosis pathology. b. Correct. This test is specifically designed to test for a DVT, in association with other clinical findings of pain on palpation, pallor or swelling of the leg, with possible loss of dorsalis pedis pulse c. Incorrect. This tests for presence of a neuroma d. Incorrect. This would test for an Achilles rupture

Question 111

You are treating a 22 year old African American female, currently on birth control, and smokes. She is 2 days status post, right anterior cruciate repair and has been complaining of moderate posterior calf pain on the surgical side. Furthermore, she is significantly tender to gentle palpation in that area. How would you perform this test? a. Extend the knee and passively dorsi-flex the foot b. Extend the knee and passively plantar flex-the foot c. Flex the knee and passively dorsi-flex the foot d. Flex the knee and passively plantar flex the foot e. Squeeze the calf to see if pain is elicited and the foot plantar flexes

Answer 111

A. Correct. Good picture in Magee’s text, 3rd edition, page 638

Question 112

What is a simple method to confirm the results of homan's sign in your clinic? a. Assess if patient can achieve passive terminal knee extension b. Perform a wick’s catheter test c. Place a blood pressure cuff over affected area and inflate to reproduce symptoms d. Ultrasound, 1Mhz, 1.5w/cm2 continuous wave, over affected area to reproduce symptoms

Answer 112

a. Incorrect. Again do not suspect this is from a general loss of tissue flexibility from immobilization. So testing for ROM is not a concern. You may miss out on something significant and life endangering. b. Incorrect. This is not indicative of a compartment syndrome, therefore this test would not be of any benefit. c. Correct. This technique has been demonstrated to be very sensitive to DVT’s and it compliments your other clinical findings, especially if the patients leg was not painful to palpation. The cuff should be inflated from 180mmHg to 200mmHg to avoid breaking down the DVT, and allowing it to become a possible pulmonary embolism. d. Incorrect. This has the potential to dislodge the DVT, and allow it to become a possible life threatening pulmonary embolism.

Question 113

What would be the best special test to determine instability to anterior talofibular ligament? a. Anterior drawer test b. Swing test c. Talar tilt test d. Thompson test

Answer 113

a. Correct. This tests the integrity of the anterior talofibular ligament and the anterior tibiofibular ligament. There would be more laxity if both tissues were involved. b. Incorrect. This tests for posterior tibiotalar subluxation c. Incorrect. This tests for a sprained or torn calcaneofibular ligament d. Incorrect. This tests for a torn Achilles tendon.