OCS McGee 2

Question 1

A 55 year old male hospital volunteer presents to your clinic with an 8 month history of right anterior hip pain. The patient reports his symptoms have increased significantly over the past 2 months. He reports no symptoms with walking, however, his symptoms are exacerbated with static stance. Further questioning reveals the patient began working for Wal-Mart 10 weeks ago as a greeter. He will stand for 1-2 hours without a break during a typical workday. The patient originally saw his family physician for this condition 7 months ago. His physician suggested that he was overweight, and that going on a “diet” might help. The patient reports he has lost approximately 45 pounds in the last 7 months. The patient is 72 inches tall and weights approximately 210 pounds.

1. A physical examination reveals the following data. (+) Trendelenberg sign, (+) Ober’s test, (+) FABER test for pain, (-) Thomas test, (-) Femoral Grind test; MMT Gluteus Medius/Minimus 4/5 with reproduction of symptoms, Gluteus Maximus 4-/5, hip flexors and knee extensors/flexors 5/5. What is the most likely diagnosis?
   a. Avascular necrosis of the femoral head
   b. Gluteus Medius/Minimus strain
   c. Pubofemoral ligament & Y-Ligament sprain
   d. Trendelenberg gait

Answer 1

a. Incorrect. We would expect pain to be elicited with the Femoral Grind test and the patient’s aggravating factors would include walking as well as static stance because of the increased compression at the hip joint.
b. Incorrect. The patient does have slight weakness at these muscles. However, the patient is complaining of pain only during static stance. These muscles are not active during bilateral static stance so they are not the source of his pain.
c. Correct. During static stance, stability at the hips is provided entirely by its ligaments and capsule. The key element of this patient’s subjective history was when he reported anterior hip pain with static stance, not walking. Moreover, his symptoms coincide with beginning employment with Wal-Mart as a greeter. The weakness observed at the Gluteal muscles is most likely from a stretch reflex at the anterior hip capsule and ligaments. The Pubofemoral ligament checks extension and abduction while the Y-Ligament checks hyperextension of the hip. If these structures are injured, an inhibitory interneuron is often activated that synapses with the posterior muscles of the hip. By inhibiting these muscles, increased stretch (and further injury) can be avoided at these ligaments. The FABER sign was positive because this test placed a passive stretch on these ligaments. Ober’s sign was positive because it involves placing the patient in hip abduction and extension during the initial phase of the test.
d. Incorrect. This patient’s gait was not assessed. His (+) Trendelenberg sign was most likely due to inhibited Gluteal muscles.

Question 2

A 55 year old male hospital volunteer presents to your clinic with an 8 month history of right anterior hip pain. The patient reports his symptoms have increased significantly over the past 2 months. He reports no symptoms with walking, however, his symptoms are exacerbated with static stance. Further questioning reveals the patient began working for Wal-Mart 10 weeks ago as a greeter. He will stand for 1-2 hours without a break during a typical workday. The patient originally saw his family physician for this condition 7 months ago. His physician suggested that he was overweight, and that going on a “diet” might help. The patient reports he has lost approximately 45 pounds in the last 7 months. The patient is 72 inches tall and weights approximately 210 pounds.

2. Assume this patient was overweight when he saw his physician 7 months ago. Based on your knowledge of the biomechanics at the hip, was this patient’s physician correct in his advice that if he lost weight his pain would resolve?
   a. Yes
   b. No

Answer 2

a. Incorrect. This patient only complained of pain with static stance. The forces at the hip during static stance is only 0.3 times the body weight. Given this perspective, it is highly unlikely that this patient’s weight was exacerbating his symptoms.
b. Correct.

Question 3

3. What is the “inverted (reverse) action” of the Piriformis muscle?
   a. Acts as a hip external rotator, flexor, and abductor beyond 30° of hip flexion
   b. Acts as a hip adductor and internal rotator beyond 45° of hip flexion
   c. Acts as a hip abductor and internal rotator beyond 60° of hip flexion
   d. Acts as a hip adductor and flexor beyond 75° of hip flexion

Answer 3

a. Incorrect. The Piriformis’ primary function is that of an external rotator, flexor and abductor. It is not its inverted action
b. Incorrect.
c. Correct.
d. Incorrect.

Question 4

A 75 year old female presents to your clinic with a 3 week history of left knee pain of an insidious onset. She reports her pain is increased with activity and decreased with rest, primarily seated in a recliner or laying in bed. Her pain is steadily getting worse without sign of improvement. Radiographs of her left knee, taken at her physician’s office, are without sign of pathology. Prior medical history is significant for osteoporosis and diabetes. She also reports she is a cancer survivor. She reports she increased her daily walking regimen one month ago from 20 minutes a day to 60 minutes a day at the request of her cardiologist. She is taking medication for hypertension, diabetes, osteoporosis, and depression. She states her husband died 5 months ago and she has been severely depressed, however, her medications are improving her mood. She also moved into an assisted-living facility last week at the request of her daughters because she was too depressed to cook and clean for one and is eating more consistently as a result.

4. You physical examination of the left knee reveals no deficits in range of motion or strength. Special tests for ligamentous and meniscal pathology are also negative. Gait assessment reveals an antalgic gait on the left. Her ability to balance in left single leg stance is also significantly diminished due to pain. Based on this information, what would the most appropriate next course of action?
   a. Perform an evaluation of her left foot and ankle
   b. Perform an evaluation of her left hip
   c. Perform an evaluation of her lumbar spine
   d. Refer her back to her physician for an MRI of her knee

Answer 4

a. Incorrect. While poor biomechanics of the foot and ankle could cause knee pain, the pain at the knee is typically caused by altered biomechanics that results in an overuse pathology. The physical exam of the knee would have elicited this.
b. Correct. The hip is a major source of pain referral to the knee. Often, in cases of avascular necrosis, a complaint of same-sided knee pain is the first sign of pathology at the hip. Also, her primary complaint of symptoms is with weightbearing – typical in the referral of pain from the hip to the knee.
c. Incorrect. The lumbar spine can refer pain, however, rarely is it isolated to the knee. It would also seem likely that a pain referral from the lumbar spine would involve symptoms at the lumbar spine as well.
d. Incorrect. An MRI is an expensive test that is typically used to rule in or rule out a suspected pathology. You do not have a diagnosis to confirm or rule out with an MRI.

Question 5

Questions 4-5 refer to the case below

A 75 year old female presents to your clinic with a 3 week history of left knee pain of an insidious onset. She reports her pain is increased with activity and decreased with rest, primarily seated in a recliner or laying in bed. Her pain is steadily getting worse without sign of improvement. Radiographs of her left knee, taken at her physician’s office, are without sign of pathology. Prior medical history is significant for osteoporosis and diabetes. She also reports she is a cancer survivor. She reports she increased her daily walking regimen one month ago from 20 minutes a day to 60 minutes a day at the request of her cardiologist. She is taking medication for hypertension, diabetes, osteoporosis, and depression. She states her husband died 5 months ago and she has been severely depressed, however, her medications are improving her mood. She also moved into an assisted-living facility last week at the request of her daughters because she was too depressed to cook and clean for one and is eating more consistently as a result.
5. Let’s assume you eventually evaluated this patient’s left hip. Your physical examination revealed the following.
• Tenderness to palpation over the groin and inguinal ligament
• Pain at end-range of hip internal and external rotation
• Pain and difficulty performing a straight leg raise in supine
• (+) Calcaneal percussion test
• (-) Femoral Grind test
• MMT hip adductors 4+/5 with slight pain

Based on all of the information presented, what is the most likely diagnosis?

a. Femoral stress fracture
b. Hip Adductor strain
c. Osteonecrosis
d. Slipped Capital Femoral Epiphysis

Answer 5

a. Correct. Femoral neck stress fractures are associated with “deep” hip pain, inguinal ligament pain, groin pain, or knee pain. Pain is typically increased with activity and is associated with a change in activity. Recall that this patient changed her daily walking regimen from 20 minutes daily to 60 minutes. This change occurred one week before symptom onset. Common physical examination findings included tenderness to palpation over the groin and inguinal ligament and pain with end-range hip rotation. Patients will often have difficulty and pain while performing a straight-leg raise and the Calcaneal Percussion test is often positive as well. These are due to overuse and not trauma.
b. Incorrect. Hip adductor MMT were strong with slight pain. The slight pain is expected due to the stress fracture. Also, it is very unlikely that the hip adductors would refer pain to the knee – their referral pattern is to the middle of the medial thigh.
c. Incorrect. We would expect a positive Femoral Grind test and pain at the hip with single limb stance.
d. Incorrect. This is seen in adolescent populations.

Question 6

6. If this patient’s pathology was a femoral neck stress fracture, which subcategory would it most likely fall into?
   a. Insufficiency fracture
   b. Trabecular microfracture

Answer 6

a. Correct. These are typically seen in the elderly populations and are a result of overuse. Predisposing factors include diabetes, osteoporosis, rheumatoid arthritis, and irradiation. Also, femoral neck stress fractures are highly correlated with eating disorders. Recall, this woman also stated she had not been eating very well due to depression.
b. Incorrect.

Question 7

Questions 7-9 refer to the case below

A 17 year old highschool cross country track runner who averages 35 miles a week reports a 6 month history of right lateral hip pain. Initially, the pain occurred only after running, but is now hurting her continuously throughout the course of the day. She reports pain with right sidelying. Past medical history is significant for left proximal Tibial fracture that was surgically repaired with open reduction internal fixation when she was 12 years old. Physical examination reveals asymmetry at the pelvic landmarks (patient standing) with the left ASIS superior compared to the right. MMT of hip flexors, internal rotators, and extensors is 5/5 without pain; abduction 4+/5 with pain; external rotators 4/5 with pain. Obers and FABER’s tests are positive. Femoral Grind test is negative. Patient demonstrates moderate ITB tightness and tenderness to palpation along the right greater trochanter.

7. What would be the most likely diagnosis?
   a. Greater Trochanteric bursitis
   b. Iliopectineal bursitis
   c. SI Joint dysfunction
   d. Slipped Captial Femoral Epiphysis

Answer 7

a. Correct. This is an overuse injury. Symptoms are elicited with tests and positions that place stress on the lateral hip structures (FABER’s, Ober’s) and MMT of posterior hip muscles that insert on the Greater Trochanter would be weak with pain. Note, the patient reports the condition has worsened and the pain is now continuous. This is suggestive of a more advanced stage of the inflammation.
b. Incorrect. This condition typically presents more anteriorly where the iliopectinial bursa covers the Iliopsoas and Pectineus muscles. Tenderness to palpation would be elicited over the femoral triangle, not the greater trochanter.
c. Incorrect. FABER’s test is often positive for SI Joint pathology and the SI Joint can refer to the hip. However, this patient has specific pain and tenderness over the Greater Trochanteric bursa.
d. Incorrect. This patient had a negative Femoral Grind test. Also, it is highly unlikely that this patient would be running 35 miles a week with this condition.

Question 8

Questions 7-9 refer to the case below

A 17 year old highschool cross country track runner who averages 35 miles a week reports a 6 month history of right lateral hip pain. Initially, the pain occurred only after running, but is now hurting her continuously throughout the course of the day. She reports pain with right sidelying. Past medical history is significant for left proximal Tibial fracture that was surgically repaired with open reduction internal fixation when she was 12 years old. Physical examination reveals asymmetry at the pelvic landmarks (patient standing) with the left ASIS superior compared to the right. MMT of hip flexors, internal rotators, and extensors is 5/5 without pain; abduction 4+/5 with pain; external rotators 4/5 with pain. Obers and FABER’s tests are positive. Femoral Grind test is negative. Patient demonstrates moderate ITB tightness and tenderness to palpation along the right greater trochanter.

1. Based on her pelvic asymmetries and her prior medical history of a tibial fracture, you decide to assess her leg length in supine. Prior to assessing her leg length, you perform which of the following techniques to align her pelvis?
   a. Watson’s Test
   b. Weber Test
   c. Weber-Barstow Maneuver
   d. Wright’s Maneuver

Answer 8

a. Incorrect. This is a test for Scaphoid Instability (Scaphoid-Shift test)
b. Incorrect. This is a test for conductive hearing loss
c. Correct. The patient lies supine with their hips and knees flexed. They raise their buttocks off of the treatment table three times and then straighten their legs for assessment. The examiner then palpates and observes for asymmetry at the medial malleoli
d. Incorrect. This is a test for Thoracic Outlet Syndrome.

Question 9

Questions 7-9 refer to the case below

A 17 year old highschool cross country track runner who averages 35 miles a week reports a 6 month history of right lateral hip pain. Initially, the pain occurred only after running, but is now hurting her continuously throughout the course of the day. She reports pain with right sidelying. Past medical history is significant for left proximal Tibial fracture that was surgically repaired with open reduction internal fixation when she was 12 years old. Physical examination reveals asymmetry at the pelvic landmarks (patient standing) with the left ASIS superior compared to the right. MMT of hip flexors, internal rotators, and extensors is 5/5 without pain; abduction 4+/5 with pain; external rotators 4/5 with pain. Obers and FABER’s tests are positive. Femoral Grind test is negative. Patient demonstrates moderate ITB tightness and tenderness to palpation along the right greater trochanter.

1. You determine that this patient has a short left leg. You suspect this is due to her left Tibial fracture when she was 12. What was the most probable Salter-Harris Classification of that fracture?
   a. Type 1
   b. Type 2
   c. Type 3
   d. Type 5

Answer 9

a. Incorrect. This involves a complete separation of the growth plate and the bone. The prognosis is good.
b. Incorrect. This is the most common form of injury involving a fracture through the metaphysis. The prognosis is excellent.
c. Correct. This is an intraarticular fracture of the epiphysis. Open reduction internal fixation is required to stabilize the injury.
d. Incorrect. This involves a crush-type injury. It is very uncommon.

Question 10

10. An increase in femoral anteversion at the hip would be most closely associated with which of the following findings?
    a. Lateral femoral torsion and toeing in
    b. Lateral femoral torsion and toeing out
    c. Medial femoral torsion and toeing in
    d. Medial femoral torsion and toeing out

Answer 10

a. Incorrect.
b. Incorrect. This would be associated with femoral retroversion
c. Correct.
d. Incorrect.

Question 11

Questions 11-12 refer to the case below

A 36 year old male presents to your clinic with right sided groin pain associated with a popping sensation. The patient cannot recall any specific mechanism of injury. He reports he is unable to sit “Indian-style” on the floor while playing with his children. Physical examination reveals negative Femoral Grind test. Placing the patient’s right hip in a position of flexion, external rotation, and abduction and then rapidly moving it into extension, internal rotation, and adduction produces a sharp pain “deep” in the groin area.

11. Based on this information, what is the most likely diagnosis?
    a. Anterior Acetabular labral tear
    b. DJD Hip
    c. Iliopectineal Bursitis
    d. Legg-Calves-Perthes disease

Answer 11

a. Correct. Acetabular tears are caused by a slipping or twisting injury. The patient will typically not be able to pinpoint an exact mechanism of injury. Pain associated with popping or snapping “deep” within the hip is a common complaint. Limited range of motion into rotation is common (this patient could not sit “Indian-style” on the floor). The special test described above is specific for Anterior Acetabular tears.
b. Incorrect. This would not involve a mechanism of injury, however, patients would most likely have a positive Femoral Grind test and not have snapping or popping associated with their pain.
c. Incorrect. This is associated with anterior hip pain without snapping or popping. It is typically an overuse injury.
d. Not even close. This patient is about 30 years too old for this diagnosis. The hip adduction test is most specific for LCPD. This test involves the examiner passively flexing and adducting the involved hip. If the knee can go past the contralateral ASIS without pain, it is negative for LCPD. It has been thought that radiographs were the best diagnostic tool for this pathology, however, recent studies reveal poor objectivity in radiographic classification of the disease.

Question 12

Questions 11-12 refer to the case below

A 36 year old male presents to your clinic with right sided groin pain associated with a popping sensation. The patient cannot recall any specific mechanism of injury. He reports he is unable to sit “Indian-style” on the floor while playing with his children. Physical examination reveals negative Femoral Grind test. Placing the patient’s right hip in a position of flexion, external rotation, and abduction and then rapidly moving it into extension, internal rotation, and adduction produces a sharp pain “deep” in the groin area.

12. What would be the best treatment option for this patient?
    a. Surgical removal of the torn portion of the labrum
    b. Strengthening exercises for the muscles crossing the hip joint
    c. Anti-inflammatory treatment
    d. Stretching exercises

Answer 12

a. Correct. This is the preferred treatment for Acetabular tears
b. Incorrect. This would be a logical choice for DJD
c. Incorrect. This would be a logical choice for Iliopectineal bursitis.
d. Incorrect. This would be a logical choice for LCPD as it is a self-limiting disease.

Question 13

13. You are performing the Supine-to-Longsit test on a patient with suspected leg length discrepancy. When the patient is supine you note the right leg to be longer than the left. When the patient moves into Longsit, the right leg becomes shorter than the left. What do these findings most likely indicate?
    a. Right anterior innominate rotation
    b. Left posterior innominate rotation
    c. Anatomical leg length dysfunction
    d. Iliosacral dysfunction

Answer 13

a. Incorrect. According to Magee (Orthopedic Physical Assessment, 3rd ed, pg 448) this would be the correct response. However, this answer is too specific for the limited information presented. The examiner would need to find a positive test for right SIJ hypomobility in conjunction with the above findings in order to be confident that the diagnosis was a right anterior innominate rotation.
b. Incorrect. Again, you would need a positive test for left SIJ hypomobility for this to be the correct diagnosis.
c. Incorrect. A positive test rules out a true anatomical leg length
d. Correct. A positive Supine-to-Longsit test rules out a sacroiliac dysfunction and rules in an iliosacral dysfunction (example: innominate rotation)

Question 14

Questions 14-16 refer to the case below

A 64 year old male is one day status post right total hip replacement. The surgeon performed the surgery with an posterio-lateral approach and chose an cemented prosthesis. The patient is alert and oriented x3, is on an epidural for pain that is scheduled to be removed the following morning. He rates his current pain at 1/10 on a visual analog scale. You are seeing the patient on your hospital’s acute care floor. His physician plans to discharge him to the rehab floor within the next 48 hours.

14. Base on this information, what would this patient’s hip precautions be?
    a. No flexion above 60°, adduction beyond midline, and external rotation
    b. No flexion above 75°, adduction beyond midline, and internal rotation
    c. No flexion above 90°, adduction beyond midline, and internal rotation
    d. No flexion above 110°, adduction beyond midline, and external rotation

Answer 14

a. Incorrect. This is the precautions for a posterior surgical approach
b. Incorrect
c. Correct
d. Incorrect

Question 15

Questions 14-16 refer to the case below

A 64 year old male is one day status post right total hip replacement. The surgeon performed the surgery with an posterio-lateral approach and chose an cemented prosthesis. The patient is alert and oriented x3, is on an epidural for pain that is scheduled to be removed the following morning. He rates his current pain at 1/10 on a visual analog scale. You are seeing the patient on your hospital’s acute care floor. His physician plans to discharge him to the rehab floor within the next 48 hours.

15. What would this patient’s weightbearing precautions be?
    a. Full weight bearing
    b. Non-weight bearing (NWB)
    c. Touch down weight bearing (TDWB)
    d. Weight bearing as tolerated (WBAT)

Answer 15

d. Correct. Cemented procedures are generally WBAT. Refer to the protocols in your course packet. Cemented procedures only weaken over time. Their fixation is as strong as they are ever going to be day 1 post-op.

Question 16

Questions 14-16 refer to the case below

A 64 year old male is one day status post right total hip replacement. The surgeon performed the surgery with an posterio-lateral approach and chose an cemented prosthesis. The patient is alert and oriented x3, is on an epidural for pain that is scheduled to be removed the following morning. He rates his current pain at 1/10 on a visual analog scale. You are seeing the patient on your hospital’s acute care floor. His physician plans to discharge him to the rehab floor within the next 48 hours.

16. Had this patient’s prosthesis been uncemented, what would his weight bearing precautions have been instead?
    a. Full weight bearing
    b. Non-weight bearing(NWB)
    c. Touch down weight bearing(TDWB)
    d. Weight bearing as tolerated(WBAT)

Answer 16

c. Correct. Toe touch weight bearing is the generally accepted protocol guidelines. Again refer to the protocols in your course packet. The reason for more limited weight bearing restrictions is the instability of the prosthesis as healing occurs.

Question 17

17. A 23 year old male presents to your clinic complaining of right thigh and testicular pain that is exacerbated with standing and walking. He reports this pain came on insidiously 3 days ago. Relieving factors include laying supine with the hips and knees flexed. The patient is not taking any medication except Tylenol prn because of a low-grade fever. Physical examination findings include tenderness to palpation at McBurney’s Point, negative Femoral Grind test, and reproduction of symptoms with SI compression test. There is no tenderness to palpation at the right thigh and MMT at the right hip are without noted deficit. Based on this information, what is the most likely diagnosis?
    a. Hernia
    b. Iliopsoas strain
    c. Retrocecal appendicitis
    d. SI Joint dysfunction

Answer 17

a. Incorrect. Hernias are not associated with thigh pain or fever
b. Incorrect. Iliopsoas does not refer pain into the testicular area. There would be deficits and/or pain with hip flexor strength testing as well.
c. Correct. Retrocecal appendicitis refers pain to the right thigh and testicle. Appendicitis is associated with insidious onset, low-grade fevers, and patients often find relief by bringing their knees to their chest (as this patient reported). Tenderness to McBurney’s Point is a key finding: it is located between the right ASIS and the umbilicus (over the appendix). The SI Compression test was most likely positive due to the fact that you have to press in the area of McBurney’s Point to perform the test.
d. Incorrect. The SI Joint can refer pain into the groin and proximal thigh. The SI Compression test was most likely positive due to the fact that you have to press in the area of McBurney’s Point to perform the test.

Question 18

1. A 64 year old male reports to you with a referral of right knee osteoarthritis. Upon interviewing him, he informs you that while squatting in his garden, he felt a “pinching sensation” in the back of his knee. Exam reveals an inability to deep knee squat on that side, and painful limited ROM in flexion beyond 90 degrees. Pt is able flex his unaffected leg to 130 degrees. He has tenderness to palpation in the postero-lateral joint line. He has a normal valgus/varus and Lachman’s test. There is pain elicited with Apley’s compression, and is relieved by distraction. Nothing significant is noted with McMurray’s. Based on these findings, do you suspect:
   a. The patient’s findings are consistent with osteoarthritis
   b. The patient may have a meniscus tear
   c. The patient may have strained his bicep’s femoris
   d. The patient may have subluxed his patella

Answer 18

a. Incorrect. Sometimes osteoarthritis may limit range of motion, but this patient had a mechanism of injury.
b. Correct. This patient had a common mechanism for someone his age for a posterior horn meniscus tear. Usually stiffness will limit the posterior translation of the meniscus on the tibia, which sets the posterior horn up for getting pinched in the joint.
c. Incorrect. Not a mechanism for a hamstring strain.
d. Incorrect. This patients pain is all posterior and not in the area of the patella retinaculum.

Question 19

2. Why would an anterior cruciate injury be more apt to swell immediately following injury versus a meniscus injury, which could take from 24 to 48 hours to swell?
   a. Cruciates are extrasynovial and extracapsular, menisci are intrasynovial
   b. Cruciates are extrasynovial and intracapsular, menisci are intrasynovial
   c. Cruciates are intrasynovial and extracapsular, menisci are extrasynovial
   d. Cruciates are intrasynovial and intracapsular, menisci are extrasynovial

Answer 19

b. Correct. The fact that the cruciates are within the capsule and have a good blood supply would set them up for a quick bleed when injured, and thus immediate swelling. Menisci are bated in synovium, and synovitis-type swelling would occur over a longer period of time. (approximately 24 hours)

Question 20

Questions 3 – 5 refer to the case below

You are evaluating a patient referred to you from the emergency room. She is a 17 year old female who was struck from behind during an MVA x 1 week ago. She indicated that her R knee struck the dashboard and she felt a “pop”. X-rays in the emergency room were negative for fracture. She notes that her R leg has buckled since on a couple of occasions. During your examination, you observe that she has a positive “sag sign”.

3. Given this presentation, what injury do you suspect that she has sustained?
   a. Anterior Cruciate Ligament Injury
   b. Medial Collateral Ligament Injury
   c. Meniscus Injury
   d. Posterior Cruciate Ligament Injury

Answer 20

a. Incorrect. This resulted from a hyperflexion mechanism. She also has a posterior sag on exam.
b. Incorrect. No valgus stress
c. Incorrect. No rotary mechanism. Not enough information to completely rule this out, but the mechanism indicated points to something else more obvious.
d. Correct. This can be a typical mechanism for a PCL injury. A posterior sag presentation should immediately raise your suspicion this structure might be involved.

Question 21

vQuestions 3 – 5 refer to the case below

You are evaluating a patient referred to you from the emergency room. She is a 17 year old female who was struck from behind during an MVA x 1 week ago. She indicated that her R knee struck the dashboard and she felt a “pop”. X-rays in the emergency room were negative for fracture. She notes that her R leg has buckled since on a couple of occasions. During your examination, you observe that she has a positive “sag sign”.

4. What would be an appropriate special test to check the integrity of this structure?
   a. Anterior Drawer Test
   b. Pivot Shift Test
   c. Posterior Drawer Test
   d. Valgus Stress Test

Answer 21

a. Incorrect. This checks the integrity of the anterior cruciate ligament. You may get a positive finding with this if the posterior elements are disrupted if you begin the test in a degree of post-tibial translation
b. Incorrect. ACL test
c. Correct.
d. Incorrect. This checks the integrity of the medial collateral ligament

Question 22

Questions 3 – 5 refer to the case below

You are evaluating a patient referred to you from the emergency room. She is a 17 year old female who was struck from behind during an MVA x 1 week ago. She indicated that her R knee struck the dashboard and she felt a “pop”. X-rays in the emergency room were negative for fracture. She notes that her R leg has buckled since on a couple of occasions. During your examination, you observe that she has a positive “sag sign”.

5. During your exam, you note laxity present with a Lachman’s test. Does this confirm the patient has a torn anterior cruciate ligament injury?
   a. True
   b. False

Answer 22

b. Correct. A torn posterior cruciate ligament may cause a degree of posterior translation at the tibofibular joint. So when you begin this test, the tibia may already be posterior translated sot that you feel increased laxity with your line of pull. Thus, giving the impression of a positive test (false positive). It is important to note the quality of the “end feel when performing a Lachman’s.

Question 23

Questions 6-7 refer to the case below.

A 13 year old male is brought to your clinic by his mother. He has a three-month history of knee pain that is worse with running, jumping, and ascending or descending stairs. His mother notes that he has had a growth spurt of about 2-3 inches over the last year. Your examination findings reveal a tender palpable bump in the area of the tibial tubercle. It is also moderately warm to touch. His ROM appears fine and he has good strength with some mild pain with resisted quadriceps action. He also has moderate tightness of his quadriceps and hamstrings.

6. Based on your findings, what is the likely diagnosis?
   a. Chondromalacia
   b. Osgood Schlater’s Disease
   c. Patella Femoral Syndrome
   d. Seaver’s Disease

Answer 23

a. Incorrect. This would likely be seen in an older individual unless there was a precipitating trauma.
b. Correct. The palpable tender bump gives this away. This is normally seen in young adolescents who are rapidly growing. The musculature is not keeping up with the long bone growth, thus creating a pull, or apophysitis traction type of inflammation at the quad insertion.
c. Incorrect, This might coexist, but is not the best answer here
d. Incorrect. Similar apophysits condition at the Achilles attachment on the calcaneous.

Question 24

Questions 6-7 refer to the case below.

A 13 year old male is brought to your clinic by his mother. He has a three-month history of knee pain that is worse with running, jumping, and ascending or descending stairs. His mother notes that he has had a growth spurt of about 2-3 inches over the last year. Your examination findings reveal a tender palpable bump in the area of the tibial tubercle. It is also moderately warm to touch. His ROM appears fine and he has good strength with some mild pain with resisted quadriceps action. He also has moderate tightness of his quadriceps and hamstrings.

7. What would be the most appropriate treatment for this patient?
   a. Open chain quadriceps strengthening exercises
   b. Knee sleeve with donut cutout
   c. Phonophoresis; 1.2 watts/cm2 x 6 minutes, 3 x week
   d. Quadricep stretching and counterforce brace

Answer 24

a. Incorrect. This would likely increase the symptoms by increasing tension on the quadriceps attachment.
b. Incorrect. May help to some degree with compression, but does not address the underlying mechanics
c. Incorrect. May help decrease inflammation, but again does not address underlying mechanics
d. Correct. Increasing flexibility of the quadriceps would decrease the tension at its insertion, thus decreasing the source of the symptoms. Also a counterforce brace is sometimes helpful in decreasing the tension at the quadriceps insertion when it’s active.

Question 25

8. A 21 year old male college rugby player presents with a one month history of insidious L knee swelling and pain with sitting. This patient has no past medical history of knee problems. Physical exam does not reveal anything significant, other then a moderately swollen L knee that is warm to touch, and painful with full flexion. A week later, this patient brings to your attention that his R knee is now similarly swollen. Upon questioning the patient further, he informs you that he has had Chlamydia, and is also experiencing painful urination. What condition should you rule out before progressing with treatment?
   a. Lyme’s disease
   b. Psoratic Arthritis
   c. Raynaud’s Syndrome
   d. Reiter’s Syndrome

Answer 25

a. Incorrect. No evidence of a tick bite, plus patient has painful urination and a history of STD.
b. Incorrect. Typically associated with skin involvement.
c. Incorrect. Associated with digital arteriole involvement, characterized by blanching and numbness of the fingers and toes.
d. Correct. The presence of an STD, and possible urethritis are strong indicators for this condition. Furthermore, the patient is now complaining of an insidious onset of symptoms in his other knee – indicating possible systemic origin of symptoms
**Our apologies to all of you rugby players

Question 26

9. The medial meniscus is C-shaped, while the lateral meniscus is O-shaped
   a. True
   b. False

Answer 26

a. Correct.

Question 27

10. A 45 year old male has had a 2 week history of insidious knee pain. Physical exam reveals nothing significant other then a hot swollen joint that is painful with movement. The patient does have a past medical history of a R tibial bone infection from a trauma several years ago. Based on this information, what condition must you be prepared to rule out?
    a. Lymes’ Disease
    b. Osteomalacia
    c. Osteomyelitis
    d. Reiter’s Syndrome

Answer 27

a. Incorrect. No evidence of a tick bite.
b. Incorrect. This is a metabolic bone disorder, characterized by weakening of the bones and multiple unexplained fractures.
c. Correct. Any sort of deep bony infection, predisposes one to this type of condition which can result in bone and joint destruction at a later time.
d. Incorrect. This can be possible, but the fact that the patient had a previous deep bony infection earlier make osteromyelitis the best answer.

Question 28

Questions 11 – 13 refer to the case below

A 50 year old flooring specialist reports to your clinic with a 1 week history of a large anterior knee effusion. The patient cannot recall a specific mechanism of injury but reports the front of his knee is very tender and it is difficult to perform his job as he has to do a lot of kneeling. Physical exam reveals a tender palpable thickening of the anterior knee. Special tests are negative, and the patient has pain with flexion greater then 100 degrees.

11. What is the most likely diagnosis?
    a. Illiotibial band syndrome
    b. Patella femoral syndrome
    c. Pes anserine tendonitis
    d. Pre patellar bursitis

Answer 28

a. Incorrect. This patient’s pain is not lateral.
b. Incorrect. Typically does not present with a large anterior effusion
c. Incorrect. Again would not cause a large anterior effusion
d. Correct. The patient is a floorer, and has to do a lot of kneeling. Repetitive kneeling can traumatize the pre patellar bursae over time and produce a round superficial anterior knee effusion that is tender to further pressure.

Question 29

Questions 11 – 13 refer to the case below

A 50 year old flooring specialist reports to your clinic with a 1 week history of a large anterior knee effusion. The patient cannot recall a specific mechanism of injury but reports the front of his knee is very tender and it is difficult to perform his job as he has to do a lot of kneeling. Physical exam reveals a tender palpable thickening of the anterior knee. Special tests are negative, and the patient has pain with flexion greater then 100 degrees.

12. What would be the best treatment choice for this patient?
    a. A padded knee sleeve, NSAIDs, and quad stretching
    b. Progressive lower extremity isotonic exercises using the DAPRE method
    c. Strengthening for the vastus medialis and hip adductors
    d. Ulrasound; 1.5 watts/cms continuous cycle, x 6 minutes, 3 x week

Answer 29

a. Correct. Protect against the mechanism of injury, and keep forces off the patellar femoral joint to prevent any further patellar femoral complications
b. Incorrect. We are not dealing with a weakness issue
c. Incorrect. Again, not dealing with a weakness issue
d. Incorrect. May assist with healing, but does not protect from the true mechanism of injury. The knee pad will protect from further trauma.

Question 30

Questions 11 – 13 refer to the case below

A 50 year old flooring specialist reports to your clinic with a 1 week history of a large anterior knee effusion. The patient cannot recall a specific mechanism of injury but reports the front of his knee is very tender and it is difficult to perform his job as he has to do a lot of kneeling. Physical exam reveals a tender palpable thickening of the anterior knee. Special tests are negative, and the patient has pain with flexion greater then 100 degrees.

13. Upon further observation, you note that the patient’s skin around the knee is very dry and cracks are apparent. Based on this, what would you recommend and why?
    a. That the patient washes the area well with soap / water, and apply skin cream to prevent infection from being introduced to the knee
    b. That the patient monitor for any echymosis
    c. That the patient follow up with his physician to consider aspiration as their may be a gram negative stain bacteria present
    d. Whirlpool therapy to decrease swelling, and to decrease dryness

Answer 30

a. Correct. Having dry skin could predispose the patient to an infection, as disintegrity of the tissue makes it easier for a bug to enter the system. Good skin hygene and moisturizer is a must.
b. Incorrect. ???
c. Incorrect. No signs of infection yet, Too hasty.
d. Incorrect. The whirlpool would likely dry the skin tissue further by washing away the natural protective skin oils.

Question 31

14. You are treating a 35 year old 385 pound man. He has known degenerative joint disease of his L knee. He has a pretty severe genu varum deformity. Where would you likely expect most of the arthritis findings to be apparent on x-ray.
    a. Lateral joint line
    b. Medial joint line
    c. Patellar femoral joint
    d. Proximal tibofibular joint

Answer 31

b. Correct. A genu vara deformity loads the medial compartment making it more susceptible it to medial compartment arthritis.

Question 32

15. What structure is most likely injured during a lateral patella subluxation?
    a. Lateral patellar retinaculum
    b. Medial patellar retinaculum
    c. Patellar tendon
    d. Vastus medialis obliques

Answer 32

a. Incorrect.
b. Correct. As the patella is displaced laterally, this stresses the supporting retinacular structure on the medial side.
c. Incorrect. Not likely
d. Incorrect. Not completely correct because it’s connective tissue expansion (medial retinaculum) is what is torn.

Question 33

16. When would aquajogging be indicated for a post-operative total knee patient?
    a. Between 3-4 weeks
    b. Between 4-5 weeks
    c. Between 5-6 weeks
    d. Between 6-7 weeks

Answer 33

d. Correct. Refer to the protocols in your course packet

Question 34

Questions 17 – 19 refer to the case below

A 19 year old female injured her R knee x 2 days ago after a fall while skiing. She recalls twisting her knee and feeling a “pop”, which was associated with immediate swelling. Physical findings include AROM between –10 degrees extension, and – 20 degrees flexion versus the uninvolved side. You note a positive Lachman’s test and a postive anterior drawer test.

17. Given your clinical examination findings, what do you suspect is the likely diagnosis?
    a. Anterior cruciate ligament injury
    b. Medial collateral ligament injury
    c. Medial meniscus injury
    d. Posterior cruciate ligament injury

Answer 34

a. Correct. You have a rotational mechanism, immediate swelling, and special tests that are positive for ACL findings.
b. Incorrect. No valgus stress noted
c. Incorrect. May be present, but not given enough information above
d. Incorrect.

Question 35

Questions 17 – 19 refer to the case below

A 19 year old female injured her R knee x 2 days ago after a fall while skiing. She recalls twisting her knee and feeling a “pop”, which was associated with immediate swelling. Physical findings include AROM between –10 degrees extension, and – 20 degrees flexion versus the uninvolved side. You note a positive Lachman’s test and a postive anterior drawer test.

18. What diagnostic test would be most appropriate to confirm your clinical findings?
    a. Computed tomography test (CT)
    b. Magnetic Resonance Arthrogram (MRA)
    c. Magnetic Resonance Imaging (MRI)
    d. X-ray

Answer 35

C. Correct. An MRI is the most sensitive to determine an anterior cruciate ligament. X-rays would not demonstrate a soft tissue injury.

Question 36

Questions 17 – 19 refer to the case below

A 19 year old female injured her R knee x 2 days ago after a fall while skiing. She recalls twisting her knee and feeling a “pop”, which was associated with immediate swelling. Physical findings include AROM between –10 degrees extension, and – 20 degrees flexion versus the uninvolved side. You note a positive Lachman’s test and a postive anterior drawer test.

19. What structures would be involved if this patient was determined to have a Terrible (Unhappy) Triad of O’ Donoghue?
    a. Anterior cruciate, medial meniscus, lateral collateral ligament
    b. Anterior cruciate, medial meniscus, medial collateral ligament
    c. Posterior cruciate, medial meniscus, lateral collateral ligament
    d. Posterior cruciate, medial meniscus, medial collateral ligament

Answer 36

b. Correct.

Question 37

20. You are treating a patient with an anterior cruciate ligament reconstruction (hamstring graft), with a meniscus repair. When would ROM beyond 90 degrees flexion be allowed?
    a. Immediately
    b. 2 weeks post-op
    c. 6 weeks post-op
    d. 10 weeks post-op

Answer 37

d. Correct. 8-10 weeks of ROM < 90 is recommended to avoid disrupting meniscal repair.