Sport/Ortho-2

Question 1

A 20-year-old college student comes to your office on Monday morning after injuring his right arm during a rugby match 2 days earlier. He is not certain of the mechanism of injury but was struck forcefully on the lower posterior part of his upper arm above the elbow. He describes paresthesias on the extensor side of his forearm and the back of his hand. His upper arm is bruised and mildly swollen at the described location.

In addition to the paresthesias on the extensor forearm and the back of the hand, which one of the following motor findings would you expect? (check one)
An inability to maintain all fingers fanned out under resistance
Weakness of elbow flexion with the hand in a prone position
Weakness of finger and wrist extension under resistance
Weakness of flexion of the fourth and fifth fingers
Weakness of thumb apposition

Answer 1

Weakness of finger and wrist extension under resistance

This student athlete likely has a contusion to the radial nerve in the spiral groove of the distal humerus, resulting in the so-called “Saturday night palsy” after undue pressure on the distal upper arm. This could be the result of significant direct pressure over several hours, or such an injury could happen acutely, as in the described scenario. Findings include paresthesias and possible decreased light or sharp touch sensation on the back of the hand and extensor forearm. Motor findings include weakness of finger and wrist extension, best evaluated by testing while the examiner applies resistance to the actions. Thumb apposition is controlled by the median nerve and splaying out the fingers (lumbricals) is mainly an ulnar nerve function. Unless the nerve has been severed, the sensory loss and motor weakness typically resolve within days to weeks.

Question 2

A 46-year-old female comes to your office because of left hip pain. After a thorough evaluation you make a diagnosis of osteoarthritis, likely associated with congenital hip dysplasia.

In addition to nonpharmacologic therapies, including physical exercise, which one of the following medications has the best evidence of treating her pain effectively? (check one)
Topical diclofenacTopical diclofenac
Topical lidocaine
Oral acetaminophen
Oral naproxen
Oral tramadol

Answer 2

Oral naproxen

Symptomatic osteoarthritis of the hip is estimated to affect 10% of U.S. adults. Nonpharmacologic measures are the cornerstone of treatment and include physical activity, including strength training, aerobic exercise, tai chi, and yoga; weight loss for those who are overweight; and education in self-management. When these interventions are not adequate to manage pain, medications should be considered. In patients without contraindications, oral NSAIDs such as naproxen should be considered as first-line management. The hip joint is less amenable to topical therapies than the knee joint and topical NSAIDs such as diclofenac do not have evidence of benefit for hip osteoarthritis. Topical lidocaine is similarly without evidence of benefit at the hip joint. Those with risk factors for gastrointestinal toxicity should receive prophylaxis with proton pump inhibitors when treated with oral NSAIDs. Acetaminophen is less effective than NSAIDs but may be considered for use. Tramadol should not be used as a first-line treatment for pain due to osteoarthritis of the hip.

Question 3

A 24-year-old male sustains a boxer’s fracture of the fifth metacarpal. A radiograph shows no rotational deformity and 25° of volar angulation. After an attempt at closed reduction the angulation remains unchanged.
Which one of the following would be most appropriate at this time?
(check one)
Open reduction
Placement of a pin to prevent further displacement
A short arm-thumb spica cast
An ulnar gutter splint

Answer 3

An ulnar gutter splint

Up to 40° of volar angulation is acceptable for fifth metacarpal fractures. For second and third metacarpal fractures, less angulation is acceptable. Appropriate treatment is a gutter splint.

Question 4

A 2-year-old child stumbles, but his mother keeps him from falling by pulling up on his right hand. An hour later the child refuses to use his right arm and cries when his mother tries to move it.

The most likely diagnosis is (check one)
dislocation of the ulna
dislocation of the olecranon epiphysis
subluxation of the head of the radius
subluxation of the head of the ulna
anterior dislocation of the humeral head

Answer 4

subluxation of the head of the radius

Subluxation of the radial head, or nursemaid’s elbow, is one of the most common injuries in children under 5 years of age. It occurs when the child’s hand is suddenly jerked up, forcing the elbow into extension and causing the radial head to slip out from the annular ligament.

Question 5

A 35-year-old female presents with a 4-month history of pain in her neck, chest, mid and lower back, hip, and right leg. She has difficulty falling asleep at night and does not feel refreshed upon awakening in the morning. She feels like she is not as mentally sharp as she used to be and feels mildly depressed at times. A physical examination is notable for multiple soft-tissue tender points without evidence of joint deformity, inflammation, or erythema.

Which one of the following would be appropriate first-line pharmacologic therapy for this patient’s condition? (check one)
Amitriptyline
Celecoxib (Celebrex)
Hydrocodone
Hydroxychloroquine (Plaquenil)
Naproxen

Answer 5

Amitriptyline

This patient meets diagnostic criteria for fibromyalgia, which is characterized by diffuse, chronic pain without evidence of inflammation, erythema, or joint deformities. Pharmacologic treatments for fibromyalgia include tricyclic antidepressants such as amitriptyline, SNRIs such as duloxetine and milnacipran, and gabapentinoids such as pregabalin. Evidence does not show benefit from NSAIDs such as celecoxib or naproxen or opioids such as hydrocodone. Hydroxychloroquine is a disease-modifying antirheumatic agent used to treat rheumatoid arthritis and malaria and is not appropriate for the treatment of fibromyalgia.

Question 6

A 68-year-old female presents for evaluation of low back pain. Which one of the following signs or symptoms would be most consistent with a diagnosis of spinal stenosis syndrome? (check one)
Pain improvement when moving from sitting to standing
Pain improvement with lumbar extension
Pain worsened by bending forward at the waist
Poor balance
Urinary incontinence

Answer 6

Poor balance

A diagnosis of lumbar spinal stenosis is characterized by the narrowing of a neural foramen or the spinal canal, which causes impingement of the nerve roots. It is most often caused by disc protrusion/herniation or degenerative changes. Degenerative changes cause ligamentous hypertrophy and development of osteophytes that cause symptoms by impinging on spinal roots. Compression of the posterior columns of the spinal canal can impact the awareness of position sense (proprioception). A report of balance problems by patients with low back pain is 70% sensitive for spinal stenosis syndrome, and the patient may exhibit a positive Romberg test and a wide-based gait. Spinal stenosis pain is increased by movements of lumbar extension such as standing upright and improved by forward flexion such as bending over a shopping cart or while sitting. Severe impingement as in cauda equina syndrome causes urinary retention and not incontinence.

Question 7

In a patient with new-onset polymyalgia rheumatica, which one of the following medications can be added to glucocorticoid therapy in order to reduce the risk of relapse? (check one)
Ibuprofen
Icosapent ethyl (Vascepa)
Indomethacin
Mesalamine
Methotrexate

Answer 7

Methotrexate

Polymyalgia rheumatica (PMR) should be treated with glucocorticoids to induce remission. There is good evidence that adjunctive therapy with methotrexate reduces both the cumulative dose of corticosteroids needed and the risk of relapse (evidence rating A). NSAIDs such as ibuprofen and indomethacin reduce pain but do not modify the inflammatory process. Icosapent ethyl is a derivative of omega-3 fatty acids that reduces cardiovascular events and may improve rheumatoid arthritis, likely via anti-inflammatory properties. However, it has not been shown to be effective in PMR. Mesalamine is used to reduce inflammation in inflammatory bowel disease but is not effective against PMR.

Question 8

A healthy 78-year-old female with no history of osteoporosis has a family history of hip fracture. Bone density screening reveals a lumbar T-score of –2.0 and a right hip T-score of –1.5. Her FRAX score is calculated at a 20% risk of major osteoporotic fracture and an 11% risk of hip fracture. She is concerned about the possibility of breaking her hip.

Which one of the following interventions would be most appropriate? (check one)
Initiating treatment with a bisphosphonate
Initiating treatment with combined estrogen/progesterone
A repeat bone density scan in 1 year
A repeat bone density scan in 3 years
A repeat bone density scan in 5 years

Answer 8

Initiating treatment with a bisphosphonate

The National Osteoporosis Foundation supports treatment of postmenopausal women with low bone mass and a 10-year risk >20% for any major fracture or ³3% for hip fracture. First-line treatment options include bisphosphonates (alendronate, ibandronate, risedronate, and zoledronic acid), teriparatide, and denosumab. These medications are considered first line due to their proven efficacy in reducing both hip and vertebral fractures. Hormonal treatment such as raloxifene and hormone replacement therapy is not recommended as first-line treatment due to associated risk and side effects as well as lack of evidence supporting efficacy in preventing hip fractures. Women with a 10-year fracture risk <20% but who have osteopenia and/or risk factors for bone loss can be monitored with periodic bone density scans, though the optimal intervals for repeat evaluation have not been definitively established.

Question 9

A 13-year-old male presents with a 3-week history of pain in the anterior right knee that is worse when descending stairs and jumping. He is active in sports but has no recent history of injury. On examination you note tenderness and swelling over the tibial tuberosity, but no redness or warmth.

Which one of the following would be most appropriate before initiating treatment? (check one)
No imaging
Plain film radiographs
Ultrasonography
MRI
A bone scan

Answer 9

No imaging

This patient has apophysitis at the insertion of the patellar tendon at the tibial tubercle. The clinical diagnosis of Osgood-Schlatter disease is based on history and examination, and imaging is not needed initially. If this patient’s symptoms persist despite treatment, or if there are atypical features or a history of trauma, imaging would be appropriate. Plain film radiography or ultrasonography would be a good first step, with ultrasonography offering the advantage of no radiation exposure. MRI and a bone scan would not be indicated.

Question 10

A 50-year-old male presents with a 3-month history of persistent burning and numbness in his anterolateral left thigh. He has not had any injury, back pain, radiation of pain, or weakness. He has not noticed any exacerbating or remitting factors. He has type 2 diabetes and a BMI of 37 kg/m2, and his job is sedentary.

An examination reveals normal deep tendon reflexes in the patella and ankle, and the straight leg raising test is negative bilaterally. His strength is preserved throughout his lower extremities. His pinprick sensation is slightly reduced along the anterolateral thigh. Burning discomfort is reproduced with tapping over the lateral aspect of the inguinal ligament.

Which one of the following is the most likely diagnosis? (check one)
Cauda equina syndrome
Diabetic neuropathy
Femoral neuropathy
Left S1 radiculopathy
Meralgia paresthetica

Answer 10

Meralgia paresthetica

Meralgia paresthetica is a common cause of anterolateral hip pain and dysesthesia. It is caused by compression of the lateral femoral cutaneous nerve as it courses under the inguinal ligament into the subcutaneous tissue of the thigh. Tapping over this area during the examination can reproduce symptoms. Obesity is a common cause due to compression of the nerve from overlying pannus. Diabetes mellitus is associated with a sevenfold higher incidence over the general population. Cauda equina syndrome presents with saddle anesthesia and generally marked neurologic disability. Diabetic neuropathy is a peripheral neuropathy initially affecting distal structures such as the toes and feet. Femoral neuropathy would affect sensation in the anteromedial thigh and medial lower leg with weakness in the quadriceps muscle group. The anterolateral thigh would represent the L3-L4 dermatome rather than S1, and the normal straight leg raising test and absence of back pain are evidence against an S1 issue.

Question 11

A 68-year-old male presents with chronic right knee pain from osteoarthritis that inhibits his activity and is associated with stiffness throughout the day. He has tried acetaminophen and NSAIDs with limited effect. He has consulted an integrative medicine specialist who recommended multiple modalities to reduce pain and increase function, and he asks whether you think they would be helpful.

Which one of the following measures recommended by the other physician has the STRONGEST evidence of benefit? (check one)
A low-impact aerobic exercise program
Lateral wedge insoles
Oral glucosamine and chondroitin
A platelet-rich plasma injection
Needle lavage of the knee

Answer 11

A low-impact aerobic exercise program

Despite the prevalence of osteoarthritis of the knee and a myriad of treatment modalities available for those with symptomatic disease, there is very limited evidence to suggest that many of these treatments are effective. There is strong evidence to suggest that self-management programs, strengthening exercises, low-impact aerobic exercises, and neuromuscular education have some benefit. Moderate evidence recommends against the use of needle lavage of the knee; the two main studies of this modality showed little or no benefit. In 15 studies, 14 outcomes were not statistically significant, including three pain and three functional outcomes. There is also moderate evidence to recommend against the use of lateral wedge insoles. Four studies of lateral wedge insoles showed no significant change in pain or function of the knee when compared to neutral insoles. The evidence is inconclusive for platelet-rich plasma injections. A few studies have shown decreased pain in patients after injection, but there was no placebo control, so the effectiveness cannot be adequately assessed. Glucosamine and chondroitin have been shown with strong evidence to be ineffective when compared to placebo.

Question 12

A 13-year-old male sees you because of pain in his throwing arm. He is a very dedicated football quarterback and has been practicing throws and playing games every day for 2 months. The pain started gradually over the season, and there is no history of acute injury. The patient is right-hand dominant, and on examination he has pain when he raises his right arm above his shoulder. There is also tenderness to palpation of the proximal and lateral humerus.

Which one of the following would be most appropriate at this point? (check one)
Injection of 10 mL of lidocaine into the subacromial space
Plain radiographs of the shoulder
Ultrasonography of the supraspinatus muscle
MRI of the shoulder
A bone scan of the shoulder

Answer 12

Plain radiographs of the shoulder

Pain in the shoulder of a young athlete can be caused by many problems, including acromioclavicular strain, biceps tendinitis, glenohumeral instability, and rotator cuff pathology. Although rotator cuff pathologies are the most frequent cause of shoulder pain in adults, they are uncommon in children. Unique to children, however, is a repetitive use injury causing disruption at the proximal growth plate of the humerus. This condition is referred to as Little League shoulder and can be seen on plain radiographs as widening, demineralization, or sclerosis at the growth plate. If the radiograph is normal but suspicion for this condition is high, a bone scan or MRI can be ordered.

Question 13

At a routine well child visit the mother of a 3-year-old male expresses concern that his toes turn in, causing a clumsy gait when he walks. You diagnose internal tibial torsion, because his feet point inward when his patellae face forward. The examination is otherwise normal.

Which one of the following is recommended at this time? (check one)
No intervention
Shoe modification with wedges to externally rotate the feet while walking
Night splinting with the feet externally rotated
Serial casting to gradually externally rotate the feet
Surgery to correct the deformity

Answer 13

No intervention

Internal tibial torsion usually resolves spontaneously by age 5. Surgery may be considered in patients older than 8 years of age who have a severe residual deformity, especially if it is symptomatic or cosmetically unacceptable. Night splints, shoe modifications, other orthotics, casting, and braces are not recommended for this condition.

Question 14

A 69-year-old male presents with acute right hip pain, which has been worsening over the past week and is now causing difficulty walking. He has had occasional hip pain in the past but this is more severe than previous episodes. He has no history of trauma and he feels well otherwise. His medical history includes hypertension, hyperlipidemia, osteoarthritis, and psoriasis. His current medications include lisinopril/hydrochlorothiazide (Zestoretic), aspirin, and adalimumab (Humira).

An examination reveals normal vital signs and a BMI of 29 kg/m2. The joint is not red or swollen. There is no tenderness over the greater trochanter, groin, or buttock. Active and passive range of motion of the hip is limited in all directions due to pain. A radiograph shows mild degenerative changes of the hip joint. A C-reactive protein level is mildly elevated.

Which one of the following would be indicated at this point to rule out a serious cause of joint pain? (check one)
A radionuclide bone scan
Arthrocentesis
CT
MR arthrography
MRI

Answer 14

Arthrocentesis

This patient has a history and physical examination concerning for septic arthritis, which is a rheumatologic emergency due to the potential for joint destruction. Joint swelling, redness, and warmth may accompany the pain but these are more difficult to detect at the hip than the knee. Systemic symptoms such as fever may occur but are absent in more than 40% of patients, particularly elderly patients and those who are immunocompromised. Risk factors for septic arthritis include underlying joint disease such as rheumatoid arthritis or osteoarthritis, and immunosuppressive states such as HIV infection, diabetes mellitus, and taking immunosuppressive medications. This patient has a history of osteoarthritis and is taking adalimumab, an immunosuppressive agent. Although there may be clues to the diagnosis of septic arthritis on imaging and laboratory assessment, the diagnostic test of choice is analysis of synovial fluid obtained through arthrocentesis. A radionuclide bone scan, CT, MR arthrography, and MRI are not sensitive enough to rule out septic arthritis.

Question 15

A 59-year-old plumber presents with swelling of his left elbow. An examination reveals swelling over the olecranon but no erythema or warmth. His uric acid levels are normal and he has no history of inflammatory disease. He has not had a fever. The swollen area is not painful and he has a normal range of motion.

Which one of the following would be the most appropriate next step? (check one)
Padding, ice, and elevation
Empiric antibiotics
Bursal aspiration
Plain radiographs
Orthopedic referral

Answer 15

Padding, ice, and elevation

This patient has olecranon bursitis, which is a superficial bursitis caused by chronic microtraumas to the
affected area. The initial management for this condition includes conservative measures such as padding,
elevation, icing, and analgesics (SOR B). If significant pain is associated with the swelling, or a decrease
in range of motion is present due to severe swelling, aspiration should be offered. This is not indicated in
this particular case and should be avoided to reduce the risk of septic bursitis. Septic bursitis would require
empiric antibiotics to cover common skin organisms (SOR B). Aspiration should be performed if infection
is suspected and the aspirate should be sent for a cell count, Gram stain, culture, glucose measurement,
and crystal analysis (SOR C). Plain radiographs are indicated only if there is acute trauma and concern that
a fracture may be present. If recurrent superficial bursitis occurs, a referral for surgery is indicated.

Question 16

A 15-year-old male sees you after injuring his right index finger while playing volleyball. He has pain and a flexion deformity at the distal interphalangeal (DIP) joint.

Which one of the following would be an indication for further evaluation before splinting? (check one)
The patient wants to continue athletic activities
The patient first presented for treatment 3 weeks after the injury
The patient is unable to passively fully extend the joint
an oral syringe
A radiograph shows a bony avulsion of 10% of the joint space

Answer 16

The patient is unable to passively fully extend the joint

Mallet finger, an injury to the distal extensor tendon of the finger at the distal interphalangeal (DIP) joint, is usually caused by forceful flexion of an extended DIP joint. This is frequently the result of being struck by an object such as a ball. The inability to actively extend the DIP joint is a hallmark of mallet finger. The inability to passively extend the DIP joint completely may be an indication of trapped soft tissue or bone that may require surgery. Up to one-third of distal extensor tendon injuries are associated with an avulsion fracture, and if the avulsion is greater than 30% of the joint space, referral to an orthopedist is recommended. Splinting with strict use of the splint and avoidance of any flexion of the DIP joint is the recommended treatment, and is beneficial even with a delayed presentation. Athletic activities may be continued with the splint in place.

Question 17

A 35-year-old female with rheumatoid arthritis currently being treated with adalimumab (Humira) injections sees you for evaluation after developing a red, swollen, warm, and painful right knee. Arthrocentesis is performed, and the synovial fluid analysis is concerning for septic arthritis.

Which one of the following organisms is the most likely cause of her infection? (check one)
Candida albicans
Escherichia coli
Mycobacterium tuberculosis
Staphylococcus aureus
Streptococcus pyogenes

Answer 17

Staphylococcus aureus

Patients with rheumatoid arthritis being treated with anti-tumor necrosis factor therapy are at increased risk for septic arthritis. The most common cause of septic arthritis in adults is Staphylococcus aureus, followed by Streptococcus species. Escherichia coli causes about a fourth of the cases in the elderly. Fungal and mycobacterial causes such as Candida albicans or Mycobacterium tuberculosis are less common but must be considered in immunocompromised patients.

Question 18

A 45-year-old female presents with throbbing right-sided heel pain that started a few weeks ago. She says the pain is worst in the morning and seems to improve during the day but will return after a long day on her feet. She does not have a history of trauma, change in exercise, unexplained fever, or unintended weight loss.

On examination the patient’s vital signs are normal. You note pain on palpation of the right medial calcaneal tuberosity and along the plantar fascia, and pain with passive dorsiflexion of the right foot. The skin over the foot reveals no sign of trauma, lesions, or masses.

Which one of the following is the most likely cause of this patient’s heel pain? (check one)
The heel spur
A calcaneal stress fracture
Heel pad syndrome
Plantar fasciitis
Sever’s disease

Answer 18

Plantar fasciitis

Plantar fasciitis is the most common cause of heel pain, with a prevalence of 10% in the general population. It often presents with throbbing heel pain that is worst in the morning with the first step after rest. Palpation of the medial calcaneal tuberosity and dorsiflexion of the affected foot will elicit sharp pain. Diagnostic imaging is not required. Heel spurs are present in approximately 50% of patients with plantar fasciitis, but can also be found in patients without plantar fasciitis.

Calcaneal stress fractures are caused by repetitive overuse and the pain usually begins after an increase in weight-bearing activities or a change in activities. It usually occurs only with activity, but may eventually also occur at rest. Heel pad syndrome causes pain with deep palpation of the middle of the heel or walking barefoot on harder surfaces. Sever’s disease is the most common cause of heel pain in children and adolescents 8–12 years of age.

Question 19

A 29-year-old male presents to your office because of pain and paresthesia in his right fourth and fifth fingers for the last several weeks. He has had some generalized weakness in his hands, noting that it is more difficult for him to grasp and pick up small objects with his thumb and forefinger. There is no history of trauma. He is very physically active and lifts weights 5–6 days per week. On physical examination you note weakness of the pincer mechanism and decreased sensation over the hypothenar eminence and fourth and fifth fingers.

These findings are associated with peripheral entrapment of which one of the following (check one)
Axillary
Median
Radial
Suprascapular
Ulnar

Answer 19

Ulnar

This patient has entrapment of the ulnar nerve at the wrist level. This is more common in activities that place pressure on the volar aspect of the wrist, including weightlifting and cycling. Classic symptoms include paresthesia of the fourth and fifth fingers and hypothenar eminence, weakness in finger adduction and abduction, and weakness of the pincer mechanism. Axillary nerve entrapment can result from shoulder dislocations, humeral neck fracture, and pressure from crutch use, and can cause decreased sensation or pain over the lateral shoulder as well as weakness with shoulder external rotation, abduction, and extension. Median nerve entrapment results in paresthesia of the first three fingers and can result in thenar muscle atrophy. The radial nerve can be entrapped or compressed at many different locations, most commonly due to sustained pressure over the radial groove. This will result in paresthesia and pain in the posterior forearm and dorsal hand as well as weakness in wrist and finger extensors, which can result in wrist and finger drop. Suprascapular nerve entrapment can present similarly to axillary nerve entrapment, with shoulder pain and abduction and forward flexion deficits.

Question 20

A 52-year-old pianist is concerned that she may have carpal tunnel syndrome. Which one of the following would be consistent with this problem? (check one)
Weakness of thumb adduction
Decreased sensation over the thenar eminence
Decreased sensation over the dorsal aspect of the fourth finger
Decreased sensation over the dorsal aspect of the fifth finger
Decreased sensation over the palmar aspect of the thumb, index, and middle finger

Answer 20

Decreased sensation over the palmar aspect of the thumb, index, and middle finger

Carpal tunnel syndrome is the most common entrapment neuropathy of the upper extremity. It is caused by compression of the median nerve as it travels through the carpal tunnel. Classically, patients with this condition experience pain and paresthesias in the distribution of the median nerve, which includes the palmar aspect of the thumb, index, and middle fingers, and the radial half of the ring finger. In more severe cases motor fibers are affected, leading to weakness of thumb abduction and opposition. Sensation over the thenar eminence should be normal in patients with carpal tunnel syndrome because it is in the distribution of the palmar cutaneous branch of the median nerve, which branches off proximal to the carpal tunnel.

Question 21

A 43-year-old male presents with a 6-week history of right ankle pain. The pain worsens with walking or running for a moderate distance and fails to improve with heat application or reduction of activity. He has been following a moderate cardiovascular exercise program for several years without problems and did not increase his physical activity before the onset of the pain. He does not recall any injury to the ankle.

On examination the area of pain is localized in the right Achilles tendon proximal to its insertion. No swelling, redness, or deformity is apparent but tenderness is elicited with application of moderate fingertip pressure to the tendon.

Which one of the following would be the most appropriate initial treatment? (check one)
Use of a heel cup in the right shoe
A 1-month course of daily NSAIDs at a prescription dosage
An eccentric gastrocnemius-strengthening program
A corticosteroid injection into the right Achilles tendon sheath
Immobilization of the right ankle for 3 weeks with a boot

Answer 21

An eccentric gastrocnemius-strengthening program

Pain located between the myotendinous junction and the insertion of the Achilles tendon that occurs during prolonged walking or running is typical for midsubstance Achilles tendinopathy. The mechanisms resulting in pain are complex and not fully understood but inflammation is believed to contribute little to the process. This is evidenced in part by the ineffectiveness of treatments typically used to reduce inflammation such as NSAIDs and corticosteroids, which are not recommended in the treatment of this condition (SOR A). Other commonly used musculoskeletal therapeutic modalities such as immobilization, ultrasonography, orthotics, massage, and stretching exercises have not been shown to consistently offer significant benefits and are not considered to be first-line therapy for Achilles tendinopathy.

A gastrocnemius-strengthening eccentric exercise program performed in sets of controlled, slow, active release from weight-bearing full extension to full flexion of the foot at the ankle has been shown to reduce pain and improve function in the 60%–90% range, making this the logical first-line treatment for Achilles tendinopathy (SOR A).

The less common insertional Achilles tendinopathy localized to the enthesis is typically more recalcitrant, and immobilization in a walking boot for a period of time may be necessary before eccentric exercise can be tolerated.

Question 22

A 45-year-old electrician presents to your office with concerns about a bump on his left elbow. He does not recall any injury. The bump is painful to touch but causes no other symptoms. He is worried because it has been consistently present for at least a month.

On examination the patient is afebrile. He has a 4-cm movable fluctuant mass at the tip of his left olecranon that is slightly tender to touch. There is no warmth or erythema and he has full range of motion of his elbow. There is no other joint involvement.

Which one of the following would you recommend? (check one)
No further evaluation
Laboratory testing, including a CBC with differential
Plain radiography
Ultrasonography
Aspiration

Answer 22

No further evaluation

This patient presents with chronic olecranon bursitis. The diagnosis can be made based on his history and the physical examination. No other testing is indicated at this time. Chronic bursitis is due to repetitive microtrauma. The olecranon is the most common location for chronic bursitis. Patients typically have no history of injury, minimal pain, no systemic symptoms, and no signs of acute infection or inflammation. Treatment initially consists of avoiding recurrent trauma by protecting the area (elbow pad), not leaning on it, ice, compression, and over-the-counter analgesics. If the lesion is inflamed or appears septic then laboratory testing should be performed, including a CBC with differential, a glucose level, an erythrocyte sedimentation rate, and a C-reactive protein level. Joint aspiration and/or ultrasonography may be indicated if the diagnosis is not apparent. A plain radiograph would be indicated to rule out a fracture in a patient with traumatic bursitis.

Question 23

Which one of the following is the preferred first-line agent in the treatment of rheumatoid arthritis? (check one)
Adalimumab (Humira)
Etanercept (Enbrel)
Hydroxychloroquine (Plaquenil)
Methotrexate (Trexall)
Prednisone

Answer 23

Methotrexate (Trexall)

The American College of Rheumatology recommends methotrexate, a nonbiologic disease-modifying antirheumatic drug (DMARD), as a first-line agent in the treatment of rheumatoid arthritis in the absence of contraindications, such as underlying liver disease. Starting DMARDs within 3 months of the onset of rheumatoid arthritis symptoms is more likely to result in sustained remissions. The addition of short-term prednisone is indicated in select cases when disease activity is high. The use of biological agents such as adalimumab, etanercept, and others is indicated only in refractory cases and in patients who cannot tolerate nonbiologic DMARDs.

Question 24

A 20-year-old football player presents with pain in the proximal fifth metatarsal. The pain was initially present only after practices, but now it causes push-off pain during practice. There is tenderness to palpation. Plain films show no signs of fracture.

Which one of the following would be most appropriate at this point? (check one)
Start NSAIDs and allow him to continue practicing as tolerated
Place him at non–weight bearing for 2 weeks and repeat the plain films
Place him in a hard shoe for 3 weeks and then reexamine
Order MRI of the foot
Order a bone scan of the foot

Answer 24

Order MRI of the foot

A stress fracture in the proximal fifth metatarsal is particularly prone to nonunion and completion of the fracture. Because complete non–weight bearing or surgical intervention may be necessary with this high-risk fracture, MRI is indicated as the most sensitive test. Bone scans are sensitive but nonspecific. Most stress fractures of the metatarsals occur distally and can be managed with a hard shoe initially, with progressive activity as tolerated. NSAIDs are discouraged because of possible effects on fracture healing.

Question 25

A 62-year-old female comes to your office for evaluation of pain in her right thumb and wrist associated with sewing. She does not have any injury, numbness, tingling, or weakness. An examination reveals an otherwise healthy-appearing female with normal vital signs and no deformity or swelling in her wrists or hands. She has tenderness to palpation at the first dorsal compartment over the radial styloid and has pain with active and passive stretching of the thumb tendons over the radial styloid. She is very worried that she will have to stop sewing and asks if there is anything she could try to alleviate her symptoms.

Which one of the following would be most appropriate at this point? (check one)
Reassurance that it will likely improve on its own within about a year
A corticosteroid injection into the first extensor compartment
Immobilization in a thumb spica splint and an NSAID for 1–4 weeks
Radiographs of the thumb and wrist
Referral to an orthopedic surgeon

Answer 25

Immobilization in a thumb spica splint and an NSAID for 1–4 weeks

De Quervain’s tenosynovitis usually occurs with repeated use of the thumb and is characterized by pain in the radial wrist. The course is typically self-limited but can last for up to a year, so waiting would not be a good option for this patient who wants to continue her usual activities as soon as possible. Conservative therapy with immobilization and NSAIDs is recommended if there are no contraindications to NSAIDs. A corticosteroid injection is helpful but is typically reserved for severe cases or if conservative therapy fails. Surgery may be beneficial but is generally not recommended unless the course is severe, given the natural history of resolution.

Question 26

An otherwise healthy 42-year-old male presents to your office with low back pain that started a week ago after he lifted a heavy box. Since the time of his injury he has been having consistent pain, numbness, and tingling that radiates down the back of his right leg to his calf.

Which one of the following would you order at this time? (check one)
No imaging
Plain radiography
CT
MRI

Answer 26

No imaging

Uncomplicated acute low back pain and/or radiculopathy is a benign, self-limited condition and early
imaging is associated with worse overall outcomes and is likely to identify minor abnormalities even in
asymptomatic patients. Imaging for acute low back pain should be reserved for cases that are suspicious
for cauda equina syndrome, malignancy, fracture, or infection. In the absence of red flags such as
progressive motor or sensory loss, new urinary retention or overflow incontinence, a history of cancer,
a recent invasive spinal procedure, or significant trauma relative to age, imaging is not warranted
regardless of whether radiculopathy is present, unless symptoms persist despite a trial of at least 6 weeks
of medical management and physical therapy.

Question 27

A 48-year-old male presents with pain in the right antecubital fossa after lifting a trailer in his garage. On examination you note ecchymosis and tenderness in the antecubital fossa. You suspect a possible distal biceps tendon rupture.

Which one of the following would be most appropriate at this point?

(check one)
A Speed’s test
Plain radiographs of the elbow
MRI of the elbow
A local corticosteroid injection
Referral for physical therapy

Answer 27

MRI of the elbow

Distal biceps tendon ruptures are relatively uncommon, accounting for about 3% of tendon ruptures. In a patient with a suspected distal biceps tendon rupture, clinical signs can be unreliable and MRI imaging is the test of choice. Bony abnormalities do not contribute to the evaluation of this tendon. A Speed’s test is used to evaluate pain related to the long head of the biceps tendon. Surgical repair is the treatment of choice when the tendon is ruptured. Physical therapy and local corticosteroid injections are not beneficial.

Question 28

A 43-year-old male sees you because of popping and clicking at the base of his index finger. On examination you note a nodule on the palmar aspect of the metacarpophalangeal joint with the finger flexed.

Which one of the following is the most likely diagnosis? (check one)
Calcific peritendinitis
Dupuytren contracture
Flexor tenosynovitis
Rheumatoid arthritis
Trigger finger

Answer 28

Trigger finger

Trigger finger, which can be associated with diabetes mellitus, presents with locking, clicking, or popping at the base of the finger or thumb. The finger may lock when flexed. Treatment consists of corticosteroid injection or splinting, and surgery may be necessary. Calcific peritendinitis causes pain, tenderness, and edema. Dupuytren contracture is manifested as a palpable cord in the palm and is not associated with locking. Flexor tenosynovitis causes fusiform digit swelling and is associated with rheumatoid arthritis. Rheumatoid arthritis involves multiple joints.

Question 29

A 73-year-old male with advanced degenerative arthritis of the knees asks what you would recommend for relief. He does not wish to have a total knee replacement. He says that NSAIDs have not been effective.

Which one of the following would be the best recommendation? (check one)
Acetaminophen
Intra-articular corticosteroids
Intra-articular hylan GF 20 (Synvisc)
Physical therapy for quadriceps strengthening
Tramadol (Ultram)

Answer 29

Physical therapy for quadriceps strengthening

Quadriceps-strengthening exercises have been shown in good studies to stabilize the knee and reduce pain for patients with degenerative arthritis. Acetaminophen has not been shown to produce clinically significant improvement from baseline pain. Intra-articular corticosteroids can acutely relieve pain and effusions but do not affect moderate-term outcomes. Hylan GF 20 products are minimally effective. Opiates and other similar drugs are addictive and should be avoided.

Question 30

A 32-year-old male presents with a 4-week history of persistent low back pain. He started feeling tightness in his low back after helping a friend move into a new apartment. The pain does not radiate, there is no associated paresthesia or numbness, and he has not had any bowel or bladder incontinence. The pain is constant and worsens with prolonged sitting. He rates the pain as 6 on a scale of 10. Ibuprofen has provided minimal relief.

Examination of the lumbar area over the paraspinous muscles reveals minimal tenderness. A neurovascular examination and a straight leg raise are normal in both lower extremities.

Which one of the following would be most appropriate at this point? (check one)
Imaging studies of the lumbar spine
A short course of an oral corticosteroid
Gabapentin (Neurontin) started at a low dose and titrated to effect
A skeletal muscle relaxant and an NSAID
A short-acting opioid and an NSAID

Answer 30

A skeletal muscle relaxant and an NSAID

This patient has acute to subacute nonspecific low back pain. Combination treatment with an NSAID and a skeletal muscle relaxant is recommended as second-line therapy when an NSAID is ineffective as monotherapy. Opioids have not been shown to have significant benefit when added to an NSAID and would not be recommended as a second-line treatment. Systemic corticosteroids do not have evidence to support their use in the treatment of acute nonspecific back pain. Gabapentin does not have evidence to support its use in treating acute back pain and has been shown to produce only minimal improvement in chronic back pain. This patient has no red-flag symptoms so imaging studies are not recommended at this time.

Question 31

A 45-year-old female who works as a house cleaner presents with left shoulder pain. On examination she has pain and relative weakness when pushing toward the midline against resistance while the shoulder is adducted and the elbow is bent to 90°. With the elbow still at 90° she is unable to keep her left hand away from her body when you position her hand behind her back.

This presentation is most consistent with an injury of which one of the following tendons? (check one)
Deltoid
Infraspinatus
Subscapularis
Supraspinatus
Teres minor

Answer 31

Subscapularis

This patient’s pain and weakness while pushing against resistance reveals weakness on internal rotation of the shoulder, which suggests a possible tear of the subscapularis tendon. The inability to keep her hand away from her body when it is placed behind her back describes a positive internal lag test, also suggesting involvement of the subscapularis tendon. The infraspinatus and teres minor are involved in external rotation rather than internal rotation. The supraspinatus and deltoid are involved in abduction of the shoulder.

Question 32

A 50-year-old male carpet layer presents with swelling of his right knee proximal to the patella. He does not have any history of direct trauma, fever, chills, or changes in the overlying skin. On examination the site is swollen but minimally tender, with no warmth or erythema.

Which one of the following would be most appropriate at this point? (check one)
Rest, ice, and compression
Aspiration of fluid for analysis
Injection of a corticosteroid
An oral corticosteroid taper
Referral to an orthopedic surgeon for resection

Answer 32

Rest, ice, and compression

Prepatellar bursitis is a common superficial bursitis caused by microtrauma from repeated kneeling and crawling. Other terms for this include housemaid’s knee, coal miner’s knee, and carpet layer’s knee. It is usually associated with minimal to no pain. This differs from inflammatory processes such as acute gouty superficial bursitis, which presents as an acutely swollen, red, inflamed bursa and, in rare cases, progresses to chronic tophaceous gout with minimal or no pain.

The proper management of prepatellar bursitis is conservative and includes ice, compression wraps, padding, elevation, analgesics, and modification of activity. There is little evidence that a corticosteroid injection is beneficial, even though it is often done. If inflammatory bursitis is suspected, a corticosteroid injection may be helpful. Fluid aspiration is indicated if septic bursitis is suspected. Surgery can be considered for significant enlargement of a bursa if it interferes with function.

Question 33

You are the team physician for the local high school track team. During a meet one of the athletes inadvertently steps off the edge of the track and inverts her right foot forcefully. She is able to bear weight but with significant pain. She reports pain across her right midfoot. An examination reveals edema over the lateral malleolus and diffuse tenderness, but she does not have any pain with palpation of the navicular, the base of the fifth metatarsal, or the posterior distal lateral and medial malleoli.

Which one of the following would be most appropriate at this time? (check one)
Radiographs of the right ankle only
Radiographs of the right foot only
Radiographs of the right foot and ankle
Lace-up ankle support, ice, compression, and clinical follow-up
Crutches and no weight bearing for 2 weeks, followed by a slow return to weight bearing

Answer 33

Lace-up ankle support, ice, compression, and clinical follow-up

The Ottawa foot and ankle rules should be used to determine the need for radiographs in foot and ankle injuries. A radiograph of the ankle is recommended if there is pain in the malleolar zone along with the inability to bear weight for at least four steps immediately after the injury and in the physician’s office or emergency department (ED), or tenderness at the tip of the posterior medial or lateral malleolus. A radiograph of the foot is recommended if there is pain in the midfoot zone along with the inability to bear weight for four steps immediately after the injury and in the physician’s office or ED, or tenderness at the base of the fifth metatarsal or over the navicular bone. The Ottawa foot and ankle rules are up to 99% sensitive for detecting fractures, although they are not highly specific. In this case there are no findings that would require radiographs, so treatment for the ankle sprain would be recommended. Compression combined with lace-up ankle support or an air cast, along with cryotherapy, is recommended and can increase mobility. Early mobilization, including weight bearing as tolerated for daily activities, is associated with better long-term outcomes than prolonged rest.

Question 34

A 16-year-old female who plays competitive soccer develops anterior knee pain that is worse with downhill running and after prolonged sitting. An examination shows no effusion or instability, no joint line tenderness, an increased Q-angle, and a negative McMurray’s test. A knee radiograph is negative.

Which one of the following is the most likely diagnosis? (check one)
Osgood-Schlatter syndrome
Patellofemoral pain syndrome
Pes anserine bursitis
Prepatellar bursitis
A torn medial meniscus

Answer 34

Patellofemoral pain syndrome

Patellofemoral pain syndrome is a common cause of anterior knee pain, especially in women. It is worse with running downhill or going down stairs. It is not associated with a knee effusion. The examination is often positive for an apprehension test over the patella. A torn meniscus can cause medial joint line tenderness as well as a positive McMurray’s test, defined as a click and/or pain when moving the knee from flexion to extension with valgus stress. Prepatellar bursitis causes anterior knee pain, usually associated with tenderness, swelling, and redness over the prepatellar bursa. Osgood-Schlatter syndrome causes anterior knee pain over the tibial tuberosity. Pes anserine bursitis causes medial knee pain just distal and slightly posterior to the joint space.

Question 35

You are called by the parents of a 6-year-old male because he has a 2-week history of awakening at night with severe back pain. You request an immediate evaluation in your office.

A likely cause of this pain is (check one)
rheumatoid arthritis
lumbar sprain
compression fracture
discitis
scoliosis

Answer 35

discitis

Back pain that regularly occurs at night and awakens a child is usually associated with tumors or infections, such as osteomyelitis, discitis, osteoid osteoma, osteoblastoma, and spinal cord tumors. Other possible symptoms associated with nighttime back pain include fever, malaise, and weight loss. Back pain that occurs at night is an indication for immediate medical evaluation.

Question 36

A 70-year-old male presents with lower extremity pain. Increased pain with which one of the following would be most consistent with lumbar spinal stenosis? (check one)
Lumbar spine extension
Lumbar spine flexion
Internal hip rotation
Pressure against the lateral hip and trochanter

Answer 36

Lumbar spine extension

Spinal extension that increases lumbar lordosis decreases the cross-sectional area of the spinal canal, thereby compressing the spinal cord further. Walking downhill can cause this. Spinal flexion that decreases lordosis has the opposite effect and will usually improve the pain, as will sitting. Pain with internal hip rotation is characteristic of hip arthritis and is often felt in the groin. Pain in the lateral hip is more typical of trochanteric bursitis.

Question 37

A 21-year-old male presents to an acute care center with pain in his left shoulder after a bicycle accident. His left arm is externally rotated and slightly abducted. A neurovascular examination is normal. Plain radiographs show an anterior shoulder dislocation. Reduction is successful, which is confirmed by a plain radiograph.

Which one of the following complications would be reduced by gentle range-of-motion exercises during immobilization? (check one)
Acromioclavicular joint injury
Adhesive capsulitis (frozen shoulder)
Recurrent dislocation
Rotator cuff injury
Shoulder impingement syndrome

Answer 37

Adhesive capsulitis (frozen shoulder)

After a shoulder dislocation, normal activity can resume when motion and strength in both arms is equal. Immobilization of the shoulder after a dislocation is recommended for at least 1 week. Recurrent shoulder dislocations are more common in younger patients and should be immobilized for 3 weeks in patients under 30 years of age. In patients over 30 years of age, 1 week of immobilization will limit the amount of joint stiffness. Prolonged immobilization is a risk factor for developing adhesive capsulitis (frozen shoulder). Gentle range-of-motion exercises should be performed during the immobilization period to limit the risk of adhesive capsulitis. Recurrent dislocations, rotator cuff injuries, shoulder impingement syndrome, and acromioclavicular joint injuries are not reduced by gentle range-of-motion exercises.

Question 38

A 45-year-old male comes to the urgent care center with left foot pain that began at a ballroom dancing competition. He states that he put all of his weight on the lateral portion of his foot while on tiptoe, and felt the pain immediately. He now cannot bear weight on the foot. On examination it appears slightly edematous with a small amount of ecchymosis. A radiograph reveals a proximal fifth metatarsal metadiaphyseal fracture. The patient is eager to return to competitive dancing as soon as possible.

Which one of the following would be the best treatment for this patient? (check one)
Full weight bearing with the use of a compression dressing as needed for pain and swelling
A posterior splint with no weight bearing for 4 weeks
A walking cast for 6 weeks
Surgical referral

Answer 38

Surgical referral

This patient has a Jones fracture. The treatment plan for this type of fracture needs to account for the activity level of the patient. It has been shown that active patients have shorter healing times and return to activity sooner with surgical management. A competitive dancer would be best managed with surgery. If the nonsurgical option is chosen the patient is given an initial posterior splint and followed up in 3–5 days, then placed in a short non–weight-bearing cast for 6 weeks, at which time a repeat radiograph is taken. If the radiograph shows healing, the patient can return to gradual weight bearing. If the radiograph does not show proper healing, then the period of non–weight bearing is extended.

Question 39

A 26-year-old recreational baseball player presents with recurrent right shoulder pain that tends to gradually worsen during play and is relieved by rest. His other daily activities have not been affected and he has no nighttime pain.

Examination of the right shoulder reveals a normal appearance, no tenderness to palpation, normal abduction strength, and a positive painful arc at 90°. The drop-arm rotator cuff test is negative, the Hawkins impingement sign is mildly positive, the empty-can supraspinatus test is moderately positive, and the Gerber liftoff test is negative. Radiographs of the right shoulder are normal.

Which one of the following would be appropriate at this time to provide long-term pain relief? (check one)
Complete shoulder rest with temporary use of a shoulder sling
Recommending that he permanently stop playing baseball
A subacromial corticosteroid injection
Physical therapy
Referral for arthroscopic surgery

Answer 39

Physical therapy

This patient has shoulder impingement syndrome (with a positive Hawkins impingement sign) and evidence of supraspinatus tendinopathy (with a positive empty-can rotator cuff test). However, the negative drop-arm rotator cuff test is evidence against a complete rotator cuff tear with a negative drop-arm rotator cuff test, and the absence of night pain supports this. Physical therapy, along with pain control using NSAIDs, acetaminophen, or short-term opiate medication, would be most appropriate as initial therapy. Complete shoulder rest is inappropriate since his daily activities are not aggravating the problem, and cessation of play is not necessary since other treatment options are available. A subacromial corticosteroid injection, while commonly done and likely to provide short-term pain relief, is unlikely to provide long-term improvement in pain and function. Surgery is a potential option if other treatments fail and a significant tear is proven, but is not preferable as an initial treatment.

Question 40

A 60-year-old male presents with a 6-week history of worsening bilateral shoulder, upper arm, and neck pain. He has morning stiffness that lasts at least an hour. The review of systems is otherwise negative. There is no localized tenderness or motor weakness on physical examination. His erythrocyte sedimentation rate is 55 mm/hr.

Which one of the following is the best treatment option for this patient at this time? (check one)
Aspirin, 1000 mg 3 times daily
Indomethacin, 25–50 mg 3 times daily
Methotrexate, 7.5 mg once a week
Prednisone, 10–20 mg once daily
Prednisone, 20 mg 3 times daily

Answer 40

Prednisone, 10–20 mg once daily

The patient described has polymyalgia rheumatica (PMR). The hallmark of this condition is the rapid and often dramatic response, typically within a few days, to low-dose corticosteroids. In fact, the lack of response to low-dose prednisone in such a case should prompt the physician to consider another diagnosis.

A related condition, giant cell arteritis, is associated with transient or even permanent vision loss, typically unilateral but sometimes bilateral. This condition usually presents with headache and tenderness of the affected artery, most commonly the temporal artery. Prompt recognition and the initiation of high-dose corticosteroids are keys to preventing blindness.

The other options listed are not pertinent to the management of PMR. While prompt response to low-dose corticosteroids confirms the diagnosis, they are usually continued for 1–2 years, with gradual tapering beginning several months after initiation of treatment (SOR C).

Question 41

A 43-year-old female presents with marked proximal muscle weakness, dysphagia, and pain in the shoulders and hips, all beginning within the past 5 weeks. She reports difficulty getting out of a chair. On examination she has a violaceous rash involving the periorbital skin, and macular erythematous lesions over the anterior chest and upper lateral thighs.

Which one of the following additional findings would you expect? (check one)
Hyperkeratotic plaques in intertriginous areas
Macules over the extensor surfaces of her joints
Polygonal papules on the flexor surface of her wrists
Distal onycholysis
Atrophic cuticles with contracted nail-fold capillaries on dermoscopy

Answer 41

Macules over the extensor surfaces of her joints

This patient’s symptoms and findings suggest dermatomyositis. This disease is distinguished from autoimmune myopathies and polymyositis by distinct dermatologic findings, including Gottron’s sign (nonpalpable macules over the extensor surface of joints). Patients may also have dilated nail-fold capillaries and ragged, thickened cuticles. Distal onycholysis is most commonly associated with onychomycosis, while hyperkeratotic plaques are not a feature of dermatomyositis. Polygonal papules on the wrist flexor surfaces are seen in lichen planus.

Question 42

Which one of the following has the best evidence supporting its use for acute low back pain without radicular symptoms? (check one)
Acupuncture
Bed rest
Lumbar support
Oral corticosteroids
Cyclobenzaprine

Answer 42

Cyclobenzaprine

NSAIDs, acetaminophen, and muscle relaxants are effective for the treatment of acute low back pain (SOR A). There is moderate-quality evidence that nonbenzodiazepine muscle relaxants are beneficial in the treatment of acute low back pain. There is also moderate-quality evidence that NSAIDs combined with nonbenzodiazepine muscle relaxants may have additive benefit for decreasing pain. Bed rest is not helpful in the treatment of acute back pain and is not recommended (SOR A). There is no evidence that lumbar support is helpful. Oral corticosteroids have not been found to be beneficial for isolated low back pain, but there is questionable benefit when there are associated radicular symptoms. There are several low-quality trials that show acupuncture has minimal or no benefit over sham treatment in acute back pain.

Question 43

A 9-year-old female presents with a 4-week history of right knee pain with activity. There is no history of trauma or recent illness. Your examination reveals lateral patellar tracking with extension of the knee.

Which one of the following is the most likely diagnosis? (check one)
Patellofemoral pain syndrome
Osgood-Schlatter disease
Growing pains
Patellar tendinopathy
Sever’s disease

Answer 43

Patellofemoral pain syndrome

Patellofemoral pain syndrome is one of the most common causes of knee pain in children, particularly adolescent girls. Pain beneath the patella is the most common symptom. Squatting, running, and other vigorous activities exacerbate the pain. Walking up and down stairs is a classic cause of the pain, and pain with sitting for an extended period is also common. The physical examination reveals isolated tenderness with palpation at the medial and lateral aspects of the knee, and the grind test is also positive.

Osgood-Schlatter disease is seen in skeletally immature patients. Rapid growth of the femur can cause tight musculature in the quadriceps across the knee joint. It typically appears between the ages of 10 and 15, during periods of rapid growth. Pain and tenderness over the tibial tubercle and the distal patellar tendon is the most common presentation. The pain is aggravated by sports participation, but also occurs with normal daily activities and even at rest.

Growing pains most often affect the thigh and quadriceps and occur during late afternoon or evening, or wake the patient at night. The joints are not affected. The pain typically goes away by morning, and may sometimes occur the day after vigorous or unusual activity.

Patellar tendinopathy is an overuse injury often seen in those who participate in jumping sports such as volleyball, and is also related to frequent stops and starts in football players. It typically causes infrapatellar pain, and findings include extensor mechanism malalignment, weakness of ankle flexors, and tightness of the hamstring, heel cord, and/or quadriceps.

Sever’s disease is an overuse syndrome most often seen between the ages of 9 and 14, and is related to osteochondrosis at the insertion of the Achilles tendon on the calcaneal tuberosity. It occurs during periods of rapid growth, causes heel pain during and after activity, and is relieved with rest. It is often related to beginning a new sport or the start of a season.

Question 44

A 50-year-old female comes to your office for routine health maintenance. She jogs 2 miles a day and has had left medial knee pain for the last 6 months. Radiographs reveal moderate degenerative arthritis of the knee. Her BMI is 24.1 kg/m2 and her physical examination, including an examination of the knee, is otherwise normal.

Which one of the following would be most effective for this patient’s arthritis? (check one)
Weight loss
A knee brace
Foot orthoses
Hyaluronic acid injection
Exercise-based physical therapy

Answer 44

Exercise-based physical therapy

Exercise-based therapy is the foundation for treating knee osteoarthritis. Foot orthoses can be helpful for anterior knee pain but this patient’s pain is located medially. The benefit of hyaluronic acid injections is controversial, and recommendations vary; recent systematic reviews do not support a clinically significant benefit. Weight loss is recommended for patients with a BMI >25.0 kg/m2. Wearing a knee brace has shown little or no benefit for reducing pain or improving knee function.

Question 45

A 90-year-old female with severe dementia is seen in the emergency department for a left knee strain. She was at home alone for 2 hours and no fall or injury was witnessed. A radiograph of the knee is negative, and she is referred to you for follow-up the next day. At the follow-up visit the patient is confused and agitated, and cries out at any attempt to examine her. She is unable to bear weight on her left leg and it appears to be externally rotated.

Which one of the following would be most appropriate at this point? (check one)
Reassurance and pain medication
A repeat radiograph of the left knee
A radiograph of the left hip
A radiograph of the lumbosacral spine
MRI of the left knee

Answer 45

A radiograph of the left hip

A fractured hip is possible and must be ruled out since there is difficulty bearing weight and the leg is externally rotated. Examination of a patient with severe dementia can be extremely difficult. Other findings with a fractured hip would include pain elicited on rotation and groin pain when applying an axial load. If the hip radiograph is negative, MRI of the knee may be considered.

Question 46

A 46-year-old runner presents with left heel pain. The pain has been occurring mostly with running, but more recently it is painful with walking. On examination there is tenderness and a palpable nodule on the midsubstance of the left Achilles tendon.

Which one of the following therapeutic options is most likely to be effective for long-term recovery? (check one)
Oral NSAIDs
Eccentric calf-strengthening exercises
Corticosteroid injection of the Achilles tendon sheath
Surgical debridement or excision of the tendon nodule
Fixation in a walking boot

Answer 46

Eccentric calf-strengthening exercises

Achilles tendinopathy is among the most common injuries in middle-aged distance runners. Oral NSAIDs may be helpful for temporary pain relief, but they contribute little to recovery from this injury. Corticosteroid injection is contraindicated due to the risk of tendon rupture. Surgical debridement and fixation in a walking boot may be considered as a last resort for difficult cases, but the most effective treatment overall is eccentric calf-strengthening exercises.

Question 47

“A 44-year-old female presents to your office reporting that she hurts all over. After performing a thorough history and physical examination and appropriate laboratory studies you diagnose fibromyalgi
You explain to the patient that the initial treatment recommendation with the most proven efficacy is” (check one)
acupuncture
aerobic exercise
amitriptyline
duloxetine (Cymbalta)

Answer 47

aerobic exercise

Aerobic exercise, a balanced diet, good sleep hygiene, and weight reduction are appropriate strategies for the management of fibromyalgia, and treatment goals should be focused on improving function and quality of life, along with managing symptoms. According to the 2017 European League Against Rheumatism, exercise is the strongest and most critical treatment for fibromyalgia. Not only does it lessen fibromyalgia symptoms, but it can also help with coexisting conditions including sleep disorders, depression, and anxiety. While some studies show improvement in symptoms with acupuncture, most evidence is low to moderate in quality. A Cochrane review found that acupuncture was superior to no treatment at all, but not superior to sham acupuncture. Pharmacologic treatments have shown only modest benefits and are often accompanied by adverse effects, so they are best used in conjunction with nonpharmacologic therapies.

Question 48

A 45-year-old female presents with a 6-month history of fatigue and arthralgias. When asked about recent illnesses the only thing she can recall is that she developed a rash on her face after a picnic about 1 month ago. An examination reveals swelling and tenderness in her left knee and over the proximal interphalangeal joints of the second and third digits of her right hand. An antinuclear antibody test and an anti–double-stranded DNA test are both positive. A CBC and blood chemistries are within normal limits.

Which one of the following medications would be the best initial treatment for this patient? (check one)
Azathioprine (Imuran)
Cyclosporine
Hydroxychloroquine (Plaquenil)
Mycophenolate (CellCept)
Rituximab (Rituxan)

Answer 48

Hydroxychloroquine (Plaquenil)

According to the American College of Rheumatology criteria, this patient has systemic lupus erythematosus, with photosensitivity, arthritis, a positive antinuclear antibody test, and a positive anti–double-stranded DNA test. She has a mild form of the disease. Hydroxychloroquine reduces arthritis pain in lupus patients (SOR A) and is the preferred initial treatment for lupus arthritis. Cyclosporine and azathioprine are indicated for severe lupus or lupus nephritis. Mycophenolate is indicated for refractory lupus or lupus nephritis. Rituximab is indicated for severe refractory lupus.

Question 49

A 54-year-old male plumber presents with a 2-month history of nonpainful swelling in the elbow. He has no history of injury or trauma. An examination is significant for a nontender, soft nodule over the olecranon process with no erythema or warmth.

Which one of the following would be most appropriate at this point? (check one)
Conservative management with ice, compression wraps, and activity modification
Broad-spectrum antibiotics with coverage for MRSA
An intrabursal corticosteroid injection
An intrabursal hyaluronic acid (Synvisc) injection
Aspiration of the bursa fluid under sterile conditions

Answer 49

Conservative management with ice, compression wraps, and activity modification

Conservative treatment is the recommended initial management for olecranon bursitis when there is no history of trauma or signs of septic bursitis. Aspiration of the bursal fluid is not recommended initially due to the risk of iatrogenic infection, but can be considered for symptomatic relief if there is significant enlargement or symptoms, or for diagnosis and culture if septic bursitis is suspected. Antibiotics are not recommended for aseptic bursitis and should be delayed in septic bursitis until after aspiration for culture. MRSA coverage may be indicated if the patient is at high risk for MRSA infection. An intrabursal corticosteroid injection is not routinely recommended for bursitis unless an underlying inflammatory condition is suspected, such as gout or rheumatoid arthritis. An intrabursal hyaluronic acid injection is not a recommended treatment for bursitis.

Question 50

A 74-year-old female comes to the emergency department with the acute onset of severe pain in the middle to lower back after lifting a small piece of furniture. Imaging demonstrates an acute nondisplaced wedge compression fracture of the T12 vertebra. An examination confirms that there is no neurologic deficit. She is admitted to the hospital.

In addition to pain management, which one of the following would you recommend? (check one)
Early mobilization as tolerated
Bed rest until a back brace is obtained
Evaluation for kyphoplasty
Evaluation for vertebroplasty
A neurosurgical evaluation

Answer 50

Early mobilization as tolerated

Generally, the goal for patients with vertebral compression fractures is early mobilization when tolerated. Bed rest is ordered only if movement is not tolerated. The evidence for back bracing is limited but it can be used after weighing the risks and benefits. Current evidence supports initial conservative treatment before considering vertebroplasty or kyphoplasty (SOR C). Neurosurgical consultation is not required in this case.

Question 51

A 42-year-old male hair stylist presents with numbness and tingling of the right fifth finger that has been progressive over the last few months. He is particularly bothered after a long day of prolonged elbow flexion. He has no pain but has noticed some clumsiness and difficulty with fine coordination of his fingers. An examination clearly shows intrinsic muscle weakness.

Which one of the following is the most likely diagnosis? (check one)
Anterior interosseous nerve syndrome
Carpal tunnel syndrome
Cubital tunnel syndrome
Pronator syndrome
Wartenberg syndrome

Answer 51

Cubital tunnel syndrome

This patient has signs and symptoms of cubital tunnel syndrome, which is the second most common peripheral neuropathy. Symptoms develop because of ulnar nerve compression in the upper extremity, leading to sensory paresthesias in the ulnar digits and intrinsic muscular weakness. Vague motor problems, including poor coordination of the fingers and hand clumsiness, are frequent complaints. Provocative testing includes demonstration of Tinel’s sign over the cubital tunnel, and the elbow flexion test with paresthesias elicited over the ulnar nerve.

Carpal tunnel syndrome causes paresthesias in the distal median nerve distribution. Wartenberg’s syndrome reflects compression of the superficial radial nerve. Pronator syndrome is a proximal median nerve neuropathy, while anterior interosseous nerve syndrome, a rare clinical entity, causes paresis or paralysis of the flexor pollicis longus, and the flexor digitorum profundus of the index and long fingers.

Question 52

A 16-year-old male is hit on his shoulder while playing football. A radiograph subsequently reveals a midclavicular fracture that is minimally displaced.

Appropriate management would be (check one)
a weekly radiograph to monitor for displacement
a sling for 2–6 weeks
a shoulder immobilizer for 6 weeks
a figure-of-eight bandage for 8 weeks
immediate referral to an orthopedist

Answer 52

a sling for 2–6 weeks

Fractures of the clavicle are common in young individuals, usually from sports injuries or direct trauma. Eighty percent of these fractures occur in the midclavicle. Unless significantly displaced, these fractures do not require referral. They can be treated with just a sling for 2–6 weeks. A sling is more comfortable and less irritating than a figure-of-eight bandage. Passive range of motion of the shoulder is indicated as soon as the pain allows. Physical therapy may be started at 4 weeks after the injury.

Question 53

An 11-year-old female is brought to your office by her parent who is concerned that the child’s spine might be curved. The most appropriate evaluation for scoliosis at this point is (check one)
comparing the length from the pelvic brim to the pelvic floor on the left and the right
scoliometer measurement with the patient bent over to 90°
scoliometer measurement with the patient upright and arms to her side
determination of the Cobb angle with the patient bent over to 90°
determination of the Cobb angle with the patient upright and arms to her side

Answer 53

scoliometer measurement with the patient bent over to 90°

The forward bend test, combined with a scoliometer measurement, is the most appropriate initial test when evaluating for scoliosis. A scoliometer should be used with the patient’s spine parallel to the floor (bent over to approximately 90°), with the arms hanging down, palms together, and feet pointing forward. If 5°–7° of trunk rotation is assessed by the scoliometer or by a scoliometer app on a smartphone, radiography can be performed to assess the Cobb angle. This radiography should be performed with the patient upright. A Cobb angle >20° may signify scoliosis, which may benefit from bracing, depending on skeletal maturity. Comparing the length from the pelvic brim to the pelvic floor on the left and the right is not indicated in the evaluation for scoliosis.

The U.S. Preventive Services Task Force changed its recommendation for scoliosis screening from grade D to grade I in 2018. Bracing has been found to reduce by over 50% the chance that mild to moderate curvatures will progress to curvatures of greater than 50°.

Question 54

Beyond short-term pain relief, local corticosteroid injection provides the best long-term improvement for which one of the following? (check one)
Greater trochanteric bursitis
Knee osteoarthritis
Lateral epicondylitis
Subacromial impingement syndrome
Trigger finger

Answer 54

Trigger finger

Reported cure rates for trigger finger after corticosteroid injection range from 54% to 86%. Corticosteroid injection for the other conditions listed results in temporary pain relief, but the underlying conditions are not improved by the injection.

Question 55

A 51-year-old female comes to your office for follow-up of fibromyalgia. She is currently taking amitriptyline, 10 mg at bedtime, and naproxen (Naprosyn), 500 mg twice daily, for her symptoms. A member of her fibromyalgia support group recommended fluoxetine (Prozac) to her and she asks you if it would be helpful.

It would be appropriate to tell her that SSRIs for the treatment of fibromyalgia (check one)
do not affect depression scores
reduce fatigue
provide some pain reduction
help with sleep problems
are superior to tricyclics for pain control

Answer 55

provide some pain reduction

Fibromyalgia is a chronic complex condition characterized by muscle pain, fatigue, muscle tenderness, and sleep disorders, often accompanied by mood disorders. SSRIs have been studied in the treatment of these symptoms, and while they have been shown to produce up to a 30% reduction in pain scores in patients with fibromyalgia, they have not been shown to affect fatigue or sleeping problems. They also have not been shown to be superior to tricyclics when treating pain. As with other patient populations, SSRIs have been shown to improve depression in those with fibromyalgia.

Question 56

A 35-year-old female with rheumatoid arthritis currently being treated with adalimumab (Humira) injections sees you for evaluation after developing a red, swollen, warm, and painful right knee. Arthrocentesis is performed, and the synovial fluid analysis is concerning for septic arthritis.

Which one of the following organisms is the most likely cause of her infection? (check one)
Candida albicans
Escherichia coli
Mycobacterium tuberculosis
Staphylococcus aureus
Streptococcus pyogenes

Answer 56

Staphylococcus aureus

Patients with rheumatoid arthritis being treated with anti-tumor necrosis factor therapy are at increased risk for septic arthritis. The most common cause of septic arthritis in adults is Staphylococcus aureus, followed by Streptococcus species. Escherichia coli causes about a fourth of the cases in the elderly. Fungal and mycobacterial causes such as Candida albicans or Mycobacterium tuberculosis are less common but must be considered in immunocompromised patients.

Question 57

A 57-year-old female presents for follow-up 6 weeks after falling and breaking her wrist. The fracture has healed but she has developed burning pain in the area of the fracture, which she rates as 9 on a scale of 10. On examination you note moderate hyperalgesia in the area with some minimal localized swelling. You suspect complex regional pain syndrome (CRPS).

CRPS is best diagnosed with which one of the following? (check one)
The patient history and physical examination
Ultrasonography
MRI
Nerve conduction testing
A technetium 99m bone scan

Answer 57

The patient history and physical examination

Complex regional pain syndrome (CRPS) usually develops after an injury, often a fracture, to a distal extremity, although it can present without prior injury. The diagnosis is made clinically using the history and physical examination. Its pathophysiology is poorly understood. Ultrasonography or MRI may be used to rule out other diagnoses but are not necessary for the diagnosis of CRPS. Nerve injury can be seen on nerve conduction testing with type 2 CRPS, also known as causalgia, but nerve injury is not always identified with type 1 CRPS, also known as reflex sympathetic dystrophy. Nerve conduction testing is not necessary for making the diagnosis, and both types of CRPS are treated with the same approach. A technetium 99m bone scan may reveal increased bone resorption at the site, but it is neither sensitive nor specific for CRPS.

Question 58

A 52-year-old female with metastatic breast cancer is hospitalized for treatment of complications from her cancer treatment. She has developed a new onset of back pain that has been progressively worsening over the past few hours. The pain is worse when she is lying down and is not responsive to pain medication.

Which one of the following would be the most appropriate next step to address this patient’s back pain? (check one)
Increase the dosage of her immediate-release morphine
Increase the dosage of her sustained-release morphine
Order cyclobenzaprine
Order an urgent MRI
Order a physical therapy consultation for mobility

Answer 58

Order an urgent MRI

Malignant epidural spinal cord compression is an oncologic emergency that requires urgent MRI to confirm
the diagnosis. It is caused by a tumor compressing the dural sac and should be suspected with new-onset
progressive back pain that is worse when the patient is lying down. It is most commonly associated with
breast cancer and develops in approximately 5% of all patients with cancer. Once the diagnosis is
confirmed, an urgent management approach is needed. Corticosteroids and neurosurgical intervention can
preserve motor and sensory function. Attempting to alleviate the pain would not address this emergency.

Question 59

An otherwise healthy 37-year-old female presents to your office with elbow pain 1 day after falling while skiing. She has pain and tenderness along the lateral aspect of the affected elbow and limited range of motion of the elbow and forearm. Radiographs confirm a nondisplaced fracture of the radial head.

Which one of the following would be most likely to produce satisfactory outcomes? (check one)
Immobilization for 3 days followed by range-of-motion exercises
A long arm posterior splint for 6 weeks
A long arm cast for 6 weeks
Referral to an orthopedist for cast placement
Referral to an orthopedist for surgical repair

Answer 59

Immobilization for 3 days followed by range-of-motion exercises

This patient has a nondisplaced radial head fracture. Current evidence supports a brief period of immobilization followed by early range-of-motion exercises to avoid decreased range of motion. This results in good outcomes in 85%–95% of patients. Immobilization for 6 weeks using either a long arm posterior splint or a long arm cast is not necessary. More advanced or displaced fractures may require a referral to an orthopedist for cast placement or operative repair, but nondisplaced radial head fractures can be managed by primary care physicians.

Question 60

An 83-year-old female tells you she has had pain in her knees for the past 15 years, although she has never discussed this problem with you before. After a thorough history and physical examination you diagnose osteoarthritis.

Which one of the following would you recommend as the most appropriate first-line treatment to reduce this patient’s pain? (check one)
Vitamin D
Glucosamine and chondroitin
Early morning total and late afternoon total serum testosterone
Corticosteroid injection of the knees
Supervised exercise

Answer 60

Supervised exercise

The goals of osteoarthritis therapy are to minimize pain and improve function. The American Academy
of Orthopedic Surgery and the American College of Rheumatology have agreed that first-line treatment
includes aerobic exercise, resistance training, and weight loss. For patients with osteoarthritis of the knee,
supervised exercise was found to reduce pain and improve physical function and quality of life (SOR A).
Vitamin D is not currently recommended, and glucosamine and chondroitin are less effective than placebo.
Initial pharmacotherapy includes full-strength acetaminophen, or oral or topical NSAIDs. If patients have
an inadequate response to these agents other treatments to consider include tramadol, other opioids,
duloxetine, or intra-articular injections with corticosteroids or hyaluronate.

Question 61

A 72-year-old female presents for a routine health maintenance visit. Which one of the following medications in her current regimen places her at risk for osteoporosis? (check one)
Atorvastatin (Lipitor)
Hydrochlorothiazide
Metformin (Glucophage)
Phenytoin (Dilantin)
Ranitidine (Zantac)

Answer 61

Phenytoin (Dilantin)

Medications reported to be associated with osteoporosis and increased fracture risk include antiepileptic
drugs, long-term heparin, cyclosporine, tacrolimus, aromatase inhibitors, glucocorticoids,
gonadotropin-releasing hormone agonists, thiazolidinediones, excessive doses of levothyroxine, proton
pump inhibitors, SSRIs, parenteral nutrients, medroxyprogesterone contraceptives, methotrexate, and
aluminum antacids. Atorvastatin, hydrochlorothiazide, metformin, and ranitidine are not associated with
osteoporosis.

Question 62

A 48-year-old male with an 8-week history of the gradual onset of nonradiating, worsening left heel pain sees you for follow-up. He started running on his neighborhood streets 3 months ago to train for a 10K race. The pain limits his training significantly. His symptoms improved when he began taking ibuprofen and took 2 weeks off from running a month ago. A radiograph of the left foot 4 weeks ago was normal. There is no other pain and he feels well otherwise.

On examination you note that his left heel is slightly swollen compared to the right and very tender when squeezed on the sides. The anterior aspect and Achilles tendon insertion of the heel are nontender. There is no erythema or warmth and the remainder of the left lower extremity examination is normal. His vital signs are normal.

Which one of the following would you recommend at this point? (check one)
A C-reactive protein level
Nerve conduction velocity testing
A repeat radiograph
Ultrasonography
MRI

Answer 62

MRI

This patient has a calcaneal stress fracture as suggested by the history of increased running on a hard
surface, improvement with rest, and a positive calcaneal squeeze on examination. A delay in diagnosis
increases the risk of delayed union. MRI is the preferred imaging modality because radiographs often do
not detect a calcaneal stress fracture. A C-reactive protein level could be indicated if there were symptoms
or signs of infection or autoimmune illness. The clinical picture does not suggest a neurologic condition,
so nerve conduction velocity testing is not appropriate. While there are some case reports of the diagnosis
of stress fractures using ultrasonography, this is not the preferred imaging method.

Question 63

A 17-year-old female presents for acute care after tripping and falling on her right knee when stepping off her electric scooter. An examination does not reveal gross deformity or notable effusion. Range of motion in the right knee is limited to 100° of flexion. There is tenderness over the proximal tibia. She can only take two steps before being unable to bear weight on the knee due to pain.

Which one of the following findings on the patient’s history and examination should prompt you to order immediate knee radiographs? (check one)
Her age
Her sex
Bony tenderness over the proximal tibia
Limited range of motion
The inability to take more than two steps

Answer 63

The inability to take more than two steps

Several decision support tools can help guide the decision to order imaging of an injured knee, such as the
Ottawa Knee Rule, the Pittsburgh Knee Rule, and American College of Radiology (ACR) criteria. The
inability to take four or more steps immediately after an injury or in the emergency setting is an indication
for radiography in all three rules.
Age is an indication for radiography in acute knee pain in patients over 55 years of age according to the
Ottawa rule, or under 12 or over 50 years of age according to the Pittsburgh rule. The patient’s sex does
not factor into the criteria for imaging.
Bony tenderness is an indication for imaging according to the ACR and Ottawa rules, but only if isolated
over the proximal fibula or over the patella without other bony tenderness. The inability to flex the knee
to 90° is also an indication for imaging according to the ACR and Ottawa rules.

Question 64

A 43-year-old female presents to your office with a 3-month history of left low back and posterior hip pain. She does not recall an injury but says she was very active during a move to a new home prior to the onset of the pain. An examination reveals that her gait, lower extremity strength, straight leg resistance, and hip and knee range of motion are normal. A log roll test is also normal. A flexion, abduction, external rotation (FABER) test produces posterior pain.

Which one of the following is the most likely diagnosis? (check one)
Femoroacetabular impingement
Greater trochanteric pain syndrome
Osteoarthritis
Piriformis syndrome
Sacroiliac joint dysfunction

Answer 64

Sacroiliac joint dysfunction

The cause of hip pain is generally determined from the patient’s history and physical examination. A
positive flexion, abduction, external rotation (FABER) test that produces pain at the sacroiliac joint, lumbar
spine, and posterior hip is associated with sacroiliac joint dysfunction. The log roll test involves passive
supine internal and external rotation of the hip. When this test is positive for pain it is associated with
piriformis syndrome. While femoroacetabular impingement may be associated with a positive FABER test,
it would produce pain in the groin. Greater trochanteric pain syndrome results in lateral hip pain rather
than posterior pain. Osteoarthritis is usually associated with a limited range of motion and groin pain.

Question 65

A 30-year-old female presents with pain over the proximal fifth metatarsal after twisting her ankle. Radiographs reveal a nondisplaced tuberosity avulsion fracture of the fifth metatarsal.

Which one of the following would be the most appropriate initial management? (check one)
A short leg walking boot
A compressive dressing with weight bearing and range-of-motion exercises as tolerated
A posterior splint with no weight bearing, and follow-up in 3–5 days
A short leg cast with no weight bearing
Surgical fixation

Answer 65

A compressive dressing with weight bearing and range-of-motion exercises as tolerated

The fifth metatarsal has the least cortical thickness of all of the metatarsals. There are strong ligaments and
capsular attachments on the proximal fifth metatarsal that can put significant stress on this area of the bone,
leading to fractures. Nondisplaced tuberosity fractures can generally be treated with compressive dressings
such as an Aircast or Ace bandage, with weight bearing and range-of-motion exercises as tolerated.
Minimally displaced (<3 mm) avulsion fractures of the fifth metatarsal tuberosity can be treated with a
short leg walking boot. If the displacement is >3 mm, an orthopedic referral is warranted.

Question 66

A 42-year-old female presents with a 2-week history of throbbing medial heel pain that is most painful when she first steps out of bed in the morning. The pain improves after she walks around for several minutes.

Which one of the following is the most likely diagnosis? (check one)
Achilles tendinopathy
Calcaneal stress fracture
Neuroma
Plantar fasciitis

Answer 66

Plantar fasciitis

Plantar fasciitis is the most common cause of heel pain, affecting more than 2 million people each year.
The pain is typically worst when the patient first gets out of bed and improves with activity. Calcaneal
stress fractures follow an increase in activity, and the pain tends to worsen with activity and is eventually
present all of the time. Achilles tendinopathy is an aching pain that also worsens with increased activity,
and there is often tenderness along the tendon. Neuromas present with a burning, tingling, or numb
sensation and a painful lump.

Question 67

A 67-year-old male diagnosed with polymyalgia rheumatica is started on long-term prednisone therapy. Which one of the following is the recommended first-line agent to prevent steroid-induced osteoporosis? (check one)
Alendronate (Fosamax)
High-dose vitamin D
Raloxifene (Evista)
Teriparatide (Forteo)

Answer 67

Alendronate (Fosamax)

Patients are at risk of developing glucocorticoid-induced osteoporosis if they are on long-term
glucocorticoid therapy, defined as >2.5 mg of prednisone for a duration of 3 months or longer. The
American College of Rheumatology recommends pharmacologic treatment for these patients, as well as
for patients receiving glucocorticoids who have a bone mineral density T-score –2.5 at either the spine
or the femoral neck and are either male and 50 years of age or female and postmenopausal. Therapy is
also recommended in patients 40 years of age who do not meet these criteria but have a 10-year risk of
major osteoporotic fracture of at least 20% or a risk of hip fracture of at least 3% according to the FRAX
tool.
Oral bisphosphonates are recommended as first-line agents for preventing glucocorticoid-induced
osteoporotic fractures, although intravenous bisphosphonates can be used if patients are unable to use the
oral forms. Supplementation of calcium (800–1000 mg) and vitamin D (400–800 IU) is also recommended.
Raloxifene and teriparatide are options when bisphosphonate therapy fails or is contraindicated (SOR A).

Question 68

A 22-year-old male presents to your office the morning after falling onto his outstretched right hand as he tripped while leaving a bar. He has a deep, dull ache in the right wrist on the radial side. The pain is worsened by gripping and squeezing. On examination there is some wrist fullness and the wrist is tender to palpation over the anatomic snuffbox. Radiographs of the wrist are negative.

Which one of the following would be most appropriate at this time? (check one)
Rest, ice, compression, elevation, and NSAIDs with no specific follow-up
Rest, ice, compression, elevation, and NSAIDs with a follow-up examination in 2 weeks
Placement of a thumb spica splint, with a follow-up examination in 2 weeks
CT of the wrist to detect an occult fracture
Ultrasonography of the wrist to detect a ligament injury

Answer 68

Placement of a thumb spica splint, with a follow-up examination in 2 weeks

The history, symptoms, and physical examination findings in this case suggest a scaphoid fracture. The
scaphoid bone is the most commonly fractured carpal bone and a fall on an outstretched hand can produce
enough force to cause this fracture. This fracture is most common in males 15–30 years of age.
The finding of anatomic snuffbox tenderness is highly sensitive but not specific for a scaphoid fracture.
Initial radiographs often do not demonstrate a fracture. When there is a high clinical suspicion for a
scaphoid fracture but radiographs are negative, it is reasonable to immobilize in a thumb spica splint and
reevaluate in 2 weeks.
18
Treatment for a sprain with or without follow-up would not be ideal in a situation where a scaphoid
fracture is suspected. MRI or bone scintigraphy can be considered if the patient desires or needs an
immediate diagnosis, but CT and ultrasonography are not appropriate imaging modalities for this fracture.

Question 69

A 70-year-old female who is an established patient at your practice calls you late on a Saturday afternoon. Earlier in the day she misjudged the location of a bench at a neighbor’s house and sat down hard on the porch floor. She felt immediate pain in her back. She went home and took naproxen, 440 mg, and sustained-release acetaminophen, 1300 mg, 3 hours ago. She still describes her pain as unbearable, rating it as 10 on a scale of 10. You agree to meet her in the emergency department, where you confirm an acute T12 vertebral compression fracture.

Of the following, the most appropriate treatment option for this patient’s acute pain is a short course of: (check one)
prescription-strength NSAIDs
methadone
transdermal fentanyl
immediate-release oxycodone (Roxicodone)

Answer 69

immediate-release oxycodone (Roxicodone)

The most appropriate treatment for this patient’s acute pain following a T12 vertebral compression fracture is round-the-clock class II narcotics. Subcutaneous calcitonin can also be useful for relieving pain from vertebral fractures. NSAIDs and acetaminophen are usually insufficient during the acute phase of a vertebral compression fracture, and this patient has already tried these. Methadone or transdermal fentanyl can be used, but plasma levels of methadone may take 5–7 days to stabilize and fentanyl takes 24–48 hours to take effect.

Question 70

An 11-year-old female is brought to your office for a well child visit. The mother is concerned because the patient’s back seems to have a curve. The patient is not aware of this although she has frequent back pain.

An examination is notable for a BMI above the 95th percentile for her age, and breast bud development. Menarche has not occurred. When she leans forward with her arms outstretched there is a 12° curve in her spine with a rib hump. Radiography reveals a measured Cobb angle of 20°.

Which one of the following indicates a need for referral to a specialist? (check one)
Back pain
A Cobb angle of 20°
Female sex
Obesity
Premenarchal status

Answer 70

A Cobb angle of 20°

There are three major risk factors for curve progression of idiopathic scoliosis: the magnitude of the curve at presentation, the potential for future growth, and female sex. Of these factors, curve progression has the most impact on the need for referral versus observation. The Cobb angle is based on spine radiology that quantifies the magnitude of the scoliosis curve. If the Cobb angle is 20° there is a high risk that the curve will progress and that the patient may need treatment. Age, sex, menstrual status, pubertal status, and growth potential are less important factors. Scoliosis typically does not cause pain and it is more likely that this patient’s weight is contributing to her back pain.

Question 71

A 50-year-old female presents with pain in her right forefoot. She recently ran her first full marathon after several years of inactivity and says the pain started gradually over the last few weeks of her training and has slowly gotten worse. You order radiographs of the foot, which show a stress fracture of the second metatarsal.

You would recommend (check one)
resumption of regular activity if the pain does not recur with activity after 1 week of rest
no weight bearing on the right foot for 6 weeks
no weight bearing for a few days, followed by a walking boot, then a rigid-soled shoe in 4–6 weeks
a walking boot for 12 weeks
referral to an orthopedic surgeon for further evaluation

Answer 71

no weight bearing for a few days, followed by a walking boot, then a rigid-soled shoe in 4–6 weeks

The recommended treatment for metatarsal stress fractures is no weight bearing for a few days, possibly using a posterior splint, transitioning to a walking boot or short leg cast, and then a rigid-soled shoe in 4–6 weeks. Callus formation on a radiograph and a lack of point tenderness signify adequate healing, and immobilization can be discontinued. Other recommended conservative therapy includes modified rest for 6–8 weeks with continuation of activities of daily living and limited walking. Normal activity can be resumed after 2–3 weeks with no pain. Additionally, the use of NSAIDs, ice, and stretching, as well as cross-training is recommended. Resuming regular activity after only 1 week of pain-free rest would not be recommended. Fractures of the fifth metatarsal should be carefully investigated to rule out a Jones fracture that may require orthopedic treatment. Treatment of the more common second and third metatarsal stress fractures is relatively straightforward.