CHAPTER 09- Musculoskeletal Review

Question 1

For which of the following diagnoses are patients most likely to complain of pain on the plantar surface of the foot?

1. Metatarsal stress fracture
2. Pes cavus
3. Pes planus
4. Morton’s neuroma

Answer 1

4. Morton’s neuroma

Morton’s neuroma is a painful condition that affects the ball of the foot, most commonly between the area of the third and fourth toe.

Question 2

What is the most common cause of heel pain?

1. Plantar fasciitis
2. Achilles tendonopathy
3. Ankle sprain
4. Compartment syndrome

Answer 2

1. Plantar fasciitis

Plantar fasciitis is one of the most common causes of heel pain. It involves pain and inflammation of a thick band of tissue, called the plantar fascia that runs across the bottom of the foot and connects the calcaneus bone to the toes. Plantar fasciitis commonly causes stabbing pain that usually occurs with the very first steps in the morning.

Question 3

Pain with a standing (weight bearing) heel raise will occur with which of the following diagnoses?

1. Achilles tendonopathy
2. Lateral ankle sprain
3. Compartment syndrome
4. Medial ankle sprain

Answer 3

1. Achilles tendonopathy

When performing a physical exam, most people with Achilles tendinopathy will complain of pain when they stand on the affected leg and raise their heel off the ground. This movement reproduces their pain.

Question 4

The following picture shows a foot deformity that is characteristic of which of the following diagnoses?

1. Compartment syndrome
2. Diabetes mellitus
3. Charcot foot
4. Pes cavus

Answer 4

3. Charcot foot

Diabetes damages blood vessels, decreasing the blood flow to the feet. Poor circulation weakens bone, and can cause disintegration of the bones and joints in the foot and ankle. As a result, people with diabetes are at a high risk for developing Charcot foot. The combination of bone disintegration and trauma can warp and deform the shape of the foot.

Question 5

Which of the following is true of the Ottawa foot and ankle rules?

1. Has a high specificity for foot and ankle fractures
2. Has high sensitivity for foot and ankle fractures
3. Is specific for fractures of the cuboid bone
4. Is correlated with decreased foot and ankle ROM

Answer 5

2. Has high sensitivity for foot and ankle fractures

Evidence supports the Ottawa ankle rules as an accurate instrument for excluding fractures of the ankle and mid-foot. The instrument has a sensitivity of almost 100% and a modest specificity, and its use should reduce the number of unnecessary radiographs by 30–40%.

Question 6

Severe uncontrolled pain, swelling, and pain with a history of foot trauma is consistent with which of the following diagnoses?

1. Pes cavus
2. Pes planus
3. Achilles tendonopathy
4. Compartment syndrome

Answer 6

4. Compartment syndrome

Compartment syndrome causes severe pain that does not go away with analgesic medications and is not relieved when the foot is raised. In more severe cases, it may include paresthesia, pallor, and pulselessness.

Question 7

Which of the following is true of a lateral ankle sprain?

1. Trauma involving an eversion force
2. Decreased ankle plantar flexion ROM
3. Treatment may involve an external support initially
4. Tenderness over the deltoid ligament

Answer 7

3. Treatment may involve an external support initially

Early management of a lateral ankle sprain includes RICE (rest, ice, compression, and elevation). External support may allow the structures around the ankle to rest, provide compression and support, and prevent recurrence.

Question 8

A traction injury to the tibial tuberosity in adolescents is termed what?

1. Osgood–Schlatter disease
2. Prepatellar bursitis
3. Infrapatellar bursitis
4. Quadriceps tendonopathy

Answer 8

1. Osgood–Schlatter disease

Osgood–Schlatter disease is a common cause of knee pain in growing adolescents. It is an inflammation of the area just below the knee where the patellar tendon attaches to the tibia.

Question 9

Which of the following knee conditions may require surgery?

1. Osgood–Schlatter disease
2. Medial tibial stress syndrome
3. Pes anserine bursitis
4. Patellar subluxation

Answer 9

4. Patellar subluxation

Some patients with patellar subluxation are not cured by conservative treatment and may need surgery. The surgeon may initially perform an arthroscopy to assess the mechanics of the knee joint and ascertain if there is an issue that can be corrected.

Question 10

Pes anserine bursitis:

1. Describes inflammation of the gastrocnemius-semimembranosus bursa.
2. Is also known as a Baker’s cyst.
3. Includes the semimembranosus tendon.
4. Can be caused by an LE biomechanical fault.

Answer 10

4. Can be caused by an LE biomechanical fault.

Pes anserine bursitis can be caused by repetitive activities, incorrect sports training techniques (e.g., a lack of stretching), obesity, osteoarthritis of the knee, incorrect positioning of the knee, turning the leg sharply with the foot planted on the ground, injury such as a direct hit to the leg, a tear in the cartilage of the knee, or flat feet.

Question 11

Swelling on the posterior aspect of the knee:

1. May be repatellar bursitis.
2. May be pes anserine bursitis.
3. May be associated with meniscus tears.
4. Usually indicates popliteal artery compromise.

Answer 11

3. May be associated with meniscus tears.

Symptoms of a torn knee meniscus include pain, swelling posteriorly, popping, and the feeling that the knee is “locking.”

Question 12

A patient with a meniscus tear may present with which of the following?

1. A history of patellar subluxation
2. Mechanical catching and joint line tenderness
3. Trauma involving valgus stress to the knee
4. Trauma involving varus stress to the knee

Answer 12

2. Mechanical catching and joint line tenderness

Symptoms of a torn meniscus commonly include the patient stating that there is a feeling of mechanical “catching” and joint line tenderness.

Question 13

A football player is hit on the lateral side of the right knee while twisting to the left. Which ligament is most likely to be injured?

1. LCL
2. MCL
3. ACL
4. PCL

Answer 13

2. MCL

The MCL (medial collateral ligament) can be injured during activities that involve bending, twisting, or a quick change of direction. The MCL can be injured in football when the outside of the knee is hit (i.e., a valgus force). This type of injury can also occur during skiing and in other sports with lots of stop-and-go movements, jumping, or weaving.

Question 14

Which of the following injuries results in rapid and moderate to severe effusion?

1. LCL
2. MCL
3. ACL
4. Meniscus tear

Answer 14

3. ACL

A gross effusion will most commonly be present within a few hours after an ACL injury; however, absence of an effusion does not mean an ACL injury has not occurred.

Question 15

Medial tibial stress syndrome may involve which of the following muscles?

1. Quadriceps femoris
2. Gastrocnemius
3. Soleus
4. Peroneal brevis

Answer 15

3. Soleus

Medial tibial stress syndrome (MTSS), commonly known as “shin splints,” is a frequent injury of the lower extremity and one of the most common causes of exertional leg pain. It is related to inflammation of the soleus muscle that is located in the posterior part of the calf.

Question 16

Limping and pain in a child’s leg of insidious onset may be indicative of what?

1. Intertrochanteric fracture
2. Hip dislocation
3. Legg-Calve-Perthes disease
4. Hip impingement

Answer 16

3. Legg-Calve-Perthes disease

Legg–Calvé–Perthes disease occurs when the blood supply is temporarily interrupted to the femoral head of the hip joint. Without sufficient blood flow, the bone begins to die and can break easily, and subsequently may heal poorly.

Question 17

Which of the following is true of intertrochanteric fractures?

1. Affects men more than women
2. Has a 50–60% mortality rate in the first year after the fracture
3. Primary intervention is ORIF
4. Carries a 30% chance of re-fracture

Answer 17

3. Primary intervention is ORIF

Open reduction and internal fixation (ORIF) is indicated for all intertrochanteric fractures, unless the patient’s medical condition is such that any anesthesia, general or spinal, is contraindicated.

Question 18

A patient is involved in an MVA where his knee hits the dashboard of the car. Which of the following are possible injuries?

1. Anterior hip dislocation
2. PCL ligament tear
3. Patellar dislocation
4. ACL tear

Answer 18

2. PCL ligament tear

PCL tears make up less than 20% of injuries to the knee ligaments. Injuries that tear the PCL often damage some of the other ligaments or cartilage in the knee as well. PCL injuries are often due to a blow to the knee while it’s bent. Common causes include: striking the knee against the dashboard during an auto accident or falling on the knee while it’s bent.

Question 19

Which of the following is true of hip dislocations?

1. 75% of dislocations are anterior.
2. With a posterior dislocation, the femoral nerve may be injured.
3. After a posterior dislocation, the limb is held in full external rotation.
4. Osteonecrosis is a potential complication.

Answer 19

4. Osteonecrosis is a potential complication.

Osteonecrosis of the hip may occur with any hip dislocation. It occurs when the blood supply to the bone is disrupted. Osteonecrosis is also called avascular necrosis or aseptic necrosis. Although it can occur in any bone, osteonecrosis most often affects the hip.

Question 20

What is the most commonly injured hip adductor muscle?

1. Adductor magnus
2. Adductor brevis
3. Pectineus
4. Adductor longus

Answer 20

4. Adductor longus

The adductor muscles of the thigh are responsible for moving the leg across the body and are susceptible to muscle strains. Strains of the adductor muscles occur where the muscle tendons attach to the pelvic bone.

Question 21

A tear to the inferior portion of the shoulder labrum is termed:

1. A Bankart lesion.
2. A SLAP tear.
3. An inferior AC joint strain.
4. An inverse biceps tear.

Answer 21

1. A Bankart lesion.

A Bankart lesion is an injury of the anterior (inferior) glenoid labrum of the shoulder due to anterior shoulder dislocation. When this happens, a pocket at the front of the glenoid forms that allows the humeral head to dislocate into it.

Question 22

A patient falling directly on the shoulder with tenderness over the superior-anterior shoulder is present in what?

1. Subacromial pain syndrome
2. Rotator cuff strain
3. AC joint injury
4. First rib stress fracture

Answer 22

3. AC joint injury

Acromioclavicular joint injuries are often seen with contact sports injuries and car accidents. The acromioclavicular joint is located at the top of the shoulder where the acromion process and the clavicle meet to form a joint.

Question 23

Shoulder pain radiating down the lateral side of the humerus to the elbow after a fall on to an outstretched arm could be caused by what?

1. Adhesive capsulitis
2. AC joint strain
3. RTC tear
4. Biceps tear

Answer 23

3. RTC tear

A rotator cuff tear may result from an acute injury such as a fall or may be caused by chronic wear and tear with degeneration of the tendon. Typically, there is pain in the front of the shoulder that radiates down the side of the arm. It may be present with overhead activities such as lifting or reaching.

Question 24

Which of the following is true of adhesive capsulitis (frozen shoulder)?

1. It is correlated with RTC tears.
2. It is more likely to occur in patients under 30 years of age.
3. It may take upward of 14 months to resolve.
4. It is treated with immobilization in the freezing stage.

Answer 24

3. It may take upward of 14 months to resolve.

Shoulder pain associated with adhesive capsulitis is progressive and initially felt mostly at night, or when the shoulder is moved close to the end of its range of motion. The pain usually progresses to constant pain at rest that is aggravated by all movements of the shoulder. In approximately 90% of patients with adhesive capsulitis, the pain may last 1–2 years.

Question 25

Of the following, which is the most commonly fractured bone in the body?

1. The scaphoid
2. The humerus
3. The ulna
4. The radius

Answer 25

4. The radius

Arm fractures account for almost 50% of all broken bones. The radius is commonly fractured when a person tries to break their “fall on an outstretched hand” (FOOSH).

Question 26

Kienbock’s disease refers to what?

1. Avascular necrosis of the scaphoid bone
2. Osteonecrosis of the lunate
3. Partial subluxation of the TFCC
4. Non-union fracture of the distal radius

Answer 26

2. Osteonecrosis of the lunate

Kienbock’s disease is a condition where the blood supply to one of the small bones in the wrist, the lunate, is interrupted. Without adequate blood supply, the bone can die. This is called osteonecrosis. Damage to the lunate causes a painful, stiff wrist and, over time, can lead to arthritis.

Question 27

A patient is being evaluated for a complaint of pain at the base of the thumb. The provider performs a Finkelstein test and the results are positive. This is indicative of which of the following disease processes?

1. DeQuervain’s tenosynovitis
2. Carpal tunnel syndrome
3. Ligamentous strain
4. Trigger finger

Answer 27

1. DeQuervain’s tenosynovitis

The test known as the Finkelstein test can help the clinician confirm De Quervain’s tenosynovitis. To perform the test, the thumb is bent down across the palm of your hand, and then covered with the fingers. The patient then bends the wrist toward their little finger. If this causes pain, it is likely due to De Quervain’s tenosynovitis.

Question 28

Thickening of the palmar skin of the hand in older adults is termed what?

1. DeQuervain’s tenosynovitis
2. Trigger finger
3. Dupuytren’s contracture
4. Swan neck deformity

Answer 28

3. Dupuytren’s contracture

Dupuytren’s contracture is a hand deformity that usually develops over years. Knots of tissue form under the skin, eventually creating a thick cord that can pull one or more fingers into a bent position.

Question 29

Trigger finger is the layperson’s term for:

1. Dupuytren’s contracture.
2. DeQuervain’s tenosynovitis.
3. Ligamentous strain of the DIP joint.
4. Stenosing tenosynovitis.

Answer 29

4. Stenosing tenosynovitis.

Stenosing tenosynovitis is a condition commonly known as “trigger finger.” It is sometimes also called “trigger thumb.” Trigger fingers are more common with certain medical conditions such as rheumatoid arthritis, gout, and diabetes. Repeated and strong gripping may lead to the condition. In most cases, the cause of the trigger finger is not known.

Question 30

Raynaud’s phenomenon is associated with which of the following?

1. Men, cold climates, and a history of hypothyroid
2. Women, scleroderma, and cold climates
3. Men, stroke, and DM
4. Women, sedentary occupation, smoking

Answer 30

2. Women, scleroderma, and cold climates

People of all ages can have Raynaud’s phenomenon. Raynaud’s phenomenon may run in families, especially in families that typically have autoimmune disorders. The primary form is the most common. It most often starts between age 15 and 25, and is most common in women and people living in cold places.

Question 31

What is ankylosing spondylitis?

1. An inflammatory arthritis affecting adolescent girls
2. An inflammatory arthritis more commonly seen in men
3. A genetic disease affecting older men
4. An infective arthritis affecting teenage boys

Answer 31

2. An inflammatory arthritis more commonly seen in men

Ankylosing spondylitis is an inflammatory disease that can cause some of the vertebrae in the spine to fuse together. This fusing makes the spine less flexible and can result in a hunched-forward posture. Ankylosing spondylitis affects men more often than women. Signs and symptoms of ankylosing spondylitis typically begin in early adulthood.

Question 32

What is the most common type of chronic LBP?

1. Degenerative lumbar disc disease
2. Spinal stenosis
3. Rheumatoid arthritis
4. Osteoarthritis of the sacroiliac joint

Answer 32

1. Degenerative lumbar disc disease

Degenerative joint disease is the most common type of low back pain. The lumbar facet joints are susceptible to wear and tear, degeneration, inflammation, and arthritic changes. This may result in pain or limited range of motion.

Question 33

Which of the following is associated with lumbar radiculopathy?

1. Negative SLR
2. Muscle weakness in particular distribution
3. Dull achy pain in the back
4. Usually occurs bilateral

Answer 33

2. Muscle weakness in particular distribution

Radicular pain radiates into the lower extremity (thigh, calf, and occasionally the foot) directly along the course of a specific spinal nerve root. The most common symptom of radicular pain is sciatica caused by compression of a spinal nerve in the low back. It often will be caused by compression of the lower spinal nerve roots (L5 and S1). With this condition, leg pain and weakness may occur and will depend on which nerve in the low back is affected.

Question 34

Which of the following is true of AAA?

1. Common cause of LBP in older men
2. Can cause bilateral LE radicular symptoms in feet and ankles
3. Surgery recommended even with small aneurysms
4. Usually asymptomatic

Answer 34

4. Usually asymptomatic

Abdominal aortic aneurysms often grow slowly and usually without symptoms, making them difficult to detect. Some aneurysms will never rupture. Many start small and stay small, others may enlarge over time. As an abdominal aortic aneurysm enlarges, some people may notice a pulsating feeling near the navel, deep constant pain in the abdomen, or back pain.

Question 35

The most common cause for lumbar surgery in the United States is:

1. Spinal tumor.
2. Ankylosing spondylitis.
3. Spondylolisthesis.
4. Spinal stenosis.

Answer 35

4. Spinal stenosis.

A lumbar laminectomy is typically performed to alleviate pain from lumbar spinal stenosis. Spinal stenosis is caused by degenerative changes that lead to enlargement of the facet joints in the back of the vertebrae.

Question 36

Which of the following is true of a patient with lumbar spinal stenosis?

1. Symptoms are improved with standing.
2. Symptoms are relieved by walking for 15–30 minutes.
3. Symptoms are worsened by laying on their stomach and pressing upward.
4. Symptoms are improved when walking bent over a shopping cart.

Answer 36

4. Symptoms are improved when walking bent over a shopping cart.

Standing upright and bending backward (extension) can make the symptoms of spinal stenosis worse. This is because lumbar flexion (bending forward) increases the diameter of the transverse foramen. It is therefore more comfortable for patients to sit or lean forward. Patients are frequently unable to walk for long distances and often state that their symptoms are improved when bending forward while walking with the support of a walker or shopping cart.

Question 37

Which of the following lumbar conditions are most likely to occur in adolescents?

1. Spondylolisthesis
2. Spinal stenosis
3. Lumbar disc herniation
4. Degenerative lumbar disc disease

Answer 37

1. Spondylolisthesis

The most common cause of low back pain in adolescent athletes is a stress fracture in one of the vertebrae. This condition is called spondylolysis and usually affects the fifth lumbar vertebra in the lower back. If the stress fracture weakens the bone so much that it is unable to maintain its proper position, the vertebra can start to shift out of place. This condition is called spondylolisthesis.

Question 38

An abnormal gait pattern is associated with which of the following lumbar conditions?

1. Lumbar instability
2. Cauda equina syndrome
3. Spondylolisthesis
4. AAA

Answer 38

2. Cauda equina syndrome

Although early treatment is required to prevent permanent problems, cauda equina syndrome may be difficult to diagnose. Symptoms vary in intensity and may evolve slowly over time. The patient may exhibit an unusual gait pattern, bladder and/or bowel dysfunction, urinary retention, severe or progressive problems in the lower extremities, including loss of or altered sensation between the legs, over the buttocks, along the inner thighs, and the back of the legs and feet.

Question 39

A positive Gowers’ sign is often found in which of the following conditions?

1. Lumbar disc herniation
2. AAA
3. Lumbar radiculopathy
4. Clinical lumbar instability

Answer 39

4. Clinical lumbar instability

Generally, Gowers’ sign is identified by the way people with proximal muscle weakness stand up from the floor. A patient with lumbar instability or weakness may bend the top half of his or her body forward, place weight on the knees using the hands, transfer the body weight supported by the hands up the legs and then raise to a standing position.

Question 40

Insidious chest wall pain can occur with which of the following?

1. AAA
2. C5-6 radiculopathy
3. Costochondritis
4. Lumbar facet syndrome

Answer 40

3. Costochondritis

Costochondritis is inflammation of the junctions of the ribs with the cartilage where it attaches at the sternum. Costochondritis causes localized chest wall pain and tenderness that can be reproduced by pushing on the involved cartilage in the front of the rib cage. Costochondritis is a relatively harmless musculoskeletal chest pain and usually resolves without treatment.

Question 41

Which of the following can cause thoracic pain that may radiate around to the front of the chest?

1. Thoracic disc herniation
2. Rib stress fracture
3. Shingles
4. All of these

Answer 41

4. All of these

When considering the differential diagnoses for a patient complaining of thoracic pain, the possibility of disc herniation, rib fracture, and shingles should all be considered as potential diagnoses.

Question 42

Which of the following is true of scoliosis?

1. Associated with uneven shoulders, a leg length discrepancy, and rib hump
2. Usually affects teenage boys and those with birth defects
3. Onset occurs in women in their third to fourth decade of life
4. Affects approximately 20% of the population

Answer 42

1. Associated with uneven shoulders, a leg length discrepancy, and rib hump

Scoliosis most typically occurs in those 10 to 18 years old, females more than males, and is often detected by school screenings or regular physician visits. A medical professional will look for: curvature of the spine, uneven shoulders and/or protrusion of one shoulder blade, asymmetry of the waistline, or one hip higher than the other.

Question 43

A Milwaukee brace is a conservative treatment for which condition?

1. Torticollis
2. Lumbar stenosis
3. Scoliosis
4. Thoracic disc herniation

Answer 43

3. Scoliosis

The Milwaukee brace is also known as a cervico-thoraco-lumbo-sacral orthosis. It is a back brace used in the treatment of spinal curvatures such as scoliosis. It is a full-torso brace that extends from the pelvis to the base of the skull. This brace is normally used with growing adolescents to hold a 25° to 40° advancing curve. The brace is intended to minimize the progression to an acceptable level, not to correct the curvature.

Question 44

Torticollis is a shortening or spasm of which of the following muscles?

1. Anterior scalene
2. Subclavius
3. Latissimus dorsi
4. Sternocleidomastoid

Answer 44

4. Sternocleidomastoid

Torticollis results in a fixed or dynamic posturing of the head and neck in tilt, rotation, and flexion. Spasms of the sternocleidomastoid, trapezius, and other neck muscles, usually more prominent on one side than the other, may cause turning or tipping of the head.

Question 45

Which of the following can cause sensory changes in the hand?

1. Thoracic disc herniation
2. Cervical stenosis
3. Lumbar stenosis
4. Torticollis

Answer 45

2. Cervical stenosis

Cervical stenosis can cause numbness, weakness, or tingling in the arm hand, leg or foot. Tingling in the hand is the most common symptom.

Question 46

Bowel and bladder dysfunction can occur with which of the following?

1. Cervical myelopathy
2. Thoracic myelopathy
3. Lumbar myelopathy
4. All of these

Answer 46

4. All of these

Myelopathy is a collective name for many different types of problems involving the spinal cord. When myelopathy occurs because of an accident or trauma, it is called a spinal cord injury. In other cases, myelopathy occurs as a result of a disease process. Symptoms of bowel or bladder dysfunction may be caused by myelopathy along any area of the spinal cord.

Question 47

Concentration and visual disturbances are common in which of the following conditions?

1. Cervical disc herniation
2. RA affecting the cervical spine
3. Cervical radiculopathy
4. Concussion

Answer 47

4. Concussion

A concussion is a traumatic brain injury that alters the way your brain functions. Effects are usually temporary but can include headaches, visual disturbances, and problems with concentration, memory, balance, and coordination.

Question 48

A patient presents with pain, swelling and tenderness over the patellar area. The patient states that she has been doing a lot of kneeling in her garden lately. The PCP recognizes that the patient has symptoms consistent with:

1. Pes anserine bursitis
2. Baker cyst
3. Prepatellar bursitis
4. LCL grade II sprain

Answer 48

3. Prepatellar bursitis

Prepatellar bursitis is an inflammation of the bursa in the front of the patella. It occurs when the bursa becomes irritated and produces too much fluid, which causes it to swell and put pressure on the adjacent parts of the knee. Prepatellar bursitis is often caused by pressure from constant kneeling. Plumbers, roofers, and gardeners are at greater risk for developing this condition.

Question 49

If the person in the preceding question added that they felt a “pop” in the knee before the swelling occurred, this would change the potential diagnosis from bursitis or sprain to which of the following?

1. LCL tear
2. MCL tear
3. Quadriceps tear
4. ACL tear

Answer 49

4. ACL tear

When the anterior cruciate ligament (ACL) is injured, the patient may state that they had heard a “popping” noise and then felt the knee “give out.” Other symptoms may include pain with swelling of the knee, loss of full range of motion, and discomfort with walking.