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Flashcards in MSK Deck (99):
1

A 22-year-old female gymnast presents to your clinic after a patellar dislocation during practice. She was treated in the emergency room with reduction of the patella and immobilization.
Radiographs and magnetic resonance imaging of the knee are negative for fracture or evidence of osteochondral lesions. You choose to treat her with immobilization for 2 weeks and then begin physical therapy. The most appropriate therapy recommendation is to focus on improving

(a) flexibility of gastrocnemius-soleus complex.
(b) strength of the iliopsoas.
(c) flexibility of the biceps femoris.
(d) strength of the vastus medialis

Answer: (d)
Commentary: Physical therapy in this patient should focus on strengthening of her medial
quadriceps muscles and restoration of normal patellar motion. Surgery in select instances addresses realignment of the patella by a lateral retinacular release and/or medial retinaculum repair when torn.

Reference: Diduch D, Scuderi GR, Scott WN. Knee injuries. In: Scuderi GR, McCann PD,
editors. Sports medicine: a comprehensive approach. 2nd ed. Philadelphia: Elsevier; 2005. p
376-7.

2013

2

A 62-year-old woman complains of right knee pain and stiffness. On physical examination, she
has a genu varum deformity. A physical therapy prescription should include

(a) isokinetic hamstring strengthening.
(b) isometric hamstring strengthening.
(c) closed kinetic chain quadriceps strengthening.
(d) open kinetic chain quadriceps strengthening

Answer: (c)
Commentary: For knee osteoarthritis, quadriceps strengthening has been well studied and is shown to be beneficial. In closed kinetic chain exercises, the distal aspect of the limb is fixed against a source of resistance, whereas in open kinetic chain exercises, the distal part of the limb is free in space. Closed chain exercises are preferred because they result in less shear force across
the joints and are also more functional.

Reference: Stitik TP, Foye PM, Stiskal D, Nadler RR. Osteoarthritis. In: DeLisa JA, Gans BM, Walsh NE. Physical medicine and rehabilitation: principles and practice.4th ed. Philadelphia: Lippincott Williams & Wilkins; 2005. p 772.

2013

3

A 25-year-old man comes to your office for evaluation of low back pain. As part of the physical
examination, you mark a point at the L5 vertebral body and another point midline 10 cm above.
You ask him to flex forward maximally while keeping his knees extended and measure the
distance between the two points. This distance is 13.5 cm. You suspect he may have what
diagnosis?

(a) Lumbar spondylolisthesis
(b) Scheuermann disease
(c) Lumbar herniated disc
(d) Ankylosing spondylitis

Answer: (d)
Commentary: The Schober test is used to assess restricted range of motion seen in ankylosing
spondylitis as the disease progresses. The distance between the 2 points with forward flexion Page 14 of 23

exceeds 15 cm in normal individuals. This clinical test is not used for the assessment of lumbar
spondylolisthesis, Scheuermann disease, or lumbar herniated discs.

Reference: Borg-Stein J, Bermas B. Spondyloarthropathies. In: Slipman CW, Derby R, Simeone
FA, Mayer TG, editors. Interventional spine: an algorithmic approach. 1st ed. Philadelphia:
Elsevier; 2008

2013

4

A 27-year-old manual laborer presents with a 6-month history of right shoulder pain. He has a
past medical history of a right shoulder dislocation after a water-skiing accident 3 years ago. On
physical exam, he has normal strength and sensation with symmetric reflexes. The shoulder
apprehension test is positive. Impingement tests and the O’Brien active compression test are
negative. Which diagnosis is most consistent with this presentation?

(a) Rotator cuff tendinitis
(b) Anterior-inferior labrum tear
(c) Glenohumeral osteoarthritis
(d) Superior labral anterior to posterior (SLAP) lesion

Answer: (b)
Commentary: This patient presents with an anterior-inferior labrum tear related to chronic
anterior shoulder instability following a prior traumatic event (dislocation). Unidirectional
instability refers to instability in only 1 direction, anterior direction being the most common. This type of instability is common after a traumatic event. Multidirectional instability refers to laxity in more than 1 direction and is associated with congenital laxity or chronic repetitive microtrauma. Anatomically, there is disruption in the anterior-inferior glenohumeral joint capsule and anterior-inferior labrum. Superior labral anterior to posterior (SLAP) lesions may occur, but that possibility is less likely in this patient, because of his history and a negative O’Brien compression test.

Reference: Finnoff JT. Musculoskeletal problems of the upper limb. In: Braddom RL, editor. Physical medicine and rehabilitation. 3rd ed. Philadelphia: Elsevier; 2007. p 832-3, 835

2013

5

A 60-year-old woman had a left total hip arthroplasty 4 weeks ago. During her gait evaluation,
she is noted to have a left lateral trunk lean during left stance phase. This gait deviation is most
likely a result of weakness in which left lower limb muscle?

(a) Gluteus medius
(b) Gluteus maximus
(c) Tensor fascia lata
(d) Vastus lateralis

Answer: (a)
Commentary: Gluteus medius weakness leads to a Trendelenburg gait. This woman's lateral trunk
lean is a compensated Trendelenburg gait. Gluteus medius or hip abductor weakness is common
following total hip arthroplasty. In one study, 36 of 76 (47%) patients with total hip arthroplasty
had hip abductor weakness. Of those 36 patients, all 36 had weakness in the gluteus medius, 28
had weakness in the gluteus minimus, and 4 had weakness in the tensor fascia latae.

Reference: (a) Hicks JE, Joe GO, Gerber LH. Rehabilitation of the patient with inflammatory
arthritis and connective-tissue disease. In: DeLisa JA, Gans BM, Walsh NE. Physical medicine and rehabilitation: principles and practice. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2005. p 736. (b) Bhave A, Mont M, Tennis S, Nickey M, Starr R, Etienne G. Functional problems and treatment solutions after total hip and knee joint arthroplasty. J Bone Joint Surg Am. 2005; 87(Suppl 2):9-21.

2013

6

Which statement is TRUE of the lower trapezius muscle?

(a) It is innervated by the thoracodorsal nerve.
(b) It is innervated by the long thoracic nerve.
(c) Contraction of this muscle results in upward rotation of the scapula.
(d) Contraction of this muscle results in abduction of the scapula

Answer: (c)
Commentary: The lower trapezius, as well as the upper trapezius and the middle trapezius, is innervated by the spinal accessory nerve (11th cranial nerve) and possibly contributions from the ventral rami of C2, C3, and C4. Contraction of the lower trapezius results in scapular depression,
adduction, and upward rotation.

Reference: Killen SH, Miller JT. Shoulder and arm and upper back. In: Cutter NC, Kevorkian
CG, editors. Handbook of manual muscle testing. NewYork: McGraw-Hill; 1999. p 20-21.

2013

7

Which non-surgical treatment for carpal tunnel syndrome is shown to provide significant short term benefit?

(a) Magnet therapy
(b) Laser therapy
(c) Therapeutic exercise
(d) Therapeutic ultrasound

Answer: (d) Commentary: Patients suffering from carpal tunnel syndrome are often offered nonsurgical treatments. Current evidence shows significant benefit from therapeutic ultrasound treatments, splinting, yoga, and carpal bone mobilization. However, trials involving the use of magnet
therapy, laser therapy, therapeutic exercise, and chiropractics have not produced significant benefits compared to placebo or control treatments.

Reference: O’Connor D, Marshall SC, Massy-Westropp N, Pitt V. Non-surgical treatment (other than steroid injection) for carpal tunnel syndrome. Cochrane Database Syst Rev 2003;(1):1

2013

8

Of the muscles listed, the most distal muscle receiving innervation from the C5 root is

(a) brachioradialis.
(b) pronator quadratus.
(c) brachialis.
(d) biceps brachii.

Answer: (a)
Commentary: The brachioradialis is innervated by C5 and C6. The biceps and brachialis are more
proximal, and pronator quadratus typically receives no C5 innervation.

Reference: Dumitru, D, Zwarts, MJ. Radiculopathies. In: Dumitru D, Amato AA, Zwarts, MJ,
editors. Electrodiagnostic medicine. 2nd ed. Philadelphia: Hanley & Belfus; 2002. p 721

2013

9

A 22-year-old runner presents with acute onset of distal calf pain. She is diagnosed with Achilles
tendinitis and is referred to physical therapy. Which therapeutic modality is the LEAST
beneficial in treating an overuse injury of this sort?
(a) Therapeutic ultrasound
(b) Iontophoresis
(c) Ice massage
(d) Neuromuscular electrical stimulation


Answer :(d)
Commentary: With acute overuse injuries, modalities such as ultrasound, iontophoresis, and ice
massage may decrease pain and facilitate rehabilitation. Electrical stimulation with recruitment
of muscle fibers may be contraindicated in treating acute overuse injuries.

2011

10

Hamstring injuries occur most commonly
a) at the proximal attachment of the lateral hamstrings to the pelvis.
b) during concentric contraction of the medial hamstrings.
c) at the distal attachment of the medial hamstrings to the tibia.
d) during eccentric contraction of the lateral hamstrings.


Answer: (d)
Commentary: The majority of hamstring injuries occur from indirect forces during running and
sprinting activities. Most injuries occur at the myotendinous junction, not at the osseous
attachments, during eccentric contraction of the hamstring. The lateral hamstrings (biceps
femoris) are affected more than the medial hamstrings (semitendinous and semimembranosus).

2011

11

Comparing the functional outcomes at 1-year post treatment of 2 groups of patients with
nonspecific low back pain greater than 12-months’ duration and no prior history of lumbar fusion,
which finding regarding structured rehabilitation with cognitive behavioral therapy (CBT) versus
lumbar fusion is TRUE?

(a) Better functional outcomes in the surgical group versus the CBT group
(b) Improvements in both groups with similar functional outcomes
(c) Better functional outcomes in the CBT group versus the surgical group
(d) Poor functional outcomes in the CBT group, but no consistent outcome in the surgical
group


Answer: (b)
Commentary: Randomized trials for surgery are difficult to conduct, particularly those that
compare surgical to nonsurgical treatment. While available studies do not allow a general
statement regarding the efficacy of fusion over nonsurgical care for discogenic back pain, 4 trials
suggest any advantage of surgery over nonsurgical care is modest, on average near or below the
minimally important change in the disability score. Both groups demonstrated improvement
compared to baseline. Highly structured rehabilitation with a cognitive-behavioral component
seems nearly equivalent to surgery in efficacy at 1 year, with fewer complications.

2011

12

Which cancer related pathological fractures require surgical management?

(a) Humeral, if life expectancy is less than 3 months
(b) Radial, if pain resolves following radiation
(c) Femoral, if life expectancy is greater than 1 month
(d) Pelvic without acetabular involvement

Answer: (c)
Commentary: The indications for surgery for pathological fractures from cancer are life
expectancy of greater than 1 month with a fracture of a weight-bearing bone, and greater than 3
months for fracture of a non-weight-bearing bone. If pain persists following radiation, fractures
should be managed surgically. Healing rates are low following pathologic fractures, with 1
review of 123 patients reporting a 35% incidence of fracture healing. Fractures of the pelvis are generally treated conservatively, unless pain persists after radiation or unless they involve the
acetabulum.


2011

13

Of the muscles listed, the most distal muscle receiving innervation from the C5 root is
(a) brachioradialis.
(b) pronator quadratus.
(c) brachialis.
(d) biceps brachii.

Answer: (a)
Commentary: The brachioradialis is innervated by C5 and C6. The biceps and brachialis are more proximal, and pronator quadratus typically receives no C5 innervation.

14

Which statement is TRUE of the lower trapezius muscle?
(a) It is innervated by the thoracodorsal nerve.
(b) It is innervated by the long thoracic nerve.
(c) Contraction of this muscle results in upward rotation of the scapula.
(d) Contraction of this muscle results in abduction of the scapula

Answer: (c)
Commentary: The lower trapezius, as well as the upper trapezius and the middle trapezius, is innervated by the spinal accessory nerve (11th cranial nerve) and possibly contributions from the ventral rami of C2, C3, and C4. Contraction of the lower trapezius results in scapular depression, adduction, and upward rotation.

2013

15

Answer: (a)
Commentary: Gluteus medius weakness leads to a Trendelenburg gait. This woman's lateral trunk lean is a compensated Trendelenburg gait. Gluteus medius or hip abductor weakness is common following total hip arthroplasty. In one study, 36 of 76 (47%) patients with total hip arthroplasty had hip abductor weakness. Of those 36 patients, all 36 had weakness in the gluteus medius, 28 had weakness in the gluteus minimus, and 4 had weakness in the tensor fascia latae

Answer: (b)
Commentary: This patient presents with an anterior-inferior labrum tear related to chronic anterior shoulder instability following a prior traumatic event (dislocation). Unidirectional instability refers to instability in only 1 direction, anterior direction being the most common. This type of instability is common after a traumatic event. Multidirectional instability refers to laxity in more than 1 direction and is associated with congenital laxity or chronic repetitive microtrauma. Anatomically, there is disruption in the anterior-inferior glenohumeral joint capsule and anterior-inferior labrum. Superior labral anterior to posterior (SLAP) lesions may occur, but
Page 16 of 23
that possibility is less likely in this patient, because of his history and a negative O’Brien compression test

2013

16

A 25-year-old man comes to your office for evaluation of low back pain. As part of the physical examination, you mark a point at the L5 vertebral body and another point midline 10 cm above. You ask him to flex forward maximally while keeping his knees extended and measure the distance between the two points. This distance is 13.5 cm. You suspect he may have what diagnosis?
(a) Lumbar spondylolisthesis
(b) Scheuermann disease
(c) Lumbar herniated disc
(d) Ankylosing spondylitis

Answer: (d)
Commentary: The Schober test is used to assess restricted range of motion seen in ankylosing spondylitis as the disease progresses. The distance between the 2 points with forward flexion exceeds 15 cm in normal individuals. This clinical test is not used for the assessment of lumbar spondylolisthesis, Scheuermann disease, or lumbar herniated discs.

2013

17

20-year-old football player reports anterior shoulder pain during a game. He completes the game,
but radiographs after the game revealed a type 2 acromioclavicular (AC) joint sprain. How is a
type 2 acromioclavicular (AC) joint injury defined?


(a) Acromioclavicular and coracoclavicular ligaments are both disrupted.
(b) Acromioclavicular and coracoclavicular ligaments are both intact.
(c) Acromioclavicular ligament is disrupted, but the coracoclavicular ligament is intact.
(d) Acromioclavicular ligament is intact, and the coracoclavicular ligament is disrupted

Answer: (c)
Commentary: Acromioclavicular joint injuries are classified into 6 types according Rockwood
classification. A type 1 injury describes a mild injury to the AC joint without disruption of either
the acromioclavicular or the coracoclavicular ligaments. A type 2 injury describes disruption of
the acromioclavicular ligament, but the coracoclavicular ligament remains intact. A type 3 injury
describes disruption of both ligaments whereas a type 4 injury entails complete disruption of both
ligaments with posterior displacement of the distal clavicle into the trapezius muscle.

2010

18

Which statement is TRUE regarding the rehabilitation of anterior cruciate ligament (ACL)
reconstruction/repair?

(a) Immediate postoperative weight bearing adversely affects subsequent knee function.
(b) A self-directed program is not as effective as regular physical therapy visits.
(c) Use of a continuous passive motion machine improves outcome.
(d) Postoperative functional bracing does not improve outcome.


Answer: (d)
Commentary: The use of postoperative functional bracing does not improve outcome. Immediate
postoperative weight bearing does not adversely affect subsequent knee function. A self-directed
program is as effective as regular physical therapy visits in a motivated patient. The use of a
continuous passive motion machine does not improve outcome.

2010

19

Compared to a younger individual, an older worker who suffers a musculoskeletal injury is more
likely to

(a) return to work sooner.
(b) have a recurrent injury.
(c) have the injury treated nonsurgically.
(d) sustain a less serious injury.

Answer: (b)
Commentary: Compared to a younger individual who suffers a musculoskeletal injury, an older
individual is more likely to have a recurrent injury, a decreased likelihood of returning to work
after the injury, increased time lost from the job as a result of the injury and a more serious injury.
Also, an older individual with a spine injury is more likely to have surgery than is a younger
individual.

2010

20

A 40-year-old woman reports left-sided facial pain for the past month along with difficulty in
moving her jaw. She hears a clicking noise with chewing along with constant tinnitus. Upon
examination, she has tenderness to palpation along her muscles of mastication on the left with
deviation of the mandible upon jaw opening. She would like to have pain relief. You suggest

(a) referral to an oral surgeon.
(b) that she perform jaw isometric exercises in a closed position with massage.
(c) a 2-week trial of an oral nonsteroidal anti-inflammatory medication.
(d) an ultrasound-guided intra-articular injection with steroids.

Answer: (c)
Commentary: This woman has a temporomandibular joint (TMJ) disorder most likely myofascial
in origin, which is the most common etiology. It is usually self-limited, and is managed
conservatively with relative rest (eg, avoiding jaw clenching, gum chewing), heat, and
nonsteroidal anti-inflammatory agents. Intra-articular steroid injections are not needed with a
myofascial origin of pain. She also does not need a referral to an oral surgeon at this time.

2010

21

An 87-year-old man on your inpatient rehabilitation unit was found on the therapy mat in much
pain after hearing a loud “cracking” noise when he transferred himself. What position of his right
lower limb would suggest hip fracture?

(a) Internal rotation and lengthened
(b) Internal rotation and shortened
(c) External rotation and lengthened
(d) External rotation and shortened

Answer: (d)
Commentary: In most cases, the lower limb of the fractured hip would be held in external rotation
(rotated outward) and would appear shortened relative to the unaffected lower limb.


2010

22

Which approach is shown to be efficacious in treating carpal tunnel syndrome?

(a) Oral corticosteroids
(b) Exercise therapy
(c) Vitamin B6
(d) Botulinum toxin injection

Answer: (a)
Commentary: Of the choices listed, only oral steroids have been shown to be efficacious in the
treatment of carpal tunnel syndrome. In addition to oral steroids, local injection of corticosteroids
and wrist splint are shown to be effective. Exercise therapy and botulinum toxin are ineffective
in the treatment of carpal tunnel syndrome.

2010

23

You are seeing a 79-year-old gentleman with chronic right shoulder pain. For the past several
years he has had limited shoulder movement and is diffusely tender around the shoulder.
Magnetic resonance imaging demonstrates a partial tear of the supraspinatus and infraspinatus
tendons with degenerative changes of the glenohumeral joint. You recommend

(a) rotator cuff repair.
(b) total shoulder arthroplasty.
(c) intra-articular viscosupplementation injection.
(d) flexibility and progressive strengthening exercises.

Answer: (d)
Commentary: The nonsurgical management of shoulder osteoarthritis (OA) with a chronic,
massive rotator cuff defect requires flexibility exercises and gentle progressive strengthening
exercises to increase shoulder function. Surgical repair involves humeral hemiarthroplasty.
Rotator cuff repair in partial thickness tears consists of surgical smoothing of the humeroscapular
motion interface with cuff curettage. Reverse total shoulder arthroplasty is used for
anterosuperior escape rotator cuff lesions. There is no role for shoulder viscosupplementation,
since it has not been shown to be beneficial.

2010

24

Which clinical scenario is most consistent with a L4-5 foraminal disc herniation?

(a) Weakness of the extensor hallicus longus, decreased sensation of the web space between
the first and second toes, absent hamstring reflex
(b) Weakness of the gastrocnemius, decreased sensation of lateral foot, absent Achilles reflex
(c) Weakness of the anterior tibialis, decreased sensation of the web space between the first
and second toes, absent hamstring reflex
(d) Weakness of quadriceps and anterior tibialis, decreased sensation of medial lower leg,
absent patellar reflex

Answer: (d)
Commentary: A foraminal disc herniation at L4-5 level would most likely affect the exiting L4
nerve root. A nerve root lesion could result in muscle weakness in the affected myotomes,
sensation loss in the affected dermatomes, and deep tendon reflex changes. The physical
examination findings most consistent with a lesion to the L4 nerve root would be weakness of
the quadriceps (L2-4), decreased sensation in L4 dermatomes, and decreased or absent patellar
deep tendon reflex (L4).


2010

25

Imaged with musculoskeletal ultrasound, normal tendon structure looks
a) hypoechoic, with hyperechoic septa.
b) hypoechoic , with fascicular pattern.
c) hyperechoic, with fibrillar echotexture.
d) hyperechoic, with posterior acoustic shadowing.

Answer:(c)
Commentary: Musculoskeletal ultrasound is an imaging modality that is able to identify and
characterize various soft tissue structures. Normal tendons appear as hyperechoic(bright echo)
structures with fibrillar or fiber-like pattern. Normal muscle appears as a hypoechoic(low echo)
structure with hyperechoic septa. Bone appears as a very hyperechoic structure with posterior
acoustic shadowing. Posterior acoustic shadowing is an artifact that refers to the anechoic
region(no echo) deep to the bone surface.

2012

26

A 20-year-old female soccer player presents to your office with chronic low back pain. Her
computed tomography(CT) scan is seen in figure 1. What abnormality is seen on these CT
images?
Fig. 1
(a) Herniated disc
(b) Facet degeneration
(c) Pars interarticularis fracture
(d) Tarlov cyst

Answer: (c)
Commentary: Spondylolysis is a defect in the pars interarticularis. These CT images(sagittal and
axial) show evidence of an L5 pars interarticularis fracture. Spondylolysis is common in the
athletic population, particularly among athletes who perform repetitive flexion-extension.
Herniated discs and Tarlov cysts are not seen in these images and are more readily evaluated on
MRI. Facet degeneration is often diagnosed by CT scan but is not seen on these images.

2012

27

A patient presents to your clinic with a 1-month history of mild hand numbness and clumsiness
without weakness. Electrodiagnosis confirms a primarily sensory median neuropathy at the wrist
without axon loss. Symptoms are not interfering with work. What is the most appropriate
treatment recommendation to provide short-term relief for this patient?
(a) Immediate referral to surgery for carpal tunnel release
(b) Neutral wrist splints to be worn at night
(c) Thumb spica splint
(d) Injection of platelet rich plasma into carpal tunnel

Answer (b)
Commentary: Wrist splints are shown to effectively decrease symptoms of carpal tunnel
syndrome in the short-term. Splints should be worn at night and during the day if possible. Brace
should place wrist in neutral (up to 5o of extension): note that many off-the-shelf carpal tunnel
braces place the wrist in excessive extensions. A thumb spica splint is not effective in treating
carpal tunnel syndrome. Conservative treatment is essential in mild to moderate cases of carpal
tunnel syndrome. Surgical referral should be considered for patients with weakness or worsening
symptoms not improved with conservative treatment. Platelet rich plasma injections are not an
effective treatment for carpal tunnel syndrome.

2012

28

Performing a seated leg extension exercise is an example of what type of kinetic chain exercise?

(a) Open
(b) Closed
(c) Static
(d) Mixed

Answer: A
Commentary: In open kinetic chain exercises the most distal segment moves around a fixed
proximal segment. In closed kinetic chain exercises the proximal segment moves around a fixed
distal segment. Static muscle contractions occur when the muscle is contracted but the proximal
and distal segments do not move. There are no mixed kinetic chain exercises.

2009

29

20-year-old college basketball player was seen in the training room after practice. He reports
“twisting” his ankle while attempting to rebound a missed shot. On further questioning, he
describes an inversion-type injury. He has swelling along the lateral aspect of the ankle. He is
tender to palpation over the anterior talofibular ligament and calcaneofibular ligament as well as
the 5th metatarsal base. He has no pain over the lateral or medial malleolus or proximally over the
fibular head. You obtain plain radiographs, which show a nondisplaced avulsion fracture of the
5th metatarsal base. What is the next step in treating this individual?

(a) Provide clearance for return to playing basketball without immobilization.
(b) Obtain a surgical consult for possible screw or pin fixation.
(c) Recommend immobilization with a postoperative shoe for 1-2 weeks.
(d) Prescribe non-weight bearing with crutches for 6-8 weeks or until radiographically
verified healing occurs

Answer: C
Commentary: Nondisplaced or minimally displaced avulsion fractures of the 5th metatarsal base
can occur with inversion ankle sprains. These generally are treated nonsurgically with a short
course of immobilization (1-2 weeks) with a postoperative shoe or a short walking boot.
Displaced fractures may require screw or pin fixation. It is important to differentiate an avulsion
fracture of the base from a fracture of the metaphyseal-diaphyseal junction (Jones fracture), since
treatment is different.

2009

30

After a lateral ankle injury, which ligament is most commonly ruptured?

a. tibiotalar ligament
b calcaneofibular ligament
c. tibiocalcaneal ligament
d anterior talofibular ligament

D

Though not all inversion ankle injuries result in the rupture of the ankle ligaments, when rupture does occur, isolated anterior talofibular ligament ruptures occur in 65% of the cases. Combined anterior talofibular ligament and calcaneofibular ligament ruptures occur in approximately 20% of cases. The tibiotalar and tibiocalcaneal ligaments are part of the deltoid ligament complex and are not involved in classic lateral ankle injuries.

2014

31

A 40-year-old painter presents to your office 2 weeks after falling off scaffolding at work. He complains of knee pain, swelling, occasional locking and give-way sensation, although he has not fallen since the accident. The case manager asks if the painter can return to work. Your recommendation includes:

A. return to sedentary work while diagnostic tests are done.
B. Return to work if the magnetic resonance image shows a normal anterior cruciate ligament
C Transfer to the emergency room to be assessed for septic knee
D return to light duty that includes ladder climbing.

A is correct

The painter’s history implies a meniscus tear. Because you know the painter must climb ladders, and stand and bend for long periods of time, further evaluation is in order to assess the best treatment options. The patient’s mechanism of injury and symptoms do not suggest an infectious etiology, making a septic joint unlikely. Return to a modified job may facilitate healing while still encouraging the patient to continue to work.

2014

32

A 40-year-old man with a history of severe asthma and alcohol abuse complains of progressive right groin pain and a decline in mobility for the past 5 years. Acetaminophen and nonsteroidal anti-inflammatory drugs are not helpful. He has also tried physical therapy and the use of a cane without improvement. On physical examination, he has an antalgic gait and limited right hip range of motion, especially with internal rotation. Which procedure would best help the patient's pain and function?

a. Total hip replacement
b. Lumbar epidural steroid injection
c. Radiofrequency rhizotomy
d. Hip injection of platelet rich plasma

Option a is correct.

This patient has osteonecrosis or avascular necrosis of the femoral head. Risk factors include glucocorticoid, alcohol, and tobacco use. When pain limits mobility and conservative management has failed, total hip replacement is indicated. Platelet rich plasma is still experimental for its primary indications of lateral epicondylitis, patellar tendinopathy, and Achilles tendinopathy.


2014

33

Overuse syndromes resulting in tendinopathies are ideally treated differently in the progressive phases of recovery. Treatments for tendinopathies may appropriately be initiated in the following order:

A. relative rest, stretching, muscle activation, strengthening.
B massage, relative rest, strengthening, muscle activation.
C aggressive stretching, relative rest, muscle activation, strengthening.
D ice, strengthening, muscle activation, stretching.

Option a is correct.

The first goal is to reduce inflammation and irritation. Rest, nonsteroidal anti-inflammatory agents, and ice each help accomplish that first goal. Aggressive stretching of sore muscles does not accomplish the first goal of reducing inflammation and irritation. Strengthening should not begin until pain is controlled and stretching is tolerated without pain. Muscle activation refers to techniques designed to elicit specific muscles within a functional muscular complex that may not be efficiently contracting in response to neural excitation.

2014

34

Activating and strengthening which muscles may help solve iliotibial band syndrome problems?

A Hip adductors
B Quadriceps
C Tensor fascia lata
D Gluteus Maximus

Option d is correct.

The iliotibial band (ITB) is a fibrous band and increasing its tensile force increases compressive forces against the fat pad underneath the band. Biomechanical contributions to ITB syndrome include hip flexor imbalance, dynamic knee valgus, contralateral hip drop. Activating and strengthening gluteus maximus, the most powerful femoral external rotator, can help prevent dynamic knee valgus and prevent ITB syndrome. Using the rectus femoris instead of the iliopsoas to generate hip flexion may lead to compensatory tensor fascia lata (TFL) activity causing hypertonicity of the TFL and hip flexor imbalance. Although strengthening hip abductors is helpful, the abductors to be strengthened should be the gluteus minimus and medius, not the TFL. Strengthening hip adductors can increase dynamic knee valgus tendencies , exacerbating symptoms. Activating and strengthening gluteus medius, quadratus lumborum, and external obliques prevents contralateral pelvic drop.

2014

35

What is the predominant cause of long-term failure of total hip arthroplasty 10 years after surgery?

a. Aseptic loosening
b. Infection in the hip joint
c. Heterotopic ossification
d. Low bone density

Option a is correct.

Aseptic loosening is the most predominant cause of long-term failure of hip arthroplasty at 10 years or longer after surgery. Infection in the joint within a year of the operation is due to direct contamination at the time of surgery; afterwards it is due to hematogenous seeding. Heterotopic ossification, if it occurs, does not change after 6 to 12 weeks postoperatively even though the bone continues to mature. Low bone density does not happen as a result of hip arthroplasty.

2014

36

A gymnast is experiencing ulnar-sided wrist pain that is exacerbated by forearm rotation. Physical exam of the painful wrist suggests greater distal radius palmar-dorsal movement relative to the ulna compared to the other wrist, suggesting distal radioulnar joint laxity. You suspect she has

a. a scaphoid fracture.
b. De Quervain syndrome.
c. a pulley injury.
d. a triangular fibrocartilage complex (TFCC) tear.

Option d is correct.

The triangular fibrocartilage complex (TFCC) is a stabilizer of the distal radioulnar joint (DRUJ). Athletes who participate in repetitive loading of the wrist may be susceptible to degenerative changes, or a fall on an outstretched arm can cause acute injuries. Scaphoid fractures typically present with dull and aching pain in the anatomic snuffbox at the radial wrist. De Quervain syndrome refers to tenosynovitis of the abductor pollicis longus and extensor pollicis brevis, and it presents with pain over the radial styloid. It often occurs in racquet sport athletes. Pulley injuries most often occur in climbers, and presents with pain over the volar aspect of the phalanx

2014

37

The anterior interosseous nerve innervates which muscle?

a. Brachioradialis
b. Extensor indicis proprius
c. Extensor hallucis longus
d Pronator quadratus

Option d is correct.

The pronator quadratus, flexor pollicis longus, and the lateral half of flexor digitorum profundus are innervated by the anterior interosseous nerve. The brachioradialis is innervated by the radial nerve, the extensor indicis proprius by the posterior interosseous nerve, and the extensor hallucis longus by the deep peroneal nerve.

2014

38

More than ninety percent of lumbar disc herniations involve which 2 levels?

a. L4-L5 and L5-S1
b. L3-L4 and L4-L5
c. L3-L4 and L5-S1
d. L2-L3 and L5-S1

Option a is correct.

Disc herniations at L4-L5 and L5-S1 comprise 98% of all lumbar disc herniations. If radicular symptoms are present then the L5 and S1 nerve roots are most likely involved.

2014

39

A 50-year-old administrative assistant presents with low back pain. After taking her history,
performing a physical examination, and reviewing her imaging studies, you determine that her
pain is likely discogenic. She asks if there are any positions which would be better for her back
while at work. Which position exerts the most pressure on the lumbar discs?

(a) Standing erect
(b) Standing erect and flexed forward
(c) Seated in a chair
(d) Seated in a chair and flexed forward

Answer: D
Commentary: Nachemson measured the relative pressure changes within the third lumbar disc
with changes of position. Standing erect was the reference position and pressures decreased with
lying supine and increased in the seated position. Seated and flexed forward further increased disc
pressures. Several other positions were evaluated

2009

40

What is the most beneficial combination of weight and plane of orientation when ordering
cervical traction to treat an acute cervical radiculopathy?

(a) 15--25 pounds applied with neck in extension
(b) 75--100 pounds applied with neck in flexion
(c) 55--75 pounds applied with neck in neutral
(d) 25--35 pounds applied with neck in flexion

Answer: D
Commentary: The weight for cervical traction is most beneficial at 25 to 35 pounds of force.
Positioning the neck at 20o to30o of flexion provides the maximal effect of distraction between
the vertebrae

2009

41

A 23-year-old postgraduate student presents to your office with bilateral knee pain. She just
began training for a half marathon but has been limited by her knee pain. She reports pain in the
anterior aspect of the knee and describes it as “beneath the knee cap.” The pain is worse when
arising after sitting for a prolonged period of time. Which physical examination finding might
you expect in this patient?

(a) Pes cavus
(b) Strong hip abductors
(c) Negative Ober test
(d) Tight quadriceps muscles

Answer: D
Commentary: Patellofemoral arthralgia is thought to result from tracking problems of the patella
within the trochlear groove. Several biomechanical issues, such as tight and inflexible quadriceps,
pes planus, tight iliotibial band, weak and ineffective vastalis medialis, and weak hip abductors,
may contribute to incorrect tracking of the patella. The Ober test assesses the tensor fascia lata
and iliotibial band for contracture and inflexibility.

2009

42

A 28-year-old man returns to clinic after failing conservative management for clinical medial
epicondylitis. In order to determine the appropriateness of a surgical referral, what is the most
cost effective diagnostic test to localize the site of pathology?

(a) Plain radiographs of the elbow and forearm
(b) Magnetic resonance imaging of upper extremity
(c) Real time ultrasound
(d) Electrodiagnostic studies

Answer: C
Commentary: Real time ultrasound is less costly than magnetic resonance imaging (MRI) and has
similar sensitivity and specificity in diagnosing medial epicondylitis. Plain radiographs and
electrodiagnostic studies will not help localize or confirm your diagnosis of medial epicondylitis,
but may help with diagnosing a fracture or nerve injury, respectively

2009

43

A 60-year-old man with left total knee arthroplasty 5 days prior continues to have difficulty with
ambulation during rehabilitation. On exam, he has 70o
of active knee flexion, a 20o
extensor lag,
and a distal lower limb normal to palpation. You then notice that he has trouble clearing his toes
during swing phase. You suspect the major cause of his difficulty walking is due to

(a) weak quadriceps strength.
(b) inadequate knee flexion range.
(c) commonperoneal nerve palsy.
(d) tibialis anterior tendon tear.

Answer: C
Commentary: The patient has a common peroneal nerve palsy which can occur after total knee
arthroplasty. Weak quadriceps strength and inadequate knee flexion may cause difficulty with
ambulation, but not the loss of ankle dorsiflexion. Tibialis anterior tendon tear will cause
difficulty with ankle dorsiflexion, but is not a common complication after knee arthroplasty.
Also, acute tendon tears present with sudden pain and palpatory defect

2009

44

Which type of muscle contraction produces the greatest amount of force generation (torque)?

(a) Fast concentric
(b) Slow concentric
(c) Isometric
(d) Fast eccentric

Answer: D
Commentary: Muscle force generation varies depending on the type of muscle contraction and the speed of the contraction. Eccentric contractions produce greater torque than isometric
contractions and isometric contractions produce greater force than concentric muscle
contractions. As the speed of contraction increases, eccentric contractions produce greater force. The opposite is true for concentric contractions, which generate greater forces at slower speeds

2009

45

22-year-old female volleyball player fell on an outstretched right hand 3 weeks ago and
complains of continued wrist pain. On examination, she has minimal swelling of the distal limb
and is tender to palpation distal to the ulnar styloid between the flexor carpi ulnaris and extensor
carpi ulnaris tendons. A plain radiograph was normal except for an ulnar plus variant. She failed
conservative treatment with splinting and activity modification. The most appropriate imaging
study to obtain would be

(a) computed tomography scan of the wrist.
(b) repeat plain films in 10 days.
(c) triple phase bone scan.
(d) magnetic resonance imaging with arthrogram

Answer: D
Commentary: This patient sustained an injury to her triangular fibrocartilage complex. This
structure is a stabilizer of the distal radioulnar joint and is composed of an avascular articular disc
and radioulnar ligament complex. It is often injured with repetitive wrist activities or compressive
loads. Tears to it are best imaged by MRI arthrogram. Injury to this complex would not be
optimally evaluated on plain films, bone scan, or computed tomography scan

2009

46

. Which factor makes it most probable that a patient is at risk for nerve damage?

(a) Bone fracture without dislocation
(b) Hematoma
(c) Open fracture
(d) High velocity trauma

Answer: B
Commentary: A hematoma places the nerve at risk for injury by 400%, since the expanding fluid
will lead to an acute compression neuropathy

2009

47

A 55-year-old woman presents to the clinic with a 6-week history of right wrist pain. She is an
administrative assistant and has been working extra hours for the past 3 months. She has been
taking anti-inflammatory medications without relief. You diagnose her with de Quervain
tenosynovitis. What is the next most appropriate step in treatment?

(a) Trial of a higher dose of anti-inflammatory medication
(b) Surgical consultation
(c) Corticosteroid injection
(d) Splinting the wrist

Answer: C
Commentary: Corticosteroid injection for de Quervain tenosynovitis has been shown to be more
effective treatment than splinting and anti-inflammatory medications

2009

48

Which factor is a criterion for hip osteoarthritis?

(a) Periarticularosteopenia
(b) Femoral head erosions with sclerosis
(c) Acetabular osteophytes
(d) Erythrocyte sedimentation rate above20mm/hr

Answer: C
Commentary: The American College of Rheumatology states that the criteria for osteoarthritis of
the hip are hip pain along with 2 of the three findings: erythrocyte sedimentation rate less than 20mm/hr, radiographic evidence of femoral/acetabular osteophytes, radiographic evidence of joint space narrowing.

2009

49

A 35-year-old man presents to your clinic with a 3-month history of groin pain exacerbated by
activity. He is an avid skier and runner. He has been taking anti-inflammatories with minimal
relief. Anteroposterior films of the hip were normal. The magnetic resonance imaging of the hip
reported a bony prominence at the femoral head-neck junction. What clinical exam finding is
most likely to correlate with these radiographic “abnormalities” ?

(a) Pain with resisted straight leg raise
(b) Pain with hip flexion, external rotation, and abduction
(c) Pain with sacral thrust
(d) Pain with hip flexion, internal rotation, and adduction

Answer:D
Commentary: This patient has radiographic evidence of femoroacetabular impingement. Two
types have been described, cam impingement and pincer impingement. Cam impingement is
described more commonly in active males and describes a non-spherical femoral head or osseous
abnormalities of the femoral head-neck junction. These bony abnormalities have abnormal
contact with the acetabulum in hip flexion, adduction, and internal rotation. Pincer impingement
describes abnormal contact between the femur and the acetabulum due to overcoverage of the
femoral head from an abnormally deep or retroverted acetabulum.

2009

50

45-year-old concert violinist presents to your clinic for evaluation of left elbow pain. She has
been diagnosed with “lateral epicondylitis” and has had pain and impaired function for 8 months.
She has been treating her symptoms with relative rest, occupational therapy and alternative
therapies, such as acupuncture and massage, without improvement in her symptoms. What other
diagnoses should you consider in this patient?

(a) Intersection syndrome
(b) Musculocutaneous neuropathy
(c) Posterior interosseous neuropathy
(d) Rotator cuff tendinopathy

Answer: C
Commentary: Patients whose symptoms are consistent with lateral epicondylitis or “tennis
elbow” but who do not respond to conservative treatments should be considered to have a
posterior interosseous neuropathy. Mild neural compression of the posterior interosseous nerve
may present with proximal and dorsal forearm pain without obvious muscle weakness, wasting,
or sensory deficits.

2009

51

A 75-year-old manwith a recent calcaneal stress fracture after starting a walking program presents
to your clinic. Initially, you should

(a) order a bone mineral density test.
(b) prescribe a lower extremity strengthening program.
(c) obtain a nuclear bone scan.
(d) prescribe a swimming program

Answer: A
Commentary: The initial assessment should include checking his bone density to establish a
diagnosis of osteopenia/osteoporosis and then identifying secondary risk factors (such as
hypogonadism, corticosteroid use, excessive alcohol use). Once a diagnosis is established,
prescribing weight-bearing and strengthening exercises are important. Obtaining a nuclear bone scan is not as helpful. Swimming is a non-weight bearing exercise

2009

52

A 45-year-old secretary comes in complaining of right hand numbness that began 6 weeks ago,
and her symptoms are beginning to bother her at night. After performing a physical exam you
diagnose her with carpal tunnel syndrome. Which treatment is shown to improve the symptoms
of carpal tunnel syndrome for up to 1 year?

(a) Oral corticosteroids
(b) Therapeutic ultrasound
(c) Wrist/hand splint
(d) Tendon glide maneuvers

Answer: C
Commentary: Using a wrist/hand splint can improve the symptoms of carpal tunnel syndrome for
up to 1 year. Therapeutic ultrasound and oral corticosteroids have been shown to provide only
short-term relief. Tendon glide maneuvers have not been shown to affect the outcome of carpal
tunnel syndrome.


2009

53

A 42-year-old man with human immunodeficiency virus (HIV) presents with proximal muscle
weakness, myalgia, and weight loss. His creatine phosphokinase (CPK) is elevated. What is the
most likely cause?

(a) HIV myopathy
(b) Fibromyalgia
(c) Antiretroviral medications
(d) Vacuolar myelopathy

Answer: A
Commentary: HIV myopathy commonly presents with proximal muscle weakness, myalgia (in
25%-50% of cases), and weight loss. Vacuolar myelopathy causes spinal cord dysfunction, such
as paraparesis, ataxia, posterior column sensory loss, spasticity, and neurogenic bowel and
bladder. CPK would not be elevated in fibromyalgia or as a result of antiretroviral medications.
Antiretroviral medications are associated with neuropathies, not myopathies

2009

54

Repeatedly lifting the shoulder past which degree of flexion or abduction is associated with an
increased prevalence of shoulder disorders?

(a) 10o

(b) 30o

(c) 45o

(d) 60o

Answer: D
Commentary: Repeatedly lifting the shoulder past 60 degrees of flexion or abduction is associated
with an increased prevalence of shoulder disorders.


2009

55

A 67-year-old man presents to your clinic with weakness and frequent falls. You suspect cervical
stenosis. Calculating anteroposterior (AP) ratios to other anatomical structures, which ratio would
enable you to assess for bony cervical spinal stenosis on lateral radiographs?

(a) AP diameter of the vertebral body to the height of vertebral body.
(b) AP diameter of the vertebral canal to the AP diameter of the vertebral body at the same
level.
(c) Vertebral height to the AP of the vertebral canal at the same level.
(d) Distance from the anterior border of the vertebral body to the tip of the spinous process.

Answer: B
Commentary: Assessment of cervical spinal stenosis on lateral radiograph can be made by calculating the ratio of the anteroposterior (AP) diameter of the vertebral canal to the AP diameter of the vertebral body at the same level. This ratio is called the Pavlov ratio. A normal ratio is 1.0 with less than 0.82 indicating stenosis. The Torg ratio is the same as Pavlov ratio.

2009

56

An 11-year-old baseball player presents to your clinic complaining of elbow pain. X-rays of the affected side reveal an 8-mm separation of the medial epicondyle. What should be the next step in management?
(a) Relative rest for at least 6 weeks
(b) Long arm cast for at least 4 weeks
(c) Refer to pediatric orthopedic surgeon
(d) Physical therapy for strengthening

(c)
"Little league elbow," seen in throwing athletes with immature skeletons, is a conglomeration of different diagnostic entities caused by valgus and extension-overload. Medial epicondylar avulsion can frequently occur. Separation from 3--5mm can be managed nonsurgically. However, separations greater 5mm usually require surgery.

2008

57

What percentage of patients with whiplash-associated disorders develop chronic symptoms?
(a) less than 25%
(b) 25%--49%
(c) 50%--75%
(d) more than 75%

(b)
Up to 33% of individuals with symptoms from whiplash-associated disorders have chronic symptoms. Symptoms associated with whiplash-associated disorders include neck pain, arm pain, paresthesias, temporomandibular joint dysfunction, headache, dizziness, visual disturbances, and difficulty with memory and concentration.

2008

58

A 32-year-old male runner presents with left foot pain 3 days after completing a marathon. If the patient has exquisite tenderness to palpation at the location of the examiner’s right thumb, (tenderness over the so-called “N” spot between anterior tibialis and extensor hallicus longus tendons as well as pain with weight bearing and hopping.) what is your next step?
(a) Order physical therapy for closed chain exercises.
(b) Order a plantarflexion night splint.
(c) Implement strict non-weight bearing.
(d) Prescribe oral steroids.

(c)
The patient has a navicular stress fracture until proven otherwise. It is among the most common stress fractures in athletes. Physical examination reveals tenderness over the so-called “N” spot between anterior tibialis and extensor hallicus longus tendons as well as pain with weight bearing and hopping. Strict non-weight bearing cast immobilization for 6 weeks should be implemented. Magnetic resonance imagining or bone scan can confirm the diagnosis.

2008

59

A 24-year-old college student reports low back and lower limb joint pain for the past several months. His heels are especially painful, which makes it difficult for him to walk or stand for prolonged periods of time. He recalls an episode of gastroenteritis requiring hospitalization 6 months ago. Upon further questioning, he admits to some mild dysuria. His neurologic exam is normal. Radiographs of his ankles will most likely demonstrate
(a) a normal joint.
(b) osteophytes and subchondral cysts in the tibiotalar joint.
(c) periosteal reaction and bony erosions of the calcaneus.
(d) avascular necrosis of the talus.

(c)
The diagnosis is reactive arthritis / seronegative spondyloarthropathy that develops after certain genitourinary or gastrointestinal infections, most commonly in young men. Non-gonococcal urethritis and conjunctivitis is the remainder of the clinical triad. Heel pain is one of the most frequent and distinctive clinical features, along with low back pain radiating into the buttocks. Periostitis and erosions occur in the ankle joint in individuals with a several month history of heel pain. Osteophytes and subchondral cysts are typical of osteoarthritis. Avascular necrosis is not typical.
Ref: Arnett FC. Seronegative spondyloarthropathies: reactive arthritis and enteropathic

2008

60

Your patient demonstrates ipsilateral pelvic drop during gait. What is the most likely cause?
(a) Scoliosis
(b) Short contralateral limb
(c) Hip adductor weakness
(d) Weak hip extensors

(a)
Deformity in the spine presents with malalignment of in the pelvis as either contralateral or ipsilateral drop. Two other causes of ipsilateral pelvic drop are contralateral hip abductor weakness and short ipsilateral limb. Weak hip extensors are a cause of backward lean. In stance, a backward lean of the trunk substitutes for weak hip extensors.

2008

61

A 22-year-old female gymnast with chronic low back pain is diagnosed with spondylolysis of the right L5 pars interarticularis. Spondylolisthesis is not identified on plain x-rays. What is the best test to determine fracture healing?
(a) magnetic resonance imaging
(b) single photon emission computed tomography
(c) computed tomography scan
(d) flexion and extension lateral x-rays

(c)
Computed tomography (CT) scans with thin cuts through the area of the pars interarticularis can identify the healing pattern of a pars stress fracture.

2008

62

Which factor increases the risk for long-term symptoms after a whiplash-type injury?
(a) Male gender
(b) Eastern European descent
(c) Preexisting hyperlordosis of cervical spine
(d) Presence of radiating pain into the limb

(d)
Risk factors for chronic whiplash-associated pain include presence of preexisting degenerative disc disease, preexisting loss of cervical lordosis, female gender, awkward head position at time of impact, presence of radiating pain into upper limbs, and prior history of headache. A famous Lithuanian study showed no incidence of long-term whiplash pain in a country that had no compensation system for whiplash.

2008

63

Which diagnosis is NOT an indication for transcutaneous electrical neurostimulation (TENS) therapy?
(a) Chronic low back pain
(b) Acute surgical pain
(c) Urinary urgency
(d) Angina

(d)
TENS therapy has not been shown to provide benefit for angina. It has been proven to have a beneficial effect in all the other diagnoses.

2008

64

Cervical traction is a useful modality for patients with
(a) cervical strain.
(b) diskitis.
(c) acute radiculopathy.
(d) vertebral compression fracture.

(c)
Cervical traction is proven effective for illnesses that involve nerve root irritation or compression of nerve roots.

2008

65

A far lateral L4-5 disc herniation pictured above will impinge on which nerve root?

(a) L3
(b) L4
(c) L5
(d) S1

(a) Since it occurs lateral to the intervertebral disc, a far lateral disc herniation is a relatively unusual
location for disc herniation. A far lateral disc herniation can actually impinge the nerve root exiting
above that intervertebral level.

2008

66

Cervical and lumbar traction applied over a 20--60 minute time period is defined as

(a) continuous.
(b) sustained.
(c) intermittent.
(d) pulsed.

(b) Sustained traction is the use of force greater than that applied in continuous traction, but less than that
used in intermittent traction, and the application time is 20--60 minutes. This time frame makes
sustained traction more practical in clinical use. Continuous traction is the use of low force of traction
over long periods of time, 20--40 hours. Intermittent traction is the use of greater forces, but for shorter
periods of time, 10--60 seconds. There is no pulsed traction.


2008

67

Which statement describes the natural history of lumbar spinal stenosis (LSS)?

(a) The majority of individuals with LSS will develop focal weakness.
(b) Of patients treated nonsurgically, 25%--50% have satisfactory outcomes.
(c) Ambulation worsens in the majority of individuals with LSS.
(d) Early surgery improves long-term outcome.

(b) The natural history of spinal stenosis is generally benign. While decompressive surgery achieves
satisfactory results in the great majority of individuals, the difference in outcomes with their
nonsurgical cohorts becomes narrower with time.


2008

68

A man presents to your clinic complaining of buttock pain that radiates posteriorly down the
thigh. On exam you note that he has a leg length discrepancy, symptoms are provoked by placing
the affected limb in the FAIR position (hip in flexion, adduction and internal rotation), and he has
a positive straight leg raise test. He has normal nerve conduction studies and a normal needle
electromyography test. Treatments that may be beneficial include
(a) stretching exercises of the iliotibial band and corticosteroid injection of the greater
trochanteric bursae.
(b) a lumbar stabilization exercise program and coricosteroid lumbar epidural spinal
injection.
(c) a lumbar stabilization exercise program and botulinum toxin injection of the lumbar
paraspinals.
(d) stretching exercises in the FAIR position and botulinum toxin injection to the piriformis

Answer (d)
Commentary: This is a description of piriformis syndrome. Although some positive findings on
needle examination may be seen with piriformis syndrome, electrodiagnostic studies are oftennormal. On the other hand, positive findings are expected in cases of lumbar radiculopathy.
Conservative treatment of piriformis syndrome begins with piriformis stretching (FAIR positionis a good position for this) and nonsteroidal anti-inflammatory drugs (NSAIDs), followed bylumbosacral stabilization, hip strengthening, and myofascial release. Botulinum toxin relievespain via multiple mechanisms and is increasingly used in the treatment of myofascial dysfunction.A lumbar stabilization exercise program and botulinum toxin injection of the lumbar paraspinals may help relieve some of this patient’s pain if he also has low back pain, but would not addressthe main issue, piriformis syndrome. Stretching exercises of the iliotibial band and corticosteroidinjection of the greater trochanteric bursae would be the treatment for greater trochantericbursitis. A lumbar stabilization exercise program and corticosteroid lumbar epidural spinalinjection would treat a lumbar radiculopathy

2011

69

A 30-year-old woman began running 2 weeks ago. She runs 4 miles a day, twice a week. She
began experiencing bilateral lower leg pain. On physical examination, she reports diffuse pain
along the medial tibia at the start of her run with improvement during the run. The most likely
diagnosis is
a) stress fracture.
b) medial tibial stress syndrome.
c) anterior tibialis tendinitis.
d) tarsal tunnel syndrome.

Answer: (b)
Commentary: This woman presents with symptoms most consistent with medial tibial stresssyndrome (MTSS) or what has been termed “shin splints.”Pain from MTSS occurs along thelower third of the posteromedial border of the tibia. A stress fracture is unlikely in this lowmileage runner who has had only 2 weeks of running activity. Stress fractures generally have afocal area of pain and are not relieved with further running. Anterior tibialis tendinitis presentswith anterolateral pain along the dorsal aspect of the ankle. Tarsal tunnel syndrome is associatedwith numbness and tingling in the foot.

2011

70

A warehouse manager asks you about prescribing lumbar supports to help his workers prevent
and treat lumbar strains. You inform him that evidence-based medicine shows that lumbar
supports
(a) prevent excessive spinal motion by providing sensory feedback.
(b) demonstrate low compliance by workers for both treatment and prevention of lumbar
strain.
(c) increase intra-abdominal pressure without increasing abdominal muscle activity.
(d) are superior to other available treatments in providing lumbar pain relief..

Answer: (b)
Commentary: While theories have been proposed regarding how lumbar supports may treat andprevent lumbar strains, evidence-based medicine does not demonstrate consistent findings tosupport their use. Studies have shown that there is very low compliance with consistent use oflumbar supports. There have been no consistent findings showing that lumbar supports prevent excessive spinal motion or increase intra-abdominal pressure without increasing abdominalmuscle activity. Outcomes studies do not demonstrate

2011

71

A 22-year-old man who is right hand-dominant presents to your office with acute onset of right
shoulder pain. He is a former college tennis player without a previous history of shoulder
pathology. Which test would you perform to evaluate for pathology involving the labrum of the
shoulder?
a) Hawkin test
b) Bowstring sign
c) O’Brien active compression test
d) Apley scratch test

Answer: (c)
Commentary: The O’Brien active compression test is used to evaluate and differentiate labral tears (superior labrum anterior posterior -- SLAP tears) from acromioclavicular joint pathology and pain. The Hawkin test is an impingement test of the shoulder and is not intended to evaluatetears of glenoid labrum. The bowstring sign is used to identify lumbar nerve root compression.The Apley scratch test is used to assess the range of motion of the shoulder.

2011

72

In athletes, the etiology of thoracic outlet syndrome is most likely due to
a) clavicle fractures.
b) anatomic variations.
c) repetitive overhead activity.
d) hyperextension injuries of the neck.

Answer: (c)
Commentary: The most common etiology of thoracic outlet syndrome(TOS) in sports is likely
related to repetitive overhead motion. Hypertrophy of sport-specific musculature may predispose
to TOS. The role of anatomic variations is uncertain in TOS and may be common in patients with
and without this disorder. Fractures of the clavicle and hyperextension injuries of the neck may be
causes of TOS in the setting of trauma

2011

73

A 70-year-old obese gentleman presents to your office for follow-up with a several month history
of increasing left hip and groin pain that occurs with walking. His history is significant for prior
alcoholism, hypothyroidism, gout, and right knee osteoarthritis. He completed a physical therapy
course that did not help much. He now has difficulty even standing or walking for a few minutes
and complains of pain with moving his leg. Radiographs taken today demonstrate sclerosis and
slight collapse of the femoral head. What is his main risk factor for developing the condition
found on his radiographs?
(a) Obesity
(b) Alcoholism
(c) Hypothyroidism
(d) Older age

Answer: (b)
Commentary: The radiographic findings are typical for avascular necrosis which can be due to
trauma, high doses and/or prolonged use of steroids, heavy alcohol use, and certain systemic
diseases (diabetes, systemic lupus erythematosus). Obesity and older age are risk factors for
developing osteoarthritis. Typical radiographic findings of osteoarthritis include joint space
narrowing, osteophytes, subchondral cysts and sclerosis; collapse of bone is not seen.
Hypothyroidism is not a risk factor for avascular necrosis

2011

74

A 33-year-old woman who is 6 months pregnant complains of right-sided, stabbing, low back
pain that is worse with movement. Which orthosis is most appropriate for her?
(a) Sacroiliac belt
Page 18 of 33
(b) Cruciform anterior spinal hyperextension orthosis
(c) Silesian belt
(d) Minerva brace

Answer: (a)
Commentary: Pregnant women frequently develop low back pain, and a sacroiliac belt can behelpful. A cruciform anterior spinal hyperextension (CASH) brace is generally used for
osteoporotic compression fractures. A silesian belt is a type of suspension for transfemoral prostheses. The Minerva brace is a cervicothoracic orthosis.

2011

75

Which cancer related pathological fractures require surgical management?
(a) Humeral, if life expectancy is less than 3 months
(b) Radial, if pain resolves following radiation
(c) Femoral, if life expectancy is greater than 1 month
(d) Pelvic without acetabular involvement

Answer: (c)
Commentary: The indications for surgery for pathological fractures from cancer are life
expectancy of greater than 1 month with a fracture of a weight-bearing bone, and greater than 3
months for fracture of a non-weight-bearing bone. If pain persists following radiation, fractures
should be managed surgically. Healing rates are low following pathologic fractures, with 1
review of 123 patients reporting a 35% incidence of fracture healing. Fractures of the pelvis are
generally treated conservatively, unless pain persists after radiation or unless they involve the
acetabulum.

2011

76

Which muscle fiber types are recruited first in isometric contractions?
(a) Type 1
(b) Type 1b
(c) Type 2
(d) Type 2b

Answer: (a)
Commentary: Fatigue-resistant type 1 fibers are recruited initially followed by type 2b fibers.
There are no type 1b fibers.

2011

77

You are called onto a football field immediately after a defensive player involved in a spearheading tackle complains of neck pain and right greater than left arm tingling. What should be the next step?
(a) Call for an ambulance and stabilize the neck.
(b) Remove the athlete’s football helmet and palpate for any neck tenderness.
(c) Return the athlete to the game if his strength exam is normal.
(d) Walk the athlete to the locker room and perform a thorough neurologic examination.

(a) A telltale sign of cervical cord involvement is bilateral symptoms. In this case, the athlete should be treated as having a potential spinal cord injury and should have his cervical spine immobilized. The football helmet should not be removed, since the cervical spine may fall into extension in the act of removing the helmet. If the airway needs to be accessed, then the face guards should be removed using special equipment. If the athlete suffered and recovered from a temporary “stinger,” involving 1 limb, he may return to play as long as his neurologic examination is normal.

2007

78

An 18-year-old, right-handed hockey player presents to you after experiencing 3 right shoulder anterior dislocations in the prior season after falls on ice. Magnetic resonance imaging shows supraspinatus tendonitis but no other lesions or tears. After 6 sessions of physical therapy, he is pain free. He has been invited to play professionally in 6 months. What is your next recommendation?
(a) Tell him that he will likely dislocate again and that he should relocate the shoulder by forcefully pushing the anterior shoulder against a wall.
(b) Refer him to a surgeon to consider shoulder stabilization surgery.
(c) Tell him he should not return to any sports because of his increased chance of dislocating again.
(d) Stress the importance of compliance with his home exercise program

(b) Recurrent dislocations should be treated with surgery at some point if the athlete would like to return to contact sports. Various anterior shoulder dislocation techniques that can be applied to reduce the shoulder, most by external rotation of the shoulder or by using gravity

2007

79

A 40-year-old man sustained an injury to his left arm, 3 weeks ago, when he lost his balance and crashed into a bookshelf. His complaints include left arm pain, weakness with extension of his wrist and fingers, and decreased hand grip. He denies any numbness but has odd sensations over the dorsum of the left hand. Prior to any testing, which problem would you consider as the most likely?
(a) Posterior interosseous neuropathy
(b) C7 radiculopathy
(c) Posterior cord brachial plexopathy
(d) Radial neuropathy

(d) Based on the clinical presentation, radial nerve injury is the most likely cause of the patient’s symptoms. Considering the location of the trauma the other possibilities seem less likely. In a posterior interosseous nerve injury one would not expect any sensory problems

2007

80

A 55-year-old long-distance truck driver is recovering from a work related low back injury that occurred during lifting. The worker has completed 2 weeks of physical therapy and continues to have low back pain, lower extremity pain, and paresthesias. The employer calls you and is upset that you have restricted the worker from truck driving during the treatment phase, citing that “driving is sedentary work.” You recommend that the driver refrain from truck driving because
(a) a minimum of 4 weeks of physical therapy will be necessary to facilitate recovery.
(b) low back pain has been found to be more frequent in people exposed to whole body vibration.
(c) workers with low back pain should not sit while symptoms of radiculopathy are present.
(d) the employer is unlikely to follow the restrictions you recommend.

(b) Whole body-vibration is associated with increased frequency of low back pain. Some studies have found a correlation between increased frequency of disc protrusion and occupational driving. The exposure to vibration will likely facilitate continued symptoms in this worker, and relative rest is indicated during the initial stages of recovery. There is no predetermined length of physical therapy that is associated with recovery. Workers with low back pain and leg pain must learn to sit without increasing symptoms. Complete avoidance will not necessarily improve recovery and is not practical. The driver can likely perform some duties with restrictions. The employer has the responsibility to provide a job that meets the restrictions set by the physician. If the employer is unable to provide a job with these restrictions then the employee must remain off work.

2007

81

A 66-year-old woman with rheumatoid arthritis is admitted to inpatient rehabilitation following a right total knee arthroplasty (TKA). On her initial day of therapy, she had difficulty walking with her physical therapist. Her medications included methotrexate (Trexall), etanercept (Enbrel), ezetimibe (Zetia), multi-vitamin, calcium with vitamin D, alendronate (Fosamax), acetaminophen/hydrocodone (Norco), and warfarin (Coumadin). Re-examination shows hip flexion 5/5, knee extension 4/5, knee flexion 4/4, ankle dorsiflexion 1–2/5, ankle plantar flexion 5/5. You suspect
(a) sciatic nerve stretch injury.
(b) posterior tibialis tendon rupture.
(c) inadequate pain control.
(d) peroneal nerve injury

(d) Temporary weaknesses of peri-articular muscles typically occurs after knee arthroplasty along with loss of full flexion and extension due to pain, edema, and the procedure itself. Ankle dorsiflexion is not typically weak following TKA and therefore peroneal nerve injury due to a hematoma would be suspected, especially since the patient is on warfarin. This injury requires surgical exploration and decompression. Sciatic nerve stretch injury, posterior tibialis tendon rupture, and inadequate pain control would not present as ankle dorsiflexion weakness

2007

82

The activity established as most predictive of developing a low back disorder is
(a) carrying an object at an increased horizontal distance from the body.
(b) lifting an object repeatedly at 20% less than the individual’s maximum lift capacity.
(c) repetitive sit-to-stand transitions with a weighted back pack.
(d) bending at knees rather than at the waist to lift an object

(a) The work by Marras and colleagues showed that increasing the horizontal distance from the trunk of an object being carried increased the risk of developing a low back disorder. This increase in distance increased the forces consistently on the anterior column of the spine. Although the other options can all place the worker at risk for a low back injury, only the increased carrying distance from the trunk has been shown to be the most predictive of a low back injury.

2007

83

Which condition is a cumulative trauma disorder that has been associated with intensive computer use?
(a) Herniated thoracic disc
(b) Shoulder adhesive capsulitis
(c) Post-traumatic stress syndrome
(d) Cervical myofascial pain

(d) The United States Department of Labor has determined that computer work is associated with a significant number of musculoskeletal disorders, many of which are considered cumulative trauma disorders. Examples include cervical and thoracic myofascial pain, rotator cuff tendonitis, medial and lateral epicondylitis, de Quervain tenosynovitis, and carpal tunnel syndrome.

2007

84

A 70-year-old woman presents with a cemented right total hip arthroplasty. She is partial weight bearing and struggling with physical therapy. The therapist asks to use ultrasound to the right hip to help with bone healing and ultimately progress the patient to weight bearing as tolerated. You advise
(a) yes, because ultrasound helps with bone healing.
(b) no, because ultrasound near arthroplasties is contraindicated.
(c) yes, because the heat may help with pain management.
(d) no, because ultrasound is expensive to use.

(b) Ultrasound is typically an inexpensive treatment that may help with pain and bone maturation, however, it is contraindicated near arthroplasties and therefore not a good treatment in this case. Further contraindications include use of ultrasound: near pacemaker, near spine or laminectomy site, near brain, eyes, or reproductive organs, is someone with malignancy or skeletal immaturity, or near sites where methyl methacrylate was applied.

2007

85

Which treatment has NOT been shown to improve epicondylitis?
(a) Low intensity laser irradiation
(b) Wrist extension strengthening exercises
(c) Acupuncture
(d) Extracorporeal shock-wave therapy

(a) Wrist strengthening, acupuncture, and shock wave therapy all help in the treatment of epicondylitis. However, low intensity laser treatment is not proven beneficial.

2007

86

What is the most common level of occult spine fracture after trauma that is missed by plain
radiographs?
(a) C7/T1
(b) T5/T6
(c) T12/L1
(d) L4/L5

(a) Occult cervical fractures are most often seen at the C1 and C7 levels. By adding computed
tomography (CT) scanning to the evaluation of trauma patients, a significant number of occultcervical fractures can be diagnosed. Of spinal fractures, 5% to 30% are multiple and may appear atnoncontiguous levels. Thus, radiographic evaluation of the entire spinal axis is necessary whenever
injury at 1 region of the spine is detected.

2006

87

An injured worker with low back pain will return to full work duties faster if treatment includes
(a) back school and lumbar corset.
(b) aerobic conditioning and weight lifting.
(c) work conditioning and “off-duty” or no-work status.
(d) functional rehabilitation and ergonomic intervention

(d) Loisel, in1997, performed a randomized controlled trial that showed that the injured worker with
low back pain returned to regular work activities 2.41 times faster if the worker received
therapeutic functional rehabilitation and ergonomic intervention when compared to usual care.

2006

88

A 36-year-old breast cancer patient presents with myofascial pain involving the upper and middle
trapezius and levator scapulae muscles. She underwent modified radical mastectomy and chest wall
irradiation 1 year ago. The breast has been reconstructed with a rather large implant. You note that
her acromial process on the affected side is depressed and protracted. Lasting relief will most likely
be achieved through a physical therapy program emphasizing
(a) ultrasound followed by shoulder mobilization.
(b) stretching of the pectoralis major and minor muscles.
(c) electrical stimulation of the painful muscles.
(d) isometric resistive exercise of the rhomboid muscles.

(b) Muscles within any radiation field are at risk for fibrosis and contracture. The pectoralis major andminor muscles are commonly shortened following radiation to the chest wall, an integral
component of breast conservation therapy. Radiation-induced shortening of the pectoralis muscles pulls the scapula into a protracted and depressed position which places tension on the medial and
superior scapular stabilizers. To achieve long-term relief, this patient will require stretching of thepectoralis muscles.

2006

89

Which surgical option would be most appropriate for a patient with rheumatoid arthritis who has
severe uncontrollable knee pain and loss of function?
(a) Synovectomy
(b) Hemiarthroplasty
(c) Total knee arthroplasty
(d) Arthrodesis

(c) Total knee arthroplasty is the surgery of choice in persons with severe pain and loss of function. A
synovectomy provides temporary pain relief and decreased swelling. Hemiarthroplasty is
contraindicated in rheumatoid arthritis due to total joint involvement. Arthrodesis would not
provide the range of motion needed for stairs, ambulation, and dressing

2006

90

A 30-year-old runner training for a marathon presents to your clinic with progressive pain in his right
medial tibia over the past 2 weeks. Which history and examination feature is more consistent with a
stress fracture rather than medial tibial stress syndrome?
(a) Diffuse rather than focal tenderness
(b) Pain with percussion around the site of pain
(c) Pain that diminishes as the run goes on
(d) No reproduction of pain with single leg hop test

(b) This is a common clinical conundrum. Medial tibial stress syndrome (frequently and improperly
referred to as shin splints) represents a range of pathology from posterior tibialis tendonitis to
periostitis. Fredericson et al determined that stress fractures, which will require more aggressive
treatment, have more focal pain and pain with percussion testing. Pain from a stress fracture
worsens as run goes on and often hurts after a run. A magnetic resonance image or bone scan can
make a definitive diagnosis.

2006

91

You are managing the care of a 63-year-old pipe fitter with shoulder pain in his dominant arm. He
has no history of trauma. An incomplete supraspinatus tear is found on imaging studies. He has
completed 8 sessions of physical therapy with improvement. He has pain at 140° of shoulder
abduction. Strength, range of motion, and neurological exam are normal. The case manager asks for
your next recommendation towards determining his work status. You recommend
(a) functional capacity evaluation exam.
(b) work conditioning.
(c) aquatic physical therapy.
(d) surgical referral

(a) A functional capacity evaluation (FCE) is the next best choice for this worker. An FCE will
determine functional deficits the worker has by assessing work simulated activities. Work
conditioning may be helpful because it includes aerobic conditioning but does not provide
information and training regarding specific work tasks. His physical findings are minimal so
additional physical therapy may not be recommended. These minimal physical exam findings in a
63-year-old man may indicate a nontraumatic incomplete cuff tear that may be a part of normal
aging. In this setting, conservative management remains appropriate. Incomplete rotator cuff tears
can be found in the asymptomatic population, especially over the age of 50.

2006

92

Which action is a sacroiliac joint provocation test?
(a) Thomas test
(b) Gillet test
(c) Thigh thrust maneuver
(d) Flexion, adduction, internal rotation (FADIR) maneuver

(c) While data on sacroiliac joint provocative tests have been equivocal in the literature, recent evidence has shown thigh thrust and pelvic distraction maneuvers to be helpful. The Thomas test is
used to assess hip flexor contracture. The Gillet test is a sacroiliac joint motion test and not a provocation test. The FADIR maneuver is used to assess piriformis tightness and provocation

2006

93

Which athelete is LEAST likely to sustain an anterior cruciate ligament (ACL) tear?

a. a 30-year old competitive runner
b. a 40 year old recreational basketball player
c. a 25-year old competitive soccer player
d. a 16 year old high school tennis player

A.

A runner does not typically stress his/her ACL: The history of a non-contact ACL injury is usually of a movement with "cutting" action, rapid acceleration or deceleration, or twisting.

2015

94

A 40 year old woman presents with shoulder and neck pain. Her exam is unremarkable except for discrete, focal, hyperirritable spots located in taut bands of skeletal muscle. An appropriate treatment would be:

a. Inject lidocaine into muscle over area of maximal tenderness in a fanwise manner.
b. inject CS into skeletal muscle over area of maximal tenderness ina fanwise manner
c. inject lidocaine and CS mixture into the AC joint space
d. inject CS into cervical epidural space under fluoroscopy.

This woman has myofascial dysfunction with one or more trigger points. Trigger points are treated with dry needling, anesthetic, or botox. CS injection into skeletal muscle can cause atrophy and necrosis. There is no indication for a joint or epidural injection. Findings more specific for AC joint, GH joint, RTC pathology, and stenosis are not noted.

2015

95

Your 67 year old patient with ankylosing spondylitis comes for an urgent appt after falling 3 weeks ago. He complains of a headache at the back of his head, along with progressive weakness, and numbness of his hands and feet. You suspect:

a. atlantoaxial subluxation
b. epidural hematoma
c. Guillain-Barre syndrome
d. occipital neuralgia

a.

Spontaneous AA subuluxation may be present in individuals with ankylosing spondylitis. Minor trauma, such as a fall, may complicate a spontaneous subluxation by increasing pressure on the spinal cord and producing long-tract signs along with an occipital headache. Although epidural hematoma also typically occurs after a fall, symptoms are more acute and usually associated with altered consciousness and bruising or skull fracture. GBS, or acute inflammatory polyneuropathy, is not associated with fall or headache. occipital neuralgia does not produce generalized weakness.

2015.

96

A 33 year old woman who is 6 months pregnant complains of right-sided stabbing low back pain that is worse with movement. Which orthosis is most appropriate for her?

a. sacroiliac belt
b. cruciform anterior spinal hyperextension orthosis
c. silesian belt
d minerva brace

a

Pregnant women frequently develop low back pain, and a sacroiliac belt can be helpful. A cruciform anterior spinal hyperextension (CASH) brace is generally used for osteoporotic compression fractures. A Silesian belt is a type of suspension for transfemoral prosthesis. The Minerva brace is a cervicothoracic orthosis.

2015.

97

After starting a walking and stretching program, a 25-year old previously healthy patient with right ankle fracture 3 months ago is noted to have a plantar flexion contracture of 20 degrees with persistent contracture. Which treatment option is the most appropriate?

a. Botulinum toxin injection into the gastrocnemius muscle
b. heel lift placed in the shoe
c. serial casting of the ankle
d. electrical stimulation of the tibialis anterior muscle

c

serial casting can be useful for treatment contractures. This otherwise healthy patient should not have spasticity, so botulinum toxin would be inappropriate. There was no mention of neurological weakness, so electrical stimulation would also be inappropriate. A Heel lift would be helpful if the patient had a limb length discrepancy, but it would not help to correct the contracture.

2015.

98

Which scenario is typical of patients with spinal stenosis and neurogenic claudication?

a. worsening leg pain with downhill walking.
b. pain relief with standing still after a long walk
c. worsening leg pain with lumbar flexion
d. pain relieve with increased anterior pelvic tilt.

a

lumbar extension, created when walking downhill, decreases spinal canal diameter and worsens neurogenic claudication symptoms. Neurogenic claudication is classically improved when a person changes from a standing or walking position to a seated position. Lumbar flexion (forward trunk lean) with uphill walking may improve leg pain because lumbar flexion increases spinal canal diameter. Anterior pelvic tilt is associated with lumbar extension and increased pain.

2015.

99

A 22 year old patient presents with left lower limb pain. Plain radiographs reveal a tumor in the shaft of the femur. You are concerned that he will sustain a pathologic fracture if:

a. 25% of the circumference is affected
b. the lesion length is 1 centimeter
c. 50% of the circumference is affected.
d. the lesion length is 2 centimeters

c

An increased risk of fracture exists when cortical bone destruction affects 50% or more of the bone's circumference, more than 60% of its diameter, more than 1.3cm of the length in the femoral neck, or more than 2.5cm of the lower limbs long bone is involved.

2015.