MSK1

Question 1

HOw do you identify a flexible pes planus?

Answer 1

If the medial longitudinal arch is flattened during loading at stance phase, but the patient forms a dynamic arch when standing up on their metatarsal heads (‘tip-toes’), the patient has flexible pes planus.

Question 2

Risk factors for plantar fasciitis?

Answer 2

Question 3

Clinical features of plantar fasciitis

Answer 3

Question 4

Management of plantar fasciitis?

Answer 4

1. Rest from aggravating activity (in acute phase - eg long walks, running)
2. NSAIDS
3. Plantar stretching exercises - podiatry/physio
4. Steroid injection under u/s guidance
5. Orthotics with appopriate heel arch

No Xrays or u/s needed

Question 5

What is Scheuermanns disease?

Answer 5

• Structural sagittal plane deformity of lower thoracic vertebrae - unknown cause
• Affects T7-12 (Except 10)
• AGE 11-17 years

increasing thoracic kyphosis over 1 -2 months

compensatory lumbar and cervical lordosis may occur

Cannot touch their toes because of thoracic kyphosis

Xray - lateral standing - demonstrates anterior wedging of vertebrae and possilby schmorls node (disc material enters vetebrae below)

Question 6

Treatment for Scheuermanns disease?

Answer 6

Extension exercises (Avoid forward flexion)

Postural correction

Avoidance of sports involving lifting and bending

Bracing or surgery if serious deformity

If caught early can try HYperextension body casts Followed by a Milwaukee Brace to prevent deformity

Question 7

Pain in parascapular region, posterolateral shoulder, upper limb +/– neck

Tingling in thumb, index or middle fingers

Shoulder movements have little or no effect on the pain

Pain with cervical movements

Tender lower cervical spine, rhomboids and infraspinatus.

Upper limb pain/paraesthesia with Spurling test

(+/– C6 or 7 neurological signs)

Answer 7

C6 or 7 radicular pain or radiculopathy from disc/osteophyte complex

Question 8

Over 50 years, female

Anterior and lateral pain

Nocturnal pain

Diffuse tenderness

Painful reduction all movements, including external rotation

Answer 8

Capsulitis

DDx

Calcific tendinitis

Question 9

Over 70 years

Gradual onset global shoulder pain and stiffness

Variable swelling and tenderness

Reduced active and passive range of most movements +/–end range pain

Answer 9

Glenohumeral joint arthritis

DDx

Polymyalgia rheumatica

Question 10

Over 25, female

Bilateral global shoulder pain, stiffness and swelling

Other joints affected

Worse in mornings

Diffuse swelling and tenderness

Painful reduction in all movements

Answer 10

Rheumatoid arthritis

Question 11

Anterolateral pain with abduction and lying on shoulder

Tender rotator cuff insertion or subacromial bursa

Painful arc of abduction & internal rotation.

Answer 11

Supraspinatus tendinopathy or subacromial bursitis

Question 12

Anterolateral pain with abduction and lying on shoulder

Tender rotator cuff insertion or subacromial bursa

Painful arc of abduction & internal rotation.

Positive impingement test

Weakness on empty can test

Answer 12

Rotator cuff tear

Question 13

Posterior pain over upper trapezius +/– neck

Shoulder movements have little or no effect on the pain

Tender upper trapezius and mid to lower cervical spine

Pain with cervical movements or quadrant/Spurling test (+ arm pain/paraesthesia

Negative impingement test

Answer 13

Referred pain from mid or lower cervical spine dysfunction

Question 14

What is Paxino’s sign - what does it test for?

Answer 14

Push the acromion towards the clavicle with the thumb

Pain in joint = positive test

Indicates AC Joint Pain

Question 15

Age over 70

with shoulder pain, decreased movement

and crepitus

Answer 15

GHL Arthritis

(Crepitus! and over 70!)

Question 16

50 - 60 year old with loss of all shoulder movements

Constant severe pain and stiffness

Answer 16

Capsulitis

(global loss of passive movement)

Question 17

30-60 year old with shoulder pain. Night pain and pain with overhead activities. Impingement signs on examination

Answer 17

Rotator cuff tendinopathy

or

subacromial bursitis

Question 18

50 yr + with night shoulder pain, pain with overhead activities, impingement signs and weakness in external rotation, empty cup sign, weakness supraspinatus

Answer 18

Rotator cuff tear (esp supraspinatus)

Question 19

15 -35 year old with history of shoulder dislocations. Positive apprehension sign

Answer 19

Shoulder instability (labrum/capsule)

Question 20

40 - 60 year old with night shoulder pain, pain and loss of movement, loss of external rotation

Answer 20

Stiffness in capsule

Question 21

Main role of supraspinatus?

Answer 21

Abduction of shoulder

Question 22

Main role of infraspinatus and teres minor

Answer 22

External rotation of the shoulder

TiREx

Question 23

Main role of subscapularis

Answer 23

Internal rotation of shoulder

Question 24

How does rupture of long head of the biceps tendon present?

Answer 24

Usually older people - lifting/fall on outstretched hand

Popping sensation

Then bruising and swelling of arm and unilateral bulge in the arm

Acutely - rest/ice - 6hrly for 20minutes

Gradual return to activities

Physiotherapy for graduated exercises

No surgery/active treatment required unless young and engaged in power sports etc

Question 25

How does acromioclavicular osteoarthritis present?

Answer 25

Either traumatic or degenerative Presents with pain in anterior shoulder Elderly or Rowers and other sports people, Builders, Pain in AC joint - Paxinos sign THumb pressure on postero-lateral aspect of acromion - push antero- superiorly - Pain in joint is a positive for Paxionos Mx - Rest Shoulder support NSAIDS Intra-articular corticosteroid injection

Question 26

What are the stages of adhesive capsulitis?

Answer 26

1. Frozen stage - 8 months (global limitation of all movements) 2. Stiff - 8 months (stiffness is more prominent) 3. REsolution - 8 months (regaining movements and reducing pain) - may fully recover - sometimes residual sx

Question 27

Management of Adhesive capsulitis?

Answer 27

1. Rest in the acute phase (avoid exercises as they may be painful) 2. ANalgesia with PCM and NSAID 3. **Oral prednisolone 30mg orally daily for three weeks. Taper over 2 weeks.** Sustained relief for about 2 months. 4. Steroid injection may help 5. Arthrographic **Hydrodilatation** if relatively mobile joint 6. Arthroscopic **adhesion removal** if more of a stiff joint 7.

Question 28

What physical signs indicate rotator cuff tear?

Answer 28

Weakness of supraspinatus (ABduction) Weakness in external rotation Impingement in internal/external rotation or both(Neers test, empty can test) If 2 out of 3 - very likely to be a rotator cuff tear IN A TEAR WEAKNESS IS MORE PROMINENT THAN PAIN

Question 29

Management of rotator cuff tendinopathy or tear?

Answer 29

1. Rest in the acute stage of pain 2. NSAID for 4 weeks 3. Physiotherapy for graduated activity 4. Corticosteroid injection

Question 30

What are the nerve roots of the Median Nerve

Answer 30

C5,6,7,8, T1

Question 31

Which nerve is affected in wrist drop?

Answer 31

Radial nerve

Question 32

Which nerve is affected in sign of benediction

Answer 32

median nerve

Question 33

Which nerve is affected in ulnar claw?

Answer 33

Ulnar nerve

Question 34

What does Froments sign test?

Answer 34

Ulnar nerve Paper test between thumb and fist Excess thumb flexion whilst pinching due to ulnar nerve damage

Question 36

What do the interossei do? Innervation

Answer 36

PAD DAB palmar adduct the fingers dorsal abduct the fingers These are innervated by the ULNAR nerve - most of the intrinsic hand muscle except the thumb which is mainly median

Question 37

Which nerve allows wrist extension

Answer 37

Radial nerve

Question 39

What is Allens Test

Answer 39

Testing patency of ulnar and radial arteries Compression and release to see if the hand becomes reperfused

Question 40

Management of flexible pes planus in kids?

Answer 40

Treatment of symptomatic, flexible flat feet is generally accepted in children with contributory background factors or secondary complications or if pes planus persists past childhood. There is evidence that symptoms related to pes planus, particularly pain, improve with non-surgical intervention. In addition to **optimisation of footwear, with or without orthotics,** management includes **physiotherapy to improve the strength of the extrinsic and intrinsic foot musculature.**