MSK - NPTE

Which of the following would be the MOST appropriate to confirm adhesive capsulitis of the shoulder? A. Fluoroscopy B. MRI C. Arthrography D. CT

C. Arthrography - an invasive procedure using x-ray and an injected contrast dye to visualize jt structures - can detect a decreased volume of fluid within the joint capsule Fluoroscopy: designed to show motion within the body with the use of x-ray and injection of a contrast dye. (It uses higher dose of radiation than arthrography; and it is to detect joint MOTION RESTRICTIONS on clinical exam with adhesive capsulitis. It is not a likely choice to confirm the diagnosis.) MRI: can potentially show inflammation. It is not useful to definitely diagnose adhesive capsulitis. CT: most commonly used to diagnose spina lesions & in diagnostic studies of the brain

posterior tibial tendon dysfunction

- the primary cause of medial ankle pain in middle-aged pts - due to the inability of the posterior tibial tendon to support the medial longitudinal arch - results in flat foot - characterized by a valgus deformity of the hindfoot due to a flattening of the medial longitudinal arch; there's also forefoot abduction - general swelling can be present, but the swelling is most often concentrated in the medial aspect of the ankle, as the tendon insertion on the navicular and medial cuneiform bones

hand deformities 1) Boutonniere deformity 2) Swan neck deformity 3) Mallet deformity

1) Boutonniere deformity: - flexion of PIP, extension of DIP - factors: a) tear of central slip (RA or trauma); b) lateral bands migrate volar 2) Swan neck deformity: - hyperextension of PIP, flexion of DIP - factors: a) volar plate loosens (RA or trauma); b) lateral bands migrate dorsal 3) Mallet deformity: - DIP kept in flexion - unable to actively extend DIP; DIP active extension lag, PROM full - factors: direct trauma to distal finger tip; avulsive fracture (fracture location has tendon or ligament attached), terminal tendon trauma

1st CMC arthrokinematics

1) Concave on convex for flexion and extension - same directions for roll & glide - flexion: ulnar roll & glide of the 1st metacarpal on the trapezium - extension: radial roll & glide of the 1st metacarpal on the trapezium 2) Convex on concave for abduction and adduction - opposite directions for roll & glide - abduction: palmar roll & dorsal glide of the 1st metacarpal on the trapezium - adduction: dorsal roll & palmar glide of the 1st metacarpal on the trapezium

Meniscus tear injury special test 1) McMurray's 2) Apley 3) Thessaly 4) Bounce home

1) McMurray's: - grasps the ankle with one hand and supports the knee with the other; then flex the knee maximally; ER the tibia while palpating the medial joint line, slowly extends the knee (assesses the medial meniscus). Then repeats with the tibia IR (assesses the lateral meniscus) - positive test: palpable or audible click or thud; or pain 2) Apley: - prone with knee flexed to 90 degrees; applies compression to knee with tibial ER (for medial meniscus) and IR (for lateral meniscus); then applies a distraction force to the knee with ER/IR of tibia (for LCL/MCL) - positive test: pain/symptoms with compression (medial/lateral meniscus); pain/symptoms with distraction (LCL/MCL) 3) Thessaly (not taught at school): - In standing, grasp the pt's hand in standing to provide additional balance while allows the pt to perform the necessary ER and IR of the femur on the tibia 4) Bounce home (not taught at school): - In supine, grasps the heel and maximally flexes the knee. Then extend the knee passively. + test: incomplete extension or a rubbery end-feel (maybe indicative of a meniscal lesion)

Slipped Capital Femoral Epiphysis (SCFE) 1) definition 2) symptoms 3) what would be the MOST appropriate initial action when suspecting SCFE

1) SCFE: separation between the femoral head and femoral neck at the growth plate 2) symptoms: - ER of femur with out toeing gait, decreased hip IR, limp - Drehmann sign: when performing hip flexion, hip immediately goes to ER - pain in KNEE, front and side of hip, thigh (sometimes no pain) Often misdiagnosed as groin pull - obese > 95% 3) non-WB in WC to prevent further/sudden slip to decrease blood supply to bone, in order to prevent avascular necrosis. And refer to orthopedic surgeon immediately

Lateral Ankle Sprain - symptoms - mechanisms of injury - special tests

1) Tenderness around the lateral malleolus 2) swelling and eccymosis around the lateral ankle, extending to the lateral shin & foot if more severe 3) mechanism of injury: PF + inversion 4) + anterior drawer, if anterior talofibular ligament is involved 5) + talar tilt, if calcaneofigular ligament is also involved 6) + squeeze test, if syndesmosis ruptured * Anterior drawer: anterior glide of talus on tib-fib in LPP; since it's difficult to grip onto talus, you can anterior glide calcaneus on tib-fib instead * Talar tilt: Mobilizing hand on calcaneus, stabilizing hand on tib-fib. DF ankle to slightly beyond neutral; Then invert calcaneus * Squeeze test: Pt prone with knee bent; Compress the proximal tibia and fibula + tests: pain and/or laxity compared to the non-involved side

Tarsal Tunnel Syndrome

1) compression of the tibial nerve 2) Through this tunnel pass the tibialis posterior, flexor hallucis longus, and flexor digitorum muscles with their surrounding synovial sheaths and the tibial nerve artery and vein.

Shoe modifications (purposes) 1) Heel lift 2) heel cushion 3) heel cup 4) metatarsal bar/pad 5) rocker bar

1) heel lift - rigid insert to add extra height to the heel - to take pressure off of the Achilles tendon * for pts with Achilles tendonitis or a recent repair of the tendon - limit the effects of a leg length discrepancy 2) heel cushion - soft pad to help cushion the heel - to decrease pain in that region * for pts with calcaneal spur or plantar fasciitis 3) heel cup - rigid insert that covers the plantar surface of the calcaneus and extends upwards on all 3 sides - to stablize the calcaneus in a neutral position as well as to provide shock absorption * for pts with calcaneal spur or plantar fasciitis 4) metatarsal bar/pad - a flat piece of padding placed just posterior to the metatarsal heads on the outer sole (i.e. bar) or inner sole (i.e., pad) - to relieve pressure from the metatarsal heads by transferring it to the metatarsal shafts * relieve pain for pts with metatarsalgia 5) rocker bar - similar to metatarsal bar, but it is a convex strip - assist pts who have difficulty with terminal stance 2/2 limited mobility within the foot, especially the great toe * helps reliee pressure from the metatarsal heads for pts with pain in that region

fibularis tendon subluxation

1) pain 2) popping sensation at the posterior lateral ankle 3) swelling and ecchymosis 4) apprehension & instability to evert the foot against resistance 5) provoked by forceful DF + eversion

Adhesive Capsulitis (Frozen Shoulder) 1) loss of motion patterns 2) stages

1) painful loss of AROM & PROM, paricularly ER Capsular pattern ER > ABD > IR 2) stages Stage 1: mild symptoms, < 3 months; achy at rest and sharp at end range; No ROM loss - can cause sleep disturbance Stage 2: "freezing stage", over next 3-9 months; onset of ROM loss progressive in all planes; all ranges painful and restricted with a capsular limitation; typicaly empty/guarding end feels; arthroscopic exam reveals aggresive synovitis/angiogenesis and some loss of motion under anesthesia Stage 3: "frozen stage", typically in 9-14 months; severe PROM limitations, with ER > ABD> IR but c/o pain diminishes over times. Synovitis/angiogenesis lessens but loss capsular volume specifically axillary fold contributing to PROM loss Stage 4: "Thawing stage. Pain begins to resolve and primarily complaint is loss of motion. Long slow and steady recovery of ROM and function. Stiffness; but reports getting better gradually. Can last up to 24 months following onset (stage 1)

The most common tendons used for ACL reconstruction grafts (allograft)

1) patellar tendon 2) tendons of the semitendinosus and gracilis - decreased incidence of post-operative patellofemoral knee pain, however, provide weaker initial fixation

A physical therapist treats a patient rehabilitating from spinal fusion in the lumbar spine. The surgical procedure required a bone autograft to stabilize the lumbar segment. What postoperative finding would be MOST likely based on the utilization of the bone graft? A. Hip pain B. Spinal hypermobility C. Hyporeflexia D. Myotomal weakness

A. Hip pain Bone grafts are most commonly taken from the anterior of posterior portions of the iliac crest. => Thus, associated with postoperative hip pain, bleeding, and increased swelling. Myotomal weakness is not unique to the Bone graft! It is common prior to fusion due to neurologic involvement. It would be anticipated postoperatively based on the surgical procedure.

A patient injured his/her R knee 3 days ago while squatting down & pivoting to lift up a heavy box. The patient complains of pain along the medial side of the knee joint and a catching sensation within the joint when bending and extending the knee. Based on the patient's clinical presentation, which of the following medications would MOST likely be prescribed? A. Naproxen B. Gabapentin C. Diazepam D. Methotrexate

A. Naproxen Conservative treatment of a possible meniscus tear involves PRICE. Nonsteroidal anti-inflammatory medications prescribed by MD for this condition include Aspirin (acetylsalicylic acid), Aleve (naproxen), Advil (ibuprofen), and Celebrex (celecoxib). Gabapentin (neurontin): anti-seizure Diazepam (valium): a benzodiazepine medication that creates a calming effect in the body; thus can be used to treat anxiety, seizures, muscle spasms, and spasticity Methotrexate (rheumatrex): antirhematic medication; can also be used to treat other autoimmune diseases and certain types of cancer, because this medication acts to inhibit immune responses

A pt who has a left ventricular assist device reports experiencing signs and symptoms consistent with thoracic outlet syndrome. Which provocative test would be the MOST appropriate to test for thoracic outlet syndrome given the presence of the left ventricular assist device? A. Roos test B. Adson maneuver C. Allen test D. Wright test

A. Roos test A left ventricular assist device (LVAD) is an implantable mechanical pump typically used in pts with heart failure to augment the function of the failing L ventricle. - Most LVADs are continuous flow, meaning pulses will NOT be palpable. Thus, any of provocative tests in which the radial pulse is palpated won't be an effective choice. Roos test: - Test costoclavicular or subcoracoid space - Shoulders ER & flexed to 90 degrees; elbows flexed to 90 degrees - rapidly open & close fist while maintaining seated position for up to 3 min - Positive test: reproduction of symptoms or inability to maintain shoulder elevation due to symptom reproduction. Adson maneuver: - Test interscalene triangle - pt actively rotates & extends head to side being tested; Inhale deeply and hold breath for up to 30s - stand at side of pt and palpate radial pulse - Positive test: absent in radial pulse or symptom reproduction Allen test: - Not taught in MSK TOS lectures - According to scorebuilder PT365, the pt's test arm is in 90 degrees of abd, ER, and elbow flexion. Rotate the head away from the test side while the therapist palpates the radial pulse. A positive test is indicated by an absent or diminished pulse; and/or reproduction of symptoms. Wright test (hyperabduction test): Positive test: absent in radial pulse or symptom reproduction Part A: subcoracoid space - abd shoulder to 90 degrees and ER shoulder. Inhale deeply. Hold position for up to 1 min. Part B: costoclavicular space - ER shoulder to 90 degrees and abd shoulder to end rage. Inhale deeply. Hold position for up to 1 min. (Cyriax release maneuver may be appropriate for pts with LVAD too, because it doesn't require radial pulse palpation. Therapist stands behind the pt, support elbows and passively elevate scapulae. Positive test: Release phenomena - parethesia and/or symptoms reproduction.)

A pt status post Colles' fracture is referred to physical therapy. The pt has mod edema in her fingers and the dorsum of her hand and complains of pain during AROM. The MOST appropriate method to quantify the pt's edema is: A. Volumetric measurements B. Circumferential measurements C. Girth measurements D. Anthropometric measurements

A. Volumetric measurements (correct answer) - often used to quantify the presence of edema in the wrist and hand, by examining the amount of water displaced following immersion Circumferential measurements: - to obtain a gross estimate of edema or muscle atrophy - would not commonly be used of the hand 2/2 the difficulty associated with obtaining an accurate measurement *** relative nonuniformity of the hand Girth measurements: - synonymous with circumferential measurements Arthropometric measurements: - used for adults include height, weight, body mass index (BMI), waist-to-hip ratio, and % of body fat - to assess items such as weight status and the risk for various diseases

A pt with grade II spondylolisthesis experiences symptoms of neurogenic claudication. Which of the following exercises would MOST likely exacerbate the symptoms? A. Walking on a treadmill with 0 incline B. Cycling with varying resistance C. Abdominal crunches on an exercise ball D. Contraction of the multifidi in a flexed position

A. Walking on a treadmill with 0 incline - symptom exacerbation due to the extension of the spine that occurs when walking upright * decreasing the anteroposterior diameter of the canal causing even more compression Pt with neurogenic claudication are typically more comfortable leaning forward or sitting (i.e., flexed spine position), thereby widening the anteroposterior diameter of the canal Cycling should be easier as the pt's lumbar spine is in a more flexed position. Abdominal crunches can be used to strengthen abdominals and reduce lumbar lordosis, which would be part of the progression of abdominal strengthening. Spondylolisthesis: forward slippage of 1 vertebra on the vertebra below (commonly at L5-S1 or L4-L5).

Which individual would be the BEST candidate to participate in a scoliosis screening? A. 10-year-old male B. 13-year-old male C. 8-year-old female D. 16-year-old female

B. 13-year-old male Peak incidence of the development of scoliosis (according to the American Academy of Orthopedic Surgeons): - females: 11-13 years; recommends screening occur minimally twice ( at 11 and 13 years of age) - males: 13-14 years; recommends screening occur minimally once (at 13 or 14 years of age)

The integrity of which nerve is assessed by the tip-to-tip pinch test? A. Posterior interosseous n. B. Anterior interosseous n. C. Deep radial n. D. Ulnar n.

B. Anterior interosseous n. - a branch of the median n. - innervates the deep muscles on the anterior forearm (except the medial half of the flexor digitorum profundus) - weakness of the flexor pollicis longus: unable to maintain tip-to-tip pinch Posterior interosseus n. - a continuation of the deep branch of the radial n. After it crosses the supinator - innervates a majority of the muscles that extend the wrist & hand Deep radial n. - provides motor function to the muscles in the posterior aspect of the forearm (primarily the extensor muscles of the wrist & hand) Ulnar n. - flexor carpi ulnaris, and the medial half of the flexor digitorum profundus, and a large of muscles on the hand

A pt reports being unable to drive due to difficulty reaching forward to grasp the steering wheel 2/2 weakness. Which of the following conditions would MOST likely be associated with this type of activity limitation? A. Rotator cuff impingement B. Peripheral nerve entrapment C. Adhesive capsulitis D. Cervical facet impingement

B. Peripheral nerve entrapment: - can cause muscle weakness and wasting, and sensation impairment, depending on the injury Rotator cuff impingement: - caused by the humeral head and the associated RTC attachments migrating proximally and becoming impinged on the undersurface of the acromion and the coracoacromial ligament - painful arc of motion (i.e., 70-120 degrees of abduction) ; & pain with overhead activities - with RTC impingement, difficulty reaching for the steering wheel would more likely be due to pain rather than weakness Adhesive capsulitis: - inflammation and fibrotic thickening of the anterior capsule of the shoulder - Loss of motion occurs in a capsular pattern with restrictions ER > abd > IR Cervical facet impingement: - painful and limited rotation and lateral flexion of the ipsilateral side of neck should be expected - will expect difficulty with turning head during driving

A pt utilizing a prosthesis following a R transfemoral amputation demos a R lateral bend with gait. Which testing procedure would be MOST anticipated based on the observed fidnding? A. Pt is positioned in R sidelying; downward pressure is applied to the distal aspect of the L limb B. Pt is positioned in L sidelying; downward pressure is applied to the distal aspect of the R limb C. Pt is positioned in unsupported sitting; therapist applies a lateral force to the pt's R shoulder D. Pt is positioned in unsupported sitting; therapist applies a lateral force to the pt's L shoulder

B. Pt is positioned in L sidelying; downward pressure is applied to the distal aspect of the R limb - to test R abductor strength Lateral bending causes: 1) prosthetic device - too short, improperly shaped lateral wall, high medial wall, & prosthesis aligned in abduction 2) related to the pt - poor balance, abduction contracture, improper training, short residual limb, weak hip abductors on the prosthetic side, hypersensitive & painful residual limb

A therapist notes limitation in the pt's ROM for DIP jt flexion when the PIP jt is held in extension. However, the pt has normal DIP flexion when the PIP jt is partially flexed. What structure is MOST likely limiting the pt's ROM? A. DIP jt capsule B. Retinacular ligaments C. Extensor digitorum muscle D. Flexor digitorum profudus muscle

B. Retinacular ligament -transverse and oblique retinacular ligaments cross the volar aspect of PIP, but cross the dorsal aspect of the DIP as they insert into the common extensor mechanism - Thus, the retinacular ligament is most taut in PIP extension and DIP flexion when PIP is extended * If the PIP jt is flexed, the structure will be put on slack and there will be more available ROM at the DIP jt

What type of splint would MOST likely be prescribed for a pt who demonstrates a positive Finkelstein's test? A. Ulnar gutter splint B. Thumb spica spling C. Radial gutter splint D. Dorsal forearm splint

B. Thumb spica splint: a rigid splint that covers the radial side of the forearm and hand as well as the thumb - immobilize the wrist & metacarpophalangeal joint of the thumb - treat gamekeeper's thumb, scaphoid fractures, first metacarpal fractures, de Quervain's disease, and other thumb injuries Finkelstein Test: 1) Make fist with thumb MPT flexed and tucked inside the fingers. Stabilize forearm. Passively move hand into ulnar deviation. 2) + test: reproduction of pain of abductor pollicis longus (APL) and extensor pollicis brevis (EPB) at the wrist 3) may be indicative of stenosing tenosynovitis in the thumb (i.e., de Quervain's disease) - repetitive stress creates inflammation of tendon causing space occupying swelling (synovitis), leading to a narrowing (stenosing) of tendon clearance Ulnar gutter splint: immobilize the metacarpals and phalanges - commonly used following a fracture to these structures Radial gutter splint: - covers radial side of the forearm and hand as well as the 2nd and 3rd digits - commonly used following a fracture of these structures -includes a thenar hole to allow for thumb free movement Dorsal forearm splint: extends from the proximal forearm to the metacarpal heads, allowing for full elbow and metacarpophalangeal joint motion - commonly used following a fracture of the carpals, distal radius, or ulnar; or sprain, tendonitis -includes a thenar hole to allow for thumb free movement

A pt has Trendelenburg gait on R. How should functional e-stim be applied in the plan of care? A. To the R hip abductors during swing phase on the R B. To the R hip abductors during stance phase on the R C. To the L hip abductors during stance phase on the R D. To the L hip abductors during swing phase on the R

B. To the R hip abductors during stance phase on the R Trendelenburg on the R: as a result of weakness of R gluteus medius => a drop of the pelvis on the L

What type of clinical presentation is MOST consistent with pain located primarily in the posterior shoulder region? A. Acromioclavicular jt arthritis B. Biceps tendinitis C. Cervical radiculopathy D. Rotator cuff tear

C. Cervical radiculopathy - often occurs due to loss of cervical lordosis with paravertebral muscle spasm - the increased muscular activity often produces pain/tenderness in the posterior neck & shoulder - pain may also extend into arm or even the chest Acromioclavicular jt arthritis: - pain in the superior shoulder region - pain with motion compressing the acromioclavicular jt: move the affected arm across the chest - common in long-term weightlifters or who performs a lot of overhead work Biceps tendinitis: - pain in anterior shoulder * deep ache directly in the front or sometimes on top of the shoulder * often worse with overhead activities or lifting heaving objects Rotator cuff tear: - pain in the anterior shoulder or in the arm * pain with palpation of the musculotendinous junction of the involved muscle and/or with stretching or resisted contraction of the muscle - pain often increases at night resulting in difficulty sleeping on the affected side

Test position for Gowers' sign A. Hooklying B. Modified plantigrade C. Squatting D. Supine

C. Squatting - assessed by having a pt attempt to stand upright from a squatting position - observed when the pt has to walk their hands up their thighs to achieve the desired upright position

A patient complains of acute low back pain & L sciatica that occurred after bending over to pick up a box. The patient has "+" signs for both the straight leg raise test and slump test. Which diagnostic technique would be the MOST desirable to definitively diagnose the suspected spinal pathology? A. Arthrography B. Nerve conduction velocity testing C. Arteriography D. Meylography

D. Meylography Myelography: combines x-ray/fluoroscopy or CT with use of a contrast dye to evaluate spinal structures, specifically the spinal cord, nerve roots, and meninges. Myelography is used to identify bone displacement, spinal stenosis, disk herniation, spinal cord compression, infection/inflammation of the meninges or tumor. Arthrography: uses x-ray & an injected contrast dye to visualize joint structures; used to identify pathology of joint structures (e.g., ligament damage, capsular tears). The test is more commonly used at peripheral joints such as the hip, knee, ankle, shoulder, elbow, and wrist; Arthrography would not likely be used for spinal joints.

Proprioceptive Neuromuscular Facilitation (PNF) patterns

D1 flexion: close your hand and pull UP and ACROSS your body D1 extension: open your hand and push DOWN and AWAY from your body (opposite of D1 flexion) D2 flexion: open your hand and pull UP and AWAY from your body D2 extension: close your hand and pull DOWN and ACROSS your body (opposite of D2 flexion) * A pt has a forward stooped posture due to ankylosing spondylitis. To improve posture, therapist can use D2 flexion

Heel wedge (shoe modification) 1) applied to the medial heel to prevent _________ 2) applied to the lateral heel to prevent _________

Heel wedge 1) applied to the medial heel to prevent excessive hindfoot eversion 2) applied to the lateral heel to prevent excessive hindfoot inversion Heel wedges can be used to treat symptoms associated with pes planus (flat foot) and pes cavus (high arch of the foot)

Normal degree of toe-out - at free/normal speed walking: __________ - at fast speed walking: __________

Normal degree of toe-out - at free/normal speed walking: 7 degrees - at fast speed walking: 3 degrees

The spine of the scapula typically aligns with the spinous process of the _____ vertebra

T3

fibularis posterior tenosynovitis - symptoms - mechanisms of injury

symptoms: 1) pain with resisted ankle PT & inversion 2) TPP along the tendon mechanisms of injury: overuse with a pronated foot and flattened longitudinal arch