Musculoskeletal practice questions: Patellofemoral pain syndrme (PFPS), Ancerine bursitis, Scaphoid fracture, Colle's fracture, De Quervain's, rotator cuff injury, ACL injury, Ankle sprain, Plantar Fasciitis, carpal tunnel, Sacroilitis, spinal stenosis

1. The "drop arm test", when positive, suggests? a. Clavicle fracture b. AC joint separation c. Large rotator cuff tear or nerve injury d. Biceps tendinitis 2. The cross-over test, when positive, may suggest? a. AC joint pain b. Glenohumeral joint instability c. Impingement syndrome d. Both a and c 3. Glenohumeral instability is commonly seen in? a Young, active patients b. Elderly c. Young, sedentary patients d. Pregnancy 4. Characteristics of rotator cuff tendinitis include? a. Pain that improves with activity and worsens with rest b. Pain located in the bicipital groove c. Pain that improves with rest and worsens with activity d. Pain related to trauma

1. c 2. d 3. a 4. c

14.Shoulder muscle asymmetry may indicate which of the following? a. Rotator cuff tear b. Nerve injury c. Adaptive hypertrophy d. All of the above 15.A snapping sound in the wrist usually represents? a. Synovitis b. Carpal tunnel syndrome c. Subluxing tendons d. Infection 16.Which nerve is being tested when the hand is placed on a flat surface, palm up and the thumb is raised against resistance? a. Radial b. Median c. Ulnar d. None of the above 17.The inability to flex the DIP joint is suggestive of? a. Ulnar collateral ligament tear b. Mallet finger c. Jersey finger d. deQuervain's tendinitis 18.When testing range of motion of the back, forward flexion most increases? a. Facet pain b. Muscular pain c. Tendon pain d. Disc pain

14. d 15. c 16. b 17. c 18. d

19.Weakness with resisted great toe dorsiflexion is suggestive of irritation of which nerve root? a. S1 b. L5 c. L4 d. L3 20.The Stork test will aggravate pain associated with? a. Spondylolysis b. Spondylolisthesis c. SI joint dysfunction d. All of the above 21.Pain with the FABER test is suggestive of? a. SI joint pathology b. Sciatica c. IT band tightness d. Synovitis 22.Which test is usually positive with a femoral neck stress fracture? a. Hop test b. Log roll test c. Ober's test d. Trendelenburg test 23.Pain from sciatica worsens with which maneuver? a. Extension of back b. Flexing knee c. Twisting of back d. Valsalva

19. b 20. d 21. a 22. a 23. d

24.Which test when positive is suggestive of deQuervain's tendinitis? a. Watson stress test b. Grind test c. Tinel's test d. Finkelstein's test 25.The presence of locking of the knee suggests what injury? a. Patellofemoral syndrome b. MCL tear c. Quadriceps strain d. Meniscal tear 26.This is the most common injury to the ankle: a. Inversion injury b. Eversion injury c. Dorsiflexion d. External rotation 27.A large (3+) effusion of the knee occurring within 12 hours of an injury suggests which of the following? a. ACL tear b. Osgood-Schlatter's disease c. Patellofemoral syndrome d. LCL sprain 28.Pain over the tibia tubercle is an important exam finding in which of the following? a. Meniscal tears b. MCL sprain c. Bipartate Patella d. Osgood-Schlatter's disease

24. d 25. d 26. a 27. a 28. d

Patella tests reveal evidence of patellofemoral dysfunction.

A. Apprehension test B. Patellar grind test C. Q-angle

Which of the following IS NOT associated with carpal tunnel syndrome? A Hypothyroidism. B Diabetes mellitus. C Amyloidosis. D Polycythemia vera. E Rheumatoid arthritis.

The correct answer is "D." All of the above are associated with carpal tunnel syndrome except for polycythemia vera. Polycythemia vera can cause erythromelalgia which is a burning pain of the hands and feet associated with erythema, pallor, or cyanosis. It responds to aspirin. Other conditions associated with carpal tunnel syndrome include pregnancy, menopause, obesity, acromegaly, and end-stage renal disease. The point here is that patients with carpal tunnel syndrome should have a systemic cause ruled out, either clinically or with labs.

9. A common source of radicular pain to the shoulder is? a. Wrist b. Hip c. Thoracic spine d. Cervical spine 10.Resisted extension and supination of the wrist tends to aggravate? a. Medial epicondylitis b. Ulnar nerve subluxation c. Lateral epicondylitis d. Olecranon bursitis 11. A sudden painful pop at the medial elbow while throwing may indicate? a. Osteoarthritis of the elbow b. Epicondylitis c. Ulnar collateral ligament tear d. Carpal tunnel syndrome 12.Recurrent popping at the medial elbow associated with tingling to the 4th and 5th finger may indicate? a. Ulnar nerve subluxation b. Ulnar collateral ligament tear c. Arthritis d. Carpal tunnel syndrome 13.Severe night pain in the shoulder that prevents sleep suggests? a. Rotator cuff tear b. Biceps tendinitis c. Glenohumeral instability d. AC separation

9. d 10. c 11. c 12. a 13. a

Treatment for Tendonitis

Allow the affected tendon ample time to rest by ceasing any physical activity that may have caused or is aggravating the inflammation. If the tendonitis is in the feet or legs, elevate them. Take anti-inflammatory medication such as ibuprofen to decrease any swelling. Apply ice to the affected area to ease pain. If possible, brace the area by applying a cast or wrapping the skin in athletic tape to keep it compressed

CRITERIA SUGGESTING THE NEED FOR EARLY IMAGING FOR BACK PAIN

Bowel or bladder dysfunction New onset of impotence Fevers or night sweats Unplanned weight loss Night pain Personal history of cancer Saddle anesthesia History of recent trauma (e.g., fall or direct blow, NOT twisting or lifting) Age >50 or <18 years Patient with current or recent use of steroids Any suspicion of an infectious or neoplastic cause for low-back pain Pain for >6 weeks

tendinosis

Tendonosis is characterized by a degeneration of the tendons. More specifically, it is caused by a degeneration of the fibrous material known as collagen, from which tendons are made. Tendonosis usually occurs as a result of a past injury. It often appears long after the injury occurs. The degeneration of collagen causes tendons to become soft and jellylike, which ultimately results in pain as tendons become flaccid and unable to function properly. Unlike tendonitis, tendonosis is often difficult to detect visually because it is not accompanied by inflammation.

RED FLAG SYMPTOMS IN LOW BACK PAIN

Unrelenting night pain Unrelenting pain at rest Neuromotor deficit Unexplained fever Greater than 6 weeks duration Age >70 Loss of bowel or bladder control Progressive focal neurologic deficits Suspicion of ankylosing spondylitis Trauma History or suspicion of cancer Osteoporosis Chronic corticosteroid use Immunosuppression Alcohol abuse Intravenous drug use

Tendonitis

caused by an inflammation of the tendons, typically caused by a sprain where the muscles of the body connect to the bones. Tendons must move and bend smoothly for functional movement. When their function is interrupted or impaired, tendons become irritated and begin to inflame. Inflammation is usually accompanied with dull or severe pain and difficulty moving joints and muscles.

pes anserinus bursitis (also referred to as anserine or pes anserine bursitis)

is an inflammatory condition of the medial knee. Especially common in certain patient populations, it often coexists with other knee disorders. Diagnosis of pes anserine bursitis should be considered when there is spontaneous pain inferomedial to the knee joint.

29.What is the typical mechanism for injury to the deltoid ligament of the ankle? a. Ankle inversion b. Ankle dorsiflexion c. Ankle plantarflexion d. Ankle eversion 30.What is the most common reason for persistent symptoms after an ankle injury? a. Underlying fracture b. Cartilage injury c. Fat pad necrosis d. Inadequate or incorrect treatment 31.The definitive exam used to evaluate for ACL tear is? a. Pivot shift b. Anterior drawer test c. Sag sign d. Lachman's test 32.A positive Thompson's test is suggestive of which injury? a. High ankle sprain b. Achilles tendon rupture c. Patellofemoral syndrome d. Lateral ankle sprain 33.A Q-angle greater than 10° in males or 15° in females predisposes to what problem? a. ACL tears b. LCL tears c. Baker's cysts d. Patellofemoral syndrome 34.What is the likelihood of having an ACL tear if a "pop" was felt or heard during a twisting knee injury? a. ~10% b. ~25% c. ~60% d. ~80% 35.Weakness with resisted dorsiflexion of the ankle suggests injury to which muscle? a. Tibialis posterior b. Gastrocnemius c. Tibialis anterior d. Peroneal longus

29. d 30. d 31. d 32. b 33. d 34. d 35. c

5. Abduction with thumbs down and 30° horizontal adduction ("empty can test") isolates which rotator cuff muscle? a. Subscapularis b. Teres minor c. Supraspinatous d. Infraspinatous 6. Loss of both active and passive shoulder motion may suggest which of the following? a. Labrum tear b. Adhesive capsulitis c. Severe impingement d. All of the above 7. When performing Neer's test, pain or lack of motion is commonly seen with? a. Impingement syndrome b. AC separation c. Glenohumeral instability d. Labrum tear 8. A positive Spurling's test (radicular pain to the shoulder and arm during axial loading to the top of the head with the neck twisted) may represent? a. Cervical nerve root irritation b. Deltoid atrophy c. Impingement syndrome d. Muscle spasm

5. c 6. d 7. a 8. a

low back pain; Evaluate for "Red Flags"

Ask about symptoms which could indicate a more serious etiology for back pain: 1. Cancer (primary or metastatic) — ask about a history of cancer, as well as recent weight loss, rest pain or pain lasting more than 4 to 6 weeks despite therapy. Cancer is more common in patients older than 50 years. 2. Spinal Infection — ask about recent infection (urinary tract or skin), fever or rest pain. Infection is more common in those with immune-compromised states (diabetes, steroid use, human immunodeficiency virus, organ transplant) or intravenous drug use. 3. Fracture (usually compression fracture) — ask about recent trauma or use of corticosteroids. Fracture risk is increased in patients older than 70 years or with a history of osteoporosis. Low back strain Degenerative disk disease OA of spine spondylolysis spondylolisthesis Lumbar radiculopathy Herniated lumbar disc spinal stenosis 4. Sciatica — ask about pain radiating down the posterior or lateral aspect of the leg to below the knee, as well as numbness, paresthesia or motor loss in legs. Sciatica pain tends to worsen with cough, sneeze or Valsalva. 5. Cauda Equina Syndrome — ask about bilateral lower extremity weakness, numbness, progressive neurological deficit or saddle anesthesia. Also ask about recent urinary incontinence/retention or fecal incontinence. 6. Ankylosing Spondylitis (AS) — ask about morning stiffness. Pain from AS usually begins slowly, persists at least 3 months and improves with exercise. The age of onset is usually younger than 40 years.

Treatment for Tendonosis

Do not take any anti-inflammatory medication. Try to move and use the affected tendon as much as possible without causing excessive pain. This will help reduce the degeneration of collagen. Massage the tendon with ice packs or bags of frozen vegetables to help ease pain. Seek physical therapy as soon as possible; damaged tendons may be in need of therapeutic exercise or even reconstructive surgery.

A summary of nerve root innervation; EXAMINATION FINDINGS OF LUMBAR AND SACRAL SPINAL NERVE ROOTS

Nerve Root/ Refex / Motor/ Sensory/ Test L2-3/None/Quadriceps/anterior thigh/Knee extension L4/Patella/tibialis anterior (foot dorsifexion, inversion)/ Medial lower leg and foot/Walk on heels L5/Medial hamstring (difficult to assess)/ Extensor hallucis longus (dorsifexion of big toe)/ dorsal foot/ Hold up great toe S1/achilles/Peroneus longus and brevis (ankle eversion) and plantar fexion of foot/ Lateral foot/ Walk on toes S2-4/anal wink/ intrinsic foot muscles, anal sphincter tone/ Perianal

Patella Tests

Several tests can be performed to evaluate for patellofemoral dysfunction or dislocation: 1. Patella apprehension test - performed by pushing the kneecap in a lateral direction with the patient lying supine. The test is positive when the patient becomes apprehensive that the patella may recurrently dislocate. This suggests a recent patella dislocation. 2. Patella grind test - with the patient lying supine, pushing down on the kneecap and grinding back and forth can aggravate the pain of patellofemoral dysfunction. This test also has a very high false-positive rate . 3. Q-angle (quadriceps angle) - the angle formed by a line connecting the ASIS of the hip and the center of the patella, with a line down the anterior tibia. Angles greater than 10° in male and 15° in female may predispose to patellofemoral problems. The wider pelvis seen in women increases their Q-angle and has been thought to contribute to their increased incidence of patellofemoral pain.

Your patient is successful in rehabilitating his left shoulder, but then he returns 2 years later with right shoulder problems. The right shoulder has become progressively stiff and painful, and his ROM is now significantly limited in all directions. Your examination is consistent with "frozen shoulder" or adhesive capsulitis. Adhesive capsulitis is most commonly associated with which of the following? A Diabetes. B Hyperthyroidism. C Spondyloarthritis. D Nondominant arm. E Male gender.

The correct answer is "A." Adhesive capsulitis has no clear predilection as to gender, race, arm dominance, or occupation. It is characterized by loss of ROM of the shoulder in all directions, with loss of both passive and active motion. It has a high incidence in patients with diabetes and tends to be more recalcitrant in those patients, of whom up to 50% will have bilateral involvement—although not necessarily concomitantly. Adhesive capsulitis is not typically related to trauma, but it can be associated with disuse due to pain, osteoarthritis, sling use, etc. Other conditions that are associated with adhesive capsulitis include hypothyroidism and Parkinson disease.

he next patient in the ED is an 18-year-old high school football player. He was playing in a football game this evening when he was tackled from the side and landed directly on the lateral aspect of his right shoulder. He states that he can actively move his arm, but is limited by pain on the top of his shoulder. He has also noticed a small painful bump on top of the right shoulder and is concerned that he "broke his collarbone." Based on the mechanism of injury and patient history, the most likely injury would be? A Acromioclavicular (AC) sprain. B Biceps tendon rupture. C Glenohumeral dislocation. D Rotator cuff tear. E Scapula fracture.

The correct answer is "A." Although any of these injuries may be present, an AC sprain is the most likely based on the history and the way the patient fell. A thorough examination should be able to further distinguish between these injuries. "B" is not likely, given the mechanism of injury. The deformity associated with biceps tendon rupture (a defect in tendon with pain and deformity in the muscle belly representing the contracted, detached muscle) would be on the upper arm or at the elbow, not on the "top" of the shoulder. "C" is incorrect. The deformity and loss of ROM of a glenohumeral dislocation (shoulder dislocation) is usually obvious. The mechanism of injury is typically a forced abduction and external rotation. "D" is less likely. A rotator cuff tear will present with pain more laterally over the subacromial space and should not have an associated deformity. The ROM is generally markedly limited by pain. "E" is unlikely. Scapula fractures are uncommon and are usually the result of high velocity blunt trauma such as a blow from a baseball bat or motorcycle accident. Plain film radiographs should be obtained to rule out a clavicle fracture, especially when any deformity is present.

A 45-year-old female hospital clerk presents with bilateral aching pain in the forearms and thenar eminences. The pain is made worse with driving and typing. She also has intermittent numbness over the same areas. She tried to ignore the symptoms, but today she dropped her coffee mug on her computer keyboard and became alarmed at her loss of strength. She has hypothyroidism and is obese, but she reports that her health is otherwise good. Based on the history alone, which of the following is the most likely diagnosis? A Carpal tunnel syndrome. B Osteoarthritis. C Ulnar neuropathy. D Diabetic neuropathy. E Stroke.

The correct answer is "A." Carpal tunnel syndrome is due to median nerve entrapment in the carpal tunnel of the wrist. Typical symptoms include numbness, paresthesias, and pain at the palmar/radial aspect of the hand, quintessentially the thenar eminence. In more severe or long-lasting cases, you may see atrophy of the thenar eminence. Patients may also develop weakness of thumb opposition. Osteoarthritis of the wrists does not usually cause nerve symptoms but can cause spondylosis and nerve root impingement on occasion. Ulnar neuropathy involves the ulnar aspect of the hand, especially the fourth and fifth fingers, rather than the radial aspect, which is involved with carpal tunnel syndrome. Diabetic neuropathy typically presents in the feet since they are innervated by the longest nerves in the body. Note: This could represent cervical disk disease as well, especially given that it is bilateral. Next: Tips

Which of the following physical examination findings would be associated with the diagnosis of De Quervain tenosynovitis? A Positive Finkelstein test. B Positive Phalen test. C Positive Tinel sign. D Sensory loss over the C7 dermatome. E Weakness of the intrinsic muscles of the hand.

The correct answer is "A." De Quervain tenosynovitis is a tendonitis of the abductor pollicis longus, the extensor pollicis brevis, and occasionally the extensor pollicis longus. Full flexion of the thumb into the palm and ulnar deviation of the wrist produces exquisite tenderness over the radial aspect of the wrist (positive Finklestein test). Other findings may include soft-tissue swelling and pain over the abductor pollicis longus and extensor pollicis brevis tendons near the radial styloid. Crepitus may also be palpable or audible with ROM.

Anterior slippage of one vertebra on another is called: A Spondylolysis. B Spondylolisthesis. C Spondylitis. D Spondyloarthropathy. E Scheuermann disease.

The correct answer is "B." Slippage of one vertebra on another is called spondylolisthesis. "A," spondylolysis, is discussed above. Spondylolysis can lead to spondylolisthesis. Spondyloarthropathy is a nonspecific term referring to inflammation of the spine and encompasses such diseases as ankylosing spondylitis, Reiter disease, enteropathic arthritis, etc. Spondylitis is a more specific term for the same thing (e.g., ankylosing spondylitis). "E," Scheuermann disease, is a process causing kyphosis by compression of the vertebrae (at least 5 degrees of wedging in three consecutive vertebrae). The cause is unknown but it tends to present in adolescence.

Based on your history and physical examination, you diagnose a rotator cuff tendinosis. Appropriate initial management of this 65-year-old male should be: A Acetaminophen and physical therapy. B Oral corticosteroids and physical therapy. C Subacromial injection with corticosteroid and physical therapy. D Surgical repair and physical therapy. E None of the above.

The correct answer is "A." For initial management in an individual >60 years of age, acetaminophen and physical therapy for 6 weeks is the best answer. If the patient has no improvement or inadequate response, a corticosteroid injection may be used judiciously. Injection likely will result in at least short-term pain relief, but there is no good evidence that it helps long term. In addition, it is thought to weaken the tendon and may accelerate extension of a tear, if present. Patients with significant symptoms or failed therapy should be considered for MRI, orthopedic referral, and surgical management. Patients under the age of 60 with acute traumatic tears should be considered for surgery, with best results within 6 weeks of injury.

Appropriate treatment for the fracture (avulsion fracture of the base of the fifth metatarsal) described above would be: A A hard soled postoperative shoe bearing weight as tolerated. B Nonweight-bearing short-leg cast for 6 to 8 weeks. C Operative internal fixation. D Walking boot with crutches for 6 to 8 weeks. E None of the above.

The correct answer is "A." Nondisplaced tuberosity fractures generally heal well with conservative measures. These may be managed with a postoperative shoe with weight bearing as tolerated. A walking boot may be needed initially if there is significant pain present preventing ambulation in a hard soled shoe, however, ankle immobilization is generally not needed for these avulsion fractures to heal. For a fracture with a displaced fragment >3 mm, orthopedic referral should be considered. Fractures to the metaphyseal-diaphyseal junction (Jones fractures) result from a vertical load placed on the lateral foot, such as an inversion injury or a stress injury. Jones fractures may potentially be managed with 6 to 8 weeks in a nonweight-bearing short-leg cast if nondisplaced, however, many require surgical intervention. Jones fractures should be referred due to the high incidence of nonunion.

Plain film radiographs, including AP and lateral of the hand and wrist as well as scaphoid views, are negative for fracture. What is the most appropriate next step for this patient? A Short-arm thumb spica cast with follow-up in 10 to 14 days. B NSAIDs, ice, compression, and elevation followed by physical therapy. C MRI or CT to rule out an occult fracture. D Orthopedic referral. E Return to play within the week.

The correct answer is "A." Scaphoid fractures are often occult acutely and usually will be evident on plain films after 10 to 14 days due to bony resorption along the fracture line. If repeat films are negative but suspicion remains high, an MRI or CT should be considered.

Which of the following muscles is the most commonly torn in the rotator cuff? A Supraspinatus. B Infraspinatus. C Subscapularis. D Teres minor.

The correct answer is "A." The supraspinatus is generally the point of origin for most tears.

In this case, the most likely structure injured would be the: A Anterior talofibular ligament. B Distal fibula. C Distal tibia. D Deltoid ligament. E Achilles tendon.

The correct answer is "A." This is a sprain of the anterior talofibular ligament. This is the first ligament injured with an inversion ankle sprain. It is followed by the calcaneofibular ligament if enough force is involved. "E," Achilles tendon injury (specifically rupture), is of special note. First, this injury presents as pain in the Achilles tendon area. With a complete Achilles tendon tear, the patient will have marked weakness of plantar flexion. A diagnostic test (Thompson test) is to squeeze the posterior calf with the patient lying supine on the bed and the feet dangling off. In response, the foot should plantar flex. If this does not occur, consider Achilles rupture. Operative and nonoperative treatments can be used.

A 24-year-old male presents to the clinic 2 days after a collision during a softball game in which he fell on his outstretched right hand ("But I made the play!" he exclaims). He reports he could not continue playing and that his pain has not improved. He has some general edema around the right wrist, poor grip strength secondary to pain, point tenderness over the radial aspect of the wrist ("snuff box tenderness"), and decreased ROM. There is no obvious deformity, and he is neurovascularly intact. Of the following, what would be the most likely diagnosis for this patient? A Colles fracture. B Scaphoid fracture. C Smith fracture. D Extensor carpi radialis strain. E Scapholunate sprain.

The correct answer is "B." Although all of these could be in the differential diagnosis, "B" is the most likely based on mechanism of injury and clinical findings. The scaphoid spans both the proximal and distal carpal row. In this position, it is quite vulnerable to high-impact injuries, such as a fall on an out-stretched hand, and is the most commonly fractured carpal bone. The absence of deformity makes a Colles or Smith fracture less likely (options "A" and "C"). Further, a sprain or a strain (options "D" and "E") are less likely given the bony point tenderness, decreased range of motion, and overall nonimprovement with conservative measures.

Appropriate initial treatment for this patient's acute back pain should include which of the following? A Strict bed rest. B Pain control. C Corset or lumbar belt. D Referral for epidural steroid injection or endoscopic disk resection. E A and B.

The correct answer is "B." In acute mechanical back pain (no longer than 6 weeks), regardless of the method of treatment, 40% are better within 1 week, 60% to 85% in 3 weeks, and 90% in 2 months. Negative prognostic factors include more than three episodes of back pain, gradual onset of symptoms, and prolonged absence from work. Bed rest does not contribute to a return of function and may worsen outcomes. Early mobilization of the patient is best for allowing him to continue activities as tolerated. Acetaminophen is a great drug for pain control and has fewer side effects than do the NSAIDs. Chiropractic care may be useful. Data on acupuncture are mixed.

Which of the following is true of plantar fasciitis? A It more commonly occurs in individuals with pes cavus. B It is more common in women. C It is commonly an acute injury. D Radiographic identification of a "heel spur" or osteophyte is pathognomonic.

The correct answer is "B." Plantar fasciitis is not associated with any particular foot type. It is nearly twice as common in women as men. It is also more common in overweight individuals. A rupture of the plantar fascia may occur acutely. Spurring may be seen in up to 50% of patients with plantar fasciitis, but is present in 20% of age matched asymptomatic adults. Thus, the finding of a spur is not diagnostic.

What is the preferred treatment for this female runner? A Arthroscopic debridement. B Decreased activity level along with and quadriceps and hip strengthening exercises. C Evaluation for "Female Athlete Triad." D Casting or immobilization. E Corticosteroid injection.

The correct answer is "B." The most effective treatment modality is a combined physical therapy regimen consisting of strength training of the hip abductors and quadriceps, as well as quadriceps stretching. Quadriceps strengthening is usually initiated by resisted straight leg raises (SLRs) to minimize patellofemoral compressive forces. NSAIDs, cross-training, and core strengthening may also be of benefit. Adjunctive trials of therapeutic modalities such as orthotics may be considered, but should not be used in isolation. Recalcitrant cases and patients with recurrent dislocation/subluxation should be referred to your friendly neighborhood orthopedic surgeon for consideration of surgical intervention.

A patient presents after "jamming" his index finger while playing basketball. He has mild swelling at the DIP joint. At rest, his DIP is flexed. He has full ROM of all joints except he cannot extend at the DIP. What is the appropriate treatment and follow-up? A RICE therapy, PRN follow-up. B A full extension splint of the DIP joint worn at all times with orthopedic follow-up in 1 to 2 weeks. C A removable aluminum splint to be worn for comfort, follow-up in clinic in 1 month. D Ibuprofen and return to full activities, PRN follow-up.

The correct answer is "B." The patient has suffered an injury to his extensor tendon mechanism, known as a "mallet finger." X-rays are indicated to evaluate for a bony fracture/avulsion. The initial treatment is an extension splint at the DIP joint, and follow-up with an orthopedic surgeon as surgical correction is sometimes required. The splint must be worn at all times.

A 24-year-old female presents to the clinic 24 hours after slipping on a patch of ice outside her home. She reports feeling a "pop" and immediate pain on the lateral aspect of the ankle. She reports significant swelling in the first few hours with pain and inability to bear weight initially, but now she is able to walk with a significant limp. She reports no significant past injuries to the foot or ankle. On examination, you note edema/effusion over the lateral ankle, some ecchymosis, tenderness, but no laxity on anterior drawer and inversion stress. There is no bony tenderness on palpation of the foot and ankle, but there is tenderness anterolaterally in the soft tissue. The most likely injury this patient has suffered is? A Fracture of the distal tibia. B Fracture of the distal fibula. C Sprain of the lateral ligament complex. D Sprain of the medial ligament complex. E Syndesmosis sprain.

The correct answer is "C." A sprain is most likely because there is no bony tenderness. And, since she is tender laterally, the lateral ligament complex is most likely sprained.

A 19-year-old male was mad at his computer and decided to punch the wall. "He fought the wall and the wall won." Radiographs demonstrate a fifth metacarpal fracture with some angulation. What is the maximal acceptable angulation and rotation for a boxer fracture, fourth or fifth metacarpal, to maintain full hand function? A 10 degrees of dorsal angulation and 10 degrees of rotation. B 30 degrees of dorsal angulation and 5 degrees of rotation. C 40 degrees of dorsal angulation and 0 degrees of rotation D 90 degrees of dorsal angulation and 0 degrees of rotation.

The correct answer is "C." Any degree of rotation, or >40 degrees of dorsal angulation, may result in significant functional deficits. Reduction should be attempted if angulation is >10 degrees. Patients should be advised that with angulations >10 to 15 degrees, there will likely be a loss of metacarpophalangeal (MCP) prominence, although there should be no loss of function. If this is unacceptable to the patient, referral is recommended.

The best test to confirm the diagnosis of the above injury would be? A Plain film radiographs. B McMurray test. C Lachman test. D Anterior drawer test.

The correct answer is "C." In the hands of an experienced clinician, the Lachman test is the most sensitive test for ACL insufficiency (80-95%). The anterior drawer sign is negative in about 50% of acute ACL tears, and often is negative subacutely. McMurray test is used to evaluate for a meniscal tear. Plain films should be obtained for all patients with acute knee injury with effusion or suspected ACL tear. A Segond fracture (small avulsion of the lateral tibial plateau) is an x-ray finding associated with ACL tears. Although an MRI may be considered a gold standard test, its sensitivity has been reported as 97% when compared against arthroscopy findings, and is positive in only 82% in cases of complete rupture. An orthopedic consult is generally indicated if ACL injury is suspected, and obtaining one is less expensive than MRI.

A 15-year-old female cross-country runner presents to your clinic with the chief complaint of bilateral knee pain. She describes a gradual increase in her symptoms during the first 3 weeks of the season. She wants to run varsity this year and has done extra running and hill training after practice each day. She describes anterior knee pain in the patellar region with little or no swelling, but complains of crepitus and pain exacerbated by running, squatting, stair climbing, and prolonged sitting with the knee bent. The most likely diagnosis for the condition described is: A Osgood-Schlatter disease. B Chondromalacia patellae. C Patellofemoral pain syndrome (PFPS). D Femoral stress fracture.

The correct answer is "C." PFPS is a common overuse syndrome seen more frequently in runners and female athletes (thus the moniker "runner's knee"). This condition is due to forces across the knee that lead to biomechanical overload of the patellofemoral joint and other anterior knee structures. Maltracking and malalignment of the patellofemoral joint can contribute to this overload, as can training errors, core weakness, and muscle imbalance. "A," Osgood-Schlatter disease, is also related to overuse but is 2 to 3 times more common in males, particularly in athletes engaging in repetitive jumping. The pain of Osgood-Schlatter is generally well localized to the tibial tubercle. Radiographic evidence of fragmentation of the epiphysis or heterotropic ossification anterior to the tubercle may be seen but is not necessary for diagnosis. "B," chondromalacia patella, is softening of the articular cartilage of the patella as seen on arthroscopy and may be a result of long-term patellofemoral dysfunction. This is a surgical diagnosis and the term should be avoided clinically. Femoral stress fracture ("D") would be unlikely to present bilaterally.

Early imaging should be obtained in all of the following presentations of LBP EXCEPT: A Neurologic symptoms such as bowel or bladder dysfunction and impotence. B History of fever, night sweats, and weight loss. C History of cancer. D Trauma. E Age >30 years.

The correct answer is "E." Patients over the age of 50 should have early imaging

Spondylolisthesis is graded based on the degree of slipping of one vertebra on the other. Which of the following patients would need surgical consultation? A Grade one (<25% slip) with no symptoms in an early teen (12-14). B Grade 2 (25-50% slip) with no symptoms in an early teen (12-14). C Grade 3 (50-100% slip) with mild pain in a 20 year-old college gymnast. D When slippage is 10% to 15% with no symptoms in a patient >60 years old. E When slippage is 25% with no symptoms in a patient >60 years old.

The correct answer is "C." Spondylolisthesis is generally a problem in the late teens and 20s. Patients often become symptomatic when there is 25% slippage or greater. Mild degrees of slip can be treated conservatively, although surgical treatment threshold varies considerably among orthopedic surgeons. Predisposing factors include recurrent lumbar hyperextension (gymnasts, football players, etc.), although many patients do not have an identifiable cause. Any adolescent athlete who presents with back pain that is made worse by hyperextension should raise your suspicion. Older patients who are asymptomatic do not need to be considered for surgical treatment unless the slip is grade 4 (100% or greater).

The best clinical test(s) for determining the presence of a meniscal injury is (are): A Posterior sag test. B Apley test. C McMurray test. D Pivot shift test. E B and C.

The correct answer is "C." The McMurray test is the best test for determining meniscal injury. This is done by flexing the knee and then extending the knee while performing internal and external rotation of the tibia/fibula. Keep one hand on the knee. The test is positive when the examiner feels a pop during the maneuver or when there is significant pain during internal or external rotation. The Apley test is done with the patient in a prone position. Move the knee to 90 degrees of flexion. Put downward pressure on the tibia/fibula while internally and externally rotating the lower leg. Pain suggests a meniscal tear. Pain should be relieved by distracting the joint. The posterior sag test is used to detect PCL injury, while the pivot shift test is used to detect ACL injury.

You prescribe your pain medication of choice and recommend rehabilitation exercises. Which of the following has been shown to be effective at reducing the recurrence of back injury in the workplace? A Back support belts. B "Back School" that teaches proper lifting techniques, stretches, etc. C Increasing physical fitness and muscle tone. D A and C. E B and C.

The correct answer is "C." The only thing that has been unequivocally shown to reduce further back injuries is improving the overall fitness of the patient and his muscle tone. Of special note, back support belts, long worn in industry, have equivocal data with most studies being negative. "Back School" also does not seem to help.

A 55-year-old obese female comes to your office complaining of knee pain when she walks. She had an MRI at an urgent care center, which showed some meniscal damage. She is tender inferiorly and medial to the patella on the proximal tibia (but not on the joint line). Which of the following is true? A Washing out her knee by arthroscopy will help to relieve her symptoms. B The finding of a meniscal injury on MRI correlates well with symptoms of pain. C Based on its location, pes anserinus bursitis is the likely cause of her pain.

The correct answer is "C." The pes anserine ("goose's foot") bursa is located on the medial, proximal aspect of the tibia and is where the tendons of the sartorius, gracilis, and semitendinosus attach. It often becomes inflamed causing significant and chronic knee pain. Conservative therapy with rest, ice, NSAIDs, and stretching may be tried initially. However, these often fail; most patients experience significant improvement with corticosteroid injections. "A" is incorrect. Several studies have found that washing out the knee and trimming the cartilage is of no benefit. "B" is also incorrect. MRI of the knee is not particularly useful for determining if a meniscal injury is the source of pain. Similar to herniated disks, many asymptomatic patients have meniscal injuries on MRI limiting our ability to assign symptoms to an MRI finding. This is especially true in the elderly with arthritis where >90% will have meniscal damage. As to "D," it obviously does not relate to the case. We call that "test taking skill." If you chose "D," woe is with you.

Which of the following is the most appropriate management of this patient's sprained ankle? A Cast for 4 weeks followed by physical therapy. B Crutches, nonweight-bearing for 2 weeks, and then progressive physical therapy. C Rest, ice, elevation, and early mobilization using external support, crutches or cane if needed. Progress to activity as tolerated. D Refer for orthopedic consultation. E Immobilization with short-leg walking cast, heat for comfort, analgesics or NSAIDs, and progress to activities as tolerated.

The correct answer is "C." Treatment for most sprains includes an external supportive brace, ice application, and elevation; early mobilization is critical and will hasten recovery. NSAIDs or acetaminophen should be used for pain control. The patient should be allowed partial weight bearing as tolerated with crutches or a cane. Patients with recurrent problems of instability should be referred to an orthopedist for evaluation.

A Colles fracture consists of: A Fractures of the midshaft of the radius and ulna. B Fractures of the head of radius and ulna that is displaced dorsally and is angulated. C Fractures of the head of the radius and ulna that are displaced ventrally and is angulated. D None of the above.

The correct answer is "D," none of the above. OK, some of you may have chosen "B." However, the head of the radius is at the elbow and not at the wrist. Thus, none of the answers is correct. A Colles fracture is a fracture of the distal radius at the metaphysis, which is displaced dorsally and often angulated. It is the most common wrist fracture in adults. The ulnar styloid is often involved, and there may be intra-articular involvement as well.

Even though SLR is negative, you continue your neurologic examination. You note symmetric patellar reflexes, diminished Achilles reflex on the right, and symmetric strength in the legs except for decreased strength with right foot plantar flexion. You also note decrease in gross sensation to light touch over the right lateral foot. Which of the following nerve roots is most likely compromised? A L3. B L4. C L5. D S1. E S2-4.

The correct answer is "D."

What initial treatment do you recommend for this patient with adhesive capsulitis? A Arthroscopic debridement. B Oral corticosteroids. C NSAIDs and a sling for comfort. D Extended progressive physical therapy. E Mobilization under anesthesia.

The correct answer is "D." A progressive stretching program with heat and NSAIDs or acetaminophen to improve comfort is the most appropriate early treatment. A corticosteroid injection (under ultrasound guidance or fluoroscopy) may be beneficial, but should be used cautiously in diabetic patients. Oral steroids have no greater benefit than NSAIDs. "C" is incorrect because a sling will contribute to further immobilization and worsening of the problem. Mobilization or capsular release under anesthesia may be a last resort in adhesive capsulitis.

An 18-year-old female gymnast lands her dismount from the balance beam awkwardly. She reports the knee buckling, hearing a pop, and experiencing immediate right knee pain. She presents to your office 45 minutes after the injury. She is able to bear some weight on the leg but reports it is already swollen and feels "loose." On examination, there is a knee effusion present. Based on the information above, the most likely isolated injury experienced by this athlete is: A Medial meniscus tear. B MCL sprain. C Distal quadriceps/patellar tendon rupture. D Anterior cruciate ligament (ACL) rupture. E Distal femur fracture.

The correct answer is "D." Did the patient or someone else hear a pop? If yes, suspect ACL tear (80%), meniscal injury (15%), and rarely a fracture. When did you notice swelling? If 0 to 12 hours after the injury, suspect ACL tear, fracture, or patellar dislocation/subluxation; if 12 to 24 hours, suspect meniscal injury. If there is hemarthrosis on aspiration, suspect ACL injury (>75%), patellar subluxation, or intra-articular fracture. A history of, "My knee gives way; buckles; feels loose; or comes apart," may be secondary to patellar subluxation/dislocation, ACL deficiency, or arthritis. Medial and lateral collateral ligament injuries, do not typically present with significant effusion and typically feel stable with forward ambulation but are painful with side-to-side movements. Muscle or tendon rupture may cause buckling, but will not typically cause effusion and will generally have an obvious deformity and inability to bear weight.

A 40-year-old female factory worker presents with progressively worsening heel pain. She has pain when she first gets out of bed in the morning. The pain tends to subside after 20 to 45 minutes but is worsened by standing on the concrete floor of the factory where she works. She has a history of diabetes and hyperlipidemia. On examination, you find an obese female with a normal stance and gait. She has exquisite tenderness to palpation just distal to the heel on the underside of the foot. Pain is exacerbated by extension of the toes. Which of the following is the most likely diagnosis? A Tarsal tunnel syndrome. B Achilles tendon rupture. C Charcot foot. D Plantar fasciitis. E Plantar fascia rupture.

The correct answer is "D." Plantar fasciitis, the most common cause of heel pain in adults, is a degenerative condition of the origin of the plantar fascia. "A" is incorrect. Tarsal tunnel syndrome is due to posterior tibial nerve entrapment and presents with diffuse pain at the medial ankle and arch of the foot. Paresthesias and dysesthesias often occur as well. "B," Achilles tendon rupture, is incorrect because the pain should be sudden, stabbing, and located in the calf (not the plantar aspect of the heel). "C" is also incorrect. Charcot foot does occur in diabetics, but it is actually the result of neuropathy and so generally does not present with pain. Instead, Charcot foot presents as an inflammatory condition (e.g., warmth, erythema, and edema) and progresses to joint instability and severe foot deformities. Finally, "E" is incorrect because plantar fascia rupture should have a sudden onset and is often related to trauma.

Spondylolysis commonly occurs in which part of the spine? A Cervical spine lateral processes. B Thoracic spine pars interarticularis. C Thoracic spine lateral processes. D Lumbar spine pars interarticularis.

The correct answer is "D." Spondylolysis is characterized by pars interarticularis stress fractures and most commonly occurs in the lumbar region.

Upon physical examination, you note the vital signs are normal. Straight leg raise (SLR) testing on the right leg at 55 degrees reproduces the patient's pain in the lower back and a painful "tightness" in the posterior thigh. He complains of the same discomfort on the left at 30 degrees. Based on these findings, which of the following statements is true? A This is a positive SLR test bilaterally and is specific for disk herniation. B This is a positive SLR test on the left and is specific for disk herniation. C This is a positive SLR test on the right and is specific for disk herniation. D This is a negative SLR test bilaterally.

The correct answer is "D." The SLR test can be performed in several ways, which are listed here. Seated active: with the patient seated on the examination table, the patient dorsiflexes the foot and extends the knee. Seated passive: with the patient seated on the examination table, the examiner passively extends the knee, and radicular symptoms will be exacerbated with passive ankle dorsiflexion. Lying passive: with the patient in a supine position, the examiner holds the knee in full extension and passively flexes the hip, and radicular symptoms will be exacerbated with passive ankle dorsiflexion. In all cases, the test is positive when radicular symptoms occur (e.g., pain and paresthesias down the leg below the level of the knee—not back or thigh pain from muscle stretching) between 25 and 75 degrees of hip flexion while lying or with knee extension while seated. The symptoms will be exacerbated with active or passive ankle dorsiflexion. However, the SLR is neither sensitive nor specific for disk disease. "Crossover" pain with radicular symptoms in the leg not lifted is very specific for disk disease but is not very sensitive.

A 45-year-old female with a history of rheumatoid arthritis, on chronic low-dose prednisone, presents to your clinic with 2 days of right knee pain. The patient reports that her knee has been swollen and painful to touch, and she now is having difficulty bearing weight due to the pain. She has had previous knee pain, but nothing this severe. She denies any trauma, fevers, chills, knee surgery, illegal drug use, or risky sexual behavior. On examination, she is well appearing, afebrile, and has a moderate right knee effusion with limited ROM. There is no overlying erythema, but the knee feels warm to touch. Which of the following diagnostics is the most valuable to rule in or rule out the diagnosis with the highest potential morbidity? A Plain films of the affected knee. B WBC count. C ESR. D Arthrocentesis. E MRI.

The correct answer is "D." The most concerning diagnosis with the highest potential morbidity in this patient is septic arthritis. Her history of rheumatoid arthritis as well as long-term steroid use put her at high risk. In a patient in whom you are concerned about septic arthritis, the most important piece of diagnostic data that you can obtain comes from synovial fluid analysis. While plain radiographs, a WBC count, an ESR, and CRP may be obtained (your friendly neighborhood orthopedic surgeon will surely want to know them), they are neither sensitive nor specific enough to rule in or rule out septic arthritis in a high-risk patient.

A 28-year-old male presents to your clinic for evaluation of lower-back pain (LBP). Yesterday morning he first noticed the discomfort, manifesting as stiffness and soreness in the lower back. The day before had been spent running a floor polisher. He describes his pain as sharp in nature and 8/10 in intensity. He denies radiation of the pain, sensory changes, and constitutional symptoms. He is concerned this may be an injury to a disk and that he may be permanently disabled due to his extreme pain. Which of the following signs or symptoms would be "red flags" indicating the need for early imaging and/or referral? A Pain radiating down one or both legs into the posterior thigh. B Severe pain, prompting the patient to request narcotics. C Pain greater with active lumbar extension than with forward flexion. D New onset erectile dysfunction with back pain. E None of the above.

The correct answer is "D." The onset of erectile dysfunction is suggestive of neurologic involvement and warrants further investigation. None of the other options are suggestive of significant disease requiring immediate intervention ("A" certainly could represent disk disease; however, this does not require immediate intervention). Of note, spontaneous erections without sexual stimulation can also be a sign of neurologic involvement.

Which of the following muscles is NOT a part of the rotator cuff? A Supraspinatus. B Infraspinatus. C Subscapularis. D Teres major. E Teres minor.

The correct answer is "D." The rotator cuff consists of the other four muscles listed and functions to rotate the arm and stabilize the humeral head.

A 27-year-old male presents to your clinic following an inversion-type injury to the foot and ankle. He cannot bear weight on the foot on presentation. He complains of pain and swelling laterally on the foot and ankle. There is some soft-tissue swelling but no obvious deformity. There is tenderness over the lateral ankle ligaments as well as over the base of the fifth metatarsal. AP and lateral films of the foot and ankle are obtained and reveal a nondisplaced fracture at the base (small portion at end) of the fifth metatarsal. What is the name of this fracture ? A Jones fracture. B Maisonneuve fracture. C Colles fracture. D Avulsion fracture of tuberosity, base fifth metatarsal

The correct answer is "D." This is an avulsion fracture of the base of the fifth metatarsal that may result from an inversion ankle injury. Classically, this has been thought to occur due to an attempt at dynamic stabilization by the peroneus brevis, causing an avulsion of the proximal portion of the metatarsal base. A Jones fracture is a transverse fracture of the proximal fifth metatarsal at the metaphyseal-diaphyseal junction and typically extends into the inter-metatarsal facet (see Fig. 12-8). Jones fractures have a high incidence of nonunion because they occur in a watershed area of blood supply. A maisonneuve fracture is a fracture of the proximal 1/3 of the fibula associated with an external rotation injury of the ankle. A colles fracture is a fracture of the distal radius (not involving the joint) with dorsal angulation of the distal fracture fragment.

Appropriate initial treatment for this patient's plantar fasciitis should include: A A heel cup or silicon pad. B Achilles stretching. C Ice or heat. D NSAIDs. E All of the above.

The correct answer is "E," all of the above. Other initial treatments to consider include night splints to maintain ankle dorsiflexion and stretch the Achilles tendon and plantar fascia. Physical therapy modalities such as ultrasound may be helpful as well. Advanced treatments, such as corticosteroid injections, may be considered after failure of initial conservative therapy. However, injections are not without risk, including plantar fascia rupture, loss of the fat pads of the feet causing significant pain and disability, and infection.

The appropriate treatment of De Quervain tendonitis includes which of the following? A Thumb spica splint. B NSAIDs. C Steroid injection. D Surgical decompression of the tendon. E All of the above.

The correct answer is "E." All of the above treatments have been used successfully for the treatment of De Quervain tendonitis. It is of note that some prefer steroid injection as the first-line therapy rather than NSAIDs. Surgery is obviously a last choice.

Phalen sign is positive (placing the wrists in a flexed position causes aching and numbness in the median nerve distribution). What is the best next step in the continuing evaluation and management of this patient? A Nerve conduction studies. B Radiograph of the wrist. C MRI of the cervical spine. D Orthopedic referral. E Initiation of treatment.

The correct answer is "E." In a clear-cut case of carpal tunnel syndrome, there is no need for further studies. If the diagnosis is in doubt, electromyogram and nerve conduction studies (EMG-NCS) may be of benefit. If the ROM in the wrist is limited, x-rays may be helpful. At this point in time, MRI and orthopedic referral are not likely to add much.

Repeat wrist radiographs including scaphoid views 2 weeks post injury indicate a nondisplaced fracture of the proximal pole of the scaphoid. You recommend which of the following treatment plans? A Wrist and thumb spica splint and physical therapy because good blood supply at the proximal pole allows fast healing. B Thumb spica cast for 6 weeks then repeat x-rays. C Short-arm cast excluding the thumb for 4 to 6 weeks. D Orthopedics referral for open reduction/internal fixation. E B or D.

The correct answer is "E." It is clear that a spica cast with the thumb included is important; whether a short- or long-arm cast is optimal is still a matter of debate. Open fixation is another option. Generally, an orthopedic surgeon should oversee treatment of scaphoid fractures since the complication rate is high. A proximal pole fracture has high risk for nonunion and avascular necrosis (90%). The blood supply to the scaphoid is through the distal pole, putting the proximal pole at high risk for complications. Evidence of healing may not be well visualized on plain films, and a CT or MRI may be needed to confirm the degree of healing. The closer the fracture line is to the proximal pole, the lower the threshold for orthopedic referral.

A 65-year-old male presents with left shoulder pain and weakness, which started 2 weeks ago after he put a new roof on his house. He does not recall a specific injury. The pain is worse with reaching for and lifting objects as well as with overhead activities. Nighttime pain is present. He describes himself active and healthy, and he only takes acetaminophen when needed for shoulder pain. You suspect that he may have rotator cuff tendinopathy. If this is the case, what do you expect to find on examination? A Tenderness to palpation of the greater tuberosity of the humerus. B Limited active ROM. C Normal passive ROM. D Shoulder shrug with attempted abduction (such as with a frozen shoulder). E Any of the above.

The correct answer is "E." Ok, so this might fit under the category of "trick question," but the shoulder examination can be normal in a patient with a rotator cuff tear or tendinopathy, or it can include any of the elements listed in "A" through "D." Notably, normal PASSIVE ROM ("C") does not rule out rotator cuff pathology.

A 58-year-old white woman presents complaining of low back pain for exactly 1 month after a fall. She has no history of fever, unexplained weight loss, diabetes, or cancer. Her past medical history is significant for mild persistent asthma and nicotine dependence. She had a hysterectomy for uterine fibroids at age 40. Which of the following characteristics should prompt further evaluation of her pain? A History of corticosteroid use B Caucasian ethnicity C Time course of back pain D History of cocaine use E Premenopausal age

The correct answer is A. Explanation: The patient's history is suspicious for a vertebral compression fracture that could be secondary to osteoporosis. Osteoporosis commonly develops in postmenopausal women, and can occur in patients who have received corticosteroid therapy. The time course of her pain is 4 weeks; 6 weeks and greater is a "red flag" symptom for further evaluation with radiographic imaging. While osteoporosis is more common in Caucasian women, it is not considered a "red flag." Postmenopausal women are at greater risk for osteoporosis rather than premenopausal women. Smoking and alcohol dependence are risk factors for osteoporosis; there is no evidence that cocaine use contributes to the development of osteoporosis.

A 22-year-old man presents with complaints of low back pain for 3 to 4 months and stiffness of the lumbar area, which worsen with inactivity. He reports difficulty in getting out of bed in the morning and may have to roll out sideways, trying not to flex or rotate the spine to minimize pain. A lumbosacral (LS) spine x-ray film would most likely show which of the following? A Degenerative joint disease with spur formation B Sacroiliitis with increased sclerosis around the sacroiliac joints C Vertebral body destruction with wedge fractures D Osteoporosis with compression fractures of L3-L5 E Diffuse osteonecrosis of the LS spine

The correct answer is B. . Explanation: A young man is not likely to have osteoporosis, osteoarthritis, or compression fractures. His morning stiffness, which worsens with rest, suggests an inflammatory arthritis, such as ankylosing spondylitis, which would include sacroiliitis with increased sclerosis around the sacroiliac joints.

A 67-year-old man with coronary artery disease, dyslipidemia, and eczema comes to you complaining of lower back pain and left leg pain. The pain is worse when he stands for long periods of time, but improves when he bends forward to push his shopping cart around the grocery store. He indicates that his feet "burn" and "ache" after walking different distances every day. His lower extremity neuromuscular examination is unremarkable. Which of the following is the most appropriate treatment for this patient? A Emergent spinal cord decompression B Epidural corticosteroid injection C Kyphoplasty D Bed rest for 4 days E Tramadol

The correct answer is B. . Explanation: The patient's history is classic for spinal stenosis. Often patients find relief by sitting or stooping. NSAIDs, physical therapy, and epidural corticosteroid injections are used to relieve pain. Surgical decompression is used in cauda equina syndrome, and kyphoplasty is useful in vertebral fractures. Bed rest is not used in the conservative treatment of back pain for any cause and has been shown to increase the duration of pain.

What is the most appropriate initial treatment? A Thumb spica splint. B Steroid injection. C NSAIDs and neutral position wrist splints. D Short-arm casts. E Bilateral figure-of-eight splints.

correct answer is "C." Conservative therapy should be initiated first, unless there is some compelling reason for more aggressive therapy (e.g., severe weakness of the hands and loss of function). Most patients respond well to NSAIDs and the use of neutral position splints. The traditional cock-up splints are not as effective as neutral position splints. The splints should be worn at night. The patient may wear the splints during the day, too, but should take them off for several hours per day to avoid disuse muscle atrophy. "A" is incorrect since a thumb spica is not needed. "B," steroid injection, might be tried if initial conservative measures fail. However, the benefit is generally limited to 1 month. "D" is just wrong—don't cast patients with carpal tunnel syndrome! "E" is a terrible idea as well since a bilateral figure-of-eight splint is basically a straight jacket.t

A 45-year-old man with no significant past medical history presents with severe back pain after lifting heavy boxes at work 2 days ago. Other than his back pain, his review of symptoms is negative. The pain radiates from his lower back down his right posterior thigh to his great toe when you perform both a straight leg raise and the contralateral leg raise tests. His strength, sensation, and reflexes are intact and symmetrical. Which of the following imaging studies should be done first in the evaluation of this patient? A Plain radiographs B MRI C Computed tomography (CT) scan D No imaging indicated E Bone scan

he correct answer is D. . Explanation: The patient has signs and symptoms of a herniated disc. There is no evidence that imaging within the first month has any morbidity benefit.

Not all heel pain is plantar fasciitis. Remember these others:

tarsal tunnel syndrome (described above), painful heel pad syndrome (pain located over the heel secondary to breakdown of fibrous septae from overuse and which may take up to 6 months to heal), and piezogenic papules (pain over medial/inferior aspect of heel, tender papules noted when patient standing).