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MSK exam

Terms in this set (92)

c. ankle
the most common site of sprain is the:

a. wrist
b. shoulder
c. ankle
d. knee
b. running on paved surfaces
risk factors for ankle sprain include all of the following except:

a. poor conditioning
b. running on paved surfaces
c. inappropriate footwear
d. lack of a warm-up period prior to exercising
c. moderate swelling, mild to moderate ecchymosis and moderate joint instability

grapefruit
Grade II ankle sprain is best described as:

a. minor swelling and minimal joint instability
b. moderate joint instability without swelling or ecchymosis
c. moderate swelling, mild to moderate ecchymosis and moderate joint instability
d. complete ankle instability, significant swelling and moderate to severe ecchymosis
d. complete ankle instability, significant swelling and moderate to severe ecchymosis

cunable to ambulate at least 4 steps
a Grade III ankle sprain is best described as:

a. minor swelling and minimal joint instability
b. moderate joint instability without swelling or ecchymosis
c. moderate swelling, mild to moderate ecchymosis and moderate joint instability
d. complete ankle instability, significant swelling and moderate to severe ecchymosis
d. many months
pts with a Grade III ankle sprain should be advised that full recovery is likely to take:
a. few days
b. 2 to 3 weeks
c. 4 to 6 weeks
d. many months
d. local corticosteroid injection
which of the following is usually not part of txment of a sprain?
a. immobilization
b. applying ice to the area
c. joint rest
d. local corticosteroid injection
a. 24 hrs
for a Grade I ankle sprain, weight-bearing should be avoided for at least:
a. 24 hrs
b. 72 hrs
c. 1 week
d. until full ROM is restored
c. grade III
a short leg cast is often needed for what type of ankle sprain?
a. grade I
b. grade II
c. grade III
d. grade IV
Cauda Equina Syndrome: S/S
- Saddle anesthesia
- bladder incontinence or retention
- fecal incontinence
- bladder leg numbness and weakness
Cauda Equina Syndrome: Cause
Pressure (usually d/t bulging disc) on a sacral nerve root results in inflammatory and ischemic changes to the nerves
Genu recurvatum
hyperextension or backward curvature of the knees
What is the likely cause of knee pain:
Age 50 and accompanied by reports of focal tenderness, "creaking" sensations, and bony deformity.

Mild stiffness (<30 minutes) on first arising in the morning and after a long period of sitting that initially improves on moving about, but it worsens with prolonged activity.

Accompanied by: Knee buckling when climbing stairs.
osteoarthritis
Osteoarthritis Tx:
Diet and exercise
PT
NSAIDS
common source of lateral knee pain in competitive runners
Iliotibial Band Syndrome

Assess by:
palpable tenderness along the band, worsened by stretching it (pushing the leg down and forward while in the hip-up lateral decubitus position)
Iliotibial Band Syndrome Tx:
Ice and anti-inflammatory agents are given as first aide.
activity modification, massage, and stretching and strengthening of the affected limb.
Referral to a physical therapist experienced in treating the condition is warranted.
Persistent swelling and pain on ambulation after 3 days may respond to a local corticosteroid injection.
Jogger presents with bilateral patellar, peripatellar, or retropatellar aching worsened by standing up, climbing stairs, or any other form of bent-knee strain, and the knee is stiff after inactivity but without locking
Chondromalacia Patellae

(Patellofemoral Pain Syndrome)
Assessment of Patellofemoral Pain Syndrome
pain reproduced by reproduced by applying pressure against the patella with the knee actively extended.

Palpable grating can be elicited at the patellofemoral joint with flexion and extension of the knee.

Radiographic findings are normal until late stages, when the posterior surface of the patella becomes irregular and marginal osteophytes develop.
Treatment for Chondromalacia Patellae/Patellofemoral Pain Syndrome
Symptomatic measures include acetaminophen or NSAIDs, ice, knee rest, and subsequent avoidance of knee overuse. Quadriceps-strengthening exercises are helpful. Surgery is a consideration in incapacitating cases.
validated screening protocol for knee fracture
The Ottawa Decision Rule

very high test sensitivity for knee fracture (nearly 100%) but a very low specificity (25%)
List the 4 elements of the Ottawa Decision Rule.

How many elements does a patient need to be positive?
Age greater than 55 years
Isolated patellar tenderness or tenderness at the head of the fibula
Inability to bear weight for four steps
Inability to flex the knee more than 90 degrees

1 or more
inflammation and swelling localized to the popliteal fossa,
a ruptured Baker cyst or popliteal vein thrombophlebitis
finding of an angry, red, tensely swollen, very warm, very tender bursa is suggestive of:

how is it treated?

.
septic bursitis

hospitalization for intravenous antibiotic therapy
Finkelstein's test
- De Quervain's tenosynovitis (caused by inflammation of the tendon and its sheath, located at the base of the thumb)
- + w/ pain and tenderness on the thumb side w/ ulnar deviation
McMurray Test
- Injury to medial meniscus
- + pain and a click upon manipulation of the knee
Pop versus lock r/t MS injury
Pop= usually ACL
Lock= meniscus
Lachman's sign
- Injury to ACL of the knee
- + knee joint laxity
- more sensitive than the anterior drawer test
Imaging of the knee:
cartilaginous or ligamentous problem (i.e., soft tissue injury or internal derangement) is an indication for MRI, as is concern about osteonecrosis.
Plain films are indicated for suspected fracture and may add to the assessment of degenerative disease.
Computed tomography (CT) provides additional sensitivity for the detection of subtle fractures that might be missed by plain films.
X-ray shows osteophytes, joint space narrowing, cystic changes in subchondral bone, and bony sclerosis
Osteoarthritis
Valgus stress test of the knee
- A test for the medial collateral ligament (MCL)- G for go feet
Varus stress test of the knee
- A test for the lateral collateral ligament (LCL)- R for return feet
Ankylosing spondylitis: More common in...
- average age of onset: early 20s
- more common in males
Ankylosing spondylitis: 1st line tx
NSAIDs
Ottawa rules of the ankle
- Grade 1 sprain: mild sprain, able to bear weight and ambulate
- Grade 2: moderate sprain, partial tear of ligament, presence of ecchymoses, mod swelling, pain, joint tender, ambulation and weight bearing painful, mild-mod joint instability. consider xray and refer
- Grade 3: unable to bear weight immediately after injury, unable to ambulate at least 4 steps, tenderness over the posterior edge of the lateral or medial malleolus. Referral to ED for fracture, ankle seris
a. squat
to confirm the results of a McMurray test, you ask the pt to:
a. squat
b. walk
c. flex the knee
d. rotate the ankle
a. twisting of the knee
the most common type of injury causing a sport-related meniscal tear involves:
a. twisting of the knee
b. hyperextension of the knee
c. repetitive hard impact on the knee (i.e. running on hard surface)
d. an unknown origin in most cases
c. inability to kneel
which of the following best describes the presentation of a pt with complete medial meniscus tear?
a. joint effusion
b. heat over the knee
c. inability to kneel
d. loss of smooth joint movement
Knee pain with a delay in the onset of swelling, difficulty walking stairs and squatting and with "Locking" of the knee is likely what type of tear?
meniscus
Difficulty bearing weight for more than a few steps, inability to flex the knee and focal tenderness:
r/o fracture
b. quadriceps-strengthening exercises
to help prevent meniscal tear, you advise:
a. limiting participation in sports
b. quadriceps-strengthening exercises
c. using a knee brace
d. applying ice to the knee before exercise
d. joint aspiration of the affected knee
initial txment for meniscal tear includes all of the following except:
a. NSAID use
b. applying ice to the affected area
c. elevation of the affected limb
d. joint aspiration of the affected knee
Activity for Knee Sprain and Tears of the ACL and Meniscus
acute pain -restriction of weight-bearing activities and the use of crutches. A knee brace is applied to provide support and prevent further injury by limiting the range of motion.

Only absolutely necessary walking is allowed, and kneeling, squatting, and stair climbing are forbidden.

One starts with isometric quadriceps and hamstring exercises
d. 90%
approximately what percent of pts experiencing low back pain will have the sxs resolve within 1 month without specific tx?
a. 33%
b. 57%
c. 78%
d. 90%
b. carpal tunnel syndrome
risk factors for the development of low back pain include all of the following except:
a. older age
b. carpal tunnel syndrome
c. scoliosis
d. spinal stenosis
c. muscle or ligamentous strain
most episodes of low back pain are caused by:
a. an acute precipitating event
b. disk herniation
c. muscle or ligamentous strain
d. nerve impingement
Musculoligamentous Strain
a specific episode of bending, twisting, or lifting.
associated with a feeling of something giving way in the lower back. The onset of pain is immediate. Pain radiates across the low back, often to the buttock and upper thigh posteriorly.
c. L5 and S1
with the straight-leg-raising test, the NP is evaluating tension on which of the following nerve roots?
a. L1 and L2
b. L3 and L4
c. L5 and S1
d. S2 and S3
Spondylolisthesis
forward subluxation of a vertebral body.


results from degenerative changes and arthritis of the facet joints, usually at L4 to L5 or L5 to S1,

About 70% of patients have chronic low back pain; sciatica is infrequent.
The pain is caused by strain imposed on the ligaments and intervertebral joints.
b. stiffness, spasm, and reduced ROM
a pt with a lumbosacral strain will typically report:
a. numbness in the extremities
b. stiffness, spasm, and reduced ROM
c. "electric" sensation running down one or both legs
d. pain at its worst when in sitting position
b. back-strengthening exercises can cause mild muscle soreness
you see a 54 y/o man c/o low back pain and is dx with acute lumbosacral strain. which of the following is the best advice to give about exercising?
a. you should not exercise until you are free of pain
b. back-strengthening exercises can cause mild muscle soreness
c. electric-like pain in response to exercise is to be expected
d. conditioning exercises should be started immediately
b. age < 50 years
risk factors for lumbar radiculopathy include all of the following except:
a. male gender
b. age < 50 years
c. overweight
d. cigarette smoking
c. shooting pain that starts at the hip and radiates to the foot
a pt with sciatica will typically report:
a. loss of bladder control
b. stiffness, spasm, and reduced ROM
c. shooting pain that starts at the hip and radiates to the foot
d. pain at its worst when lying down
a. loss of deep tendon reflexes
early neurological changes in pts with lumbar radiculopathy include:
a. loss of deep tendon reflexes
b. poor two-point discrimination
c. reduced muscle strength
d. footdrop
d. soft tissue abnormality
common causes of sciatica include all of the following except:
a. herniated disk
b. spinal stenosis
c. compression fx
d. soft tissue abnormality
a. cauda equina syndrome
you see a 48 y/o woman who reports low back pain. during the eval, she mentions new-onset loss of bowel and bladder control. this most likely indicates:
a. cauda equina syndrome
b. muscular spasm
c. vertebral fx
d. sciatic nerve entrapment
c. L5
loss of posterior tibial reflex often indicates a lesion at:
a. L3
b. L4
c. L5
d. S1
c. L5 to S1
loss of Achilles tendon reflex most likely indicates a lesion at:
a. L1 to L2
b. L3 to L4
c. L5 to S1
d. S2 to S3
a. Spurling
which test is demonstrated when the examiner applies pressure to the top of the head with the neck bending forward, producing pain or numbness inthe upper extremities?
a. Spurling
b. McMurray
c. Lachman
d. Newman
c. MRI
which of the following tests yields the greatest amt of clinical info in a pt with acute lumbar radiculopathy?
a. lumbosacral radiograph series
b. ESR measurement
c. MRI
d. bone scan
d. C6 to C7
the most common site for cervical radiculopathy is:
a. C3 to C4
b. C4 to C5
c. C5 to C6
d. C6 to C7
c. L4 to L5 and L5 to S1
the most common site for lumbar disk herniation are:
a. L1 to Ls and L2 to L3
b. L2 to L3 and L4 to L5
c. L4 to L5 and L5 to S1
d. L5 to S1 and S1 to S2
d. bed rest for at least 5 days
you see a 37 y/o man c/o low back pain consisting of stiffness and spasms but without any sign of neurologic involvement. you recommend all of the following interventions except:
a. application of cold packs for 20 mins 3-4 x a day
b. use of NSAIDs or acetaminophen for pain control
c. initiation of aerobic and toning exercises
d. bed rest for at least 5 days
b. joint overuse/repeated trauma
the most common cause of acute bursitis is:
a. inactivity
b. joint overuse/repeated trauma
c. fibromyalgia
d. bacterial infection
d. nonsteroidal anti-inflammatory drugs
first-line tx options for bursitis usually include:
a. corticosteroid bursal injection
b. heat to area
c. weight-bearing exercises
d. nonsteroidal anti-inflammatory drugs
a. swelling and redness over the affected area
pts with bursitis typically present with:
a. swelling and redness over the affected area
b. limited elbow range of motion
c. nerve impingement
d. destruction of the joint space
c. localized tenderness under the superomedial angle of the scapula
pts with subscapular bursitis typically present with:
a. limited shoulder ROM
b. heat over affected area
c. localized tenderness under the superomedial angle of the scapula
d. cervical nerve root irritation
a. increased pain from resisted hip abduction
pts with gluteus medius or deep trochanteric bursitis typically present with
a. increased pain from resisted hip abduction
b. limited hip ROM
c. sciatic nerve pain
d. heat over the affected area
a. bursal aspiration
first-line tx for prepatellar bursitis should include:
a. bursal aspiration
b. intrabursal corticosteroid injection
c. acetaminophen
d. knee splinting
Ankle Sprain
ligamentous injury

caused by an abnormal motion, a sudden change in directions or a misstep on an uneven surface
Sprain Management
RICE, NSAIDs, crutch, walking, x-ray to r/o fx
Muscle sprain and strain
-localized tenderness, pain, ecchymosis, swelling

Grade I
-stretching tearing of muscle fibers, movement strong and painful

Grade II
-tearing of muscle fibers with hemorrhage, mild loss of muscle strength, painful

Grade III
-rupture of muscle, damage to fascia, weak movement, pain
Muscle sprain and strain Prevention
proper stretching and warm-up exercises
Stress fracture
fracture resulting from indirect trauma to a bone that results in a fine line fracture
Subjective
Stress fx
insidious onset of pain worsened by weight bearing, mild erythema, swelling, and point tenderness
Objective
Stress fx
x-ray changes often not apparent for 3-4weeks, bone scan may be useful
Management
Stress fx
limit physical activity, NSAIDs and follow up in 4-6 weeks
Subjective
Bursitis
history of sudden or gradual pain with repeat activity
Objective
Bursitis
pinpoint tenderness to affected area
Subjective/objective data
Gout
sudden report of red, warm, edematous joint with restricted ROM, Exquisitely tender, usually first metatarsal phalanx (big toe); although may occur in other joints

tophi (urate crystals) in soft tissues, joint swelling, rash, skin desquamation may occur

Serum uric acid >7mg/dl
increased Sed rate
Gout Management
Non-pharmacological:
low purine diet, exercise, decrease ETOH, intake, increase fluid intake, wt loss

pharmacological:
NSAIDs, colchicine 0.6mg ever 1-2 hours to a max dose, corticosteroid injections

Prevention:
allopurinal 100-150mgg daily or BID
uloric 40-80mg dialy
De Quervain Tenosynovitis
chronic stenosing tenosynovitis (first dorsal compartment)
(painful condition affecting the tendons on the thumb side of the wrist)
- often encountered in occupations that require repetitive wrist and thumb movements

Picking up children
De Quervain Tenosynovitis
Sub/Obj
insidious onset of burning, aching pain over the radial aspect of the wrist and base of the thumb
-common in nursing mothers due to hold infant
-pain worse with grasping
-positive Finklestien test (fist hand with thumb tucked in--as pt makes a tight fist the pain gets worse)
De Quervain Tenosynovitis
Management
splinting, NSAIDs, rest affected joint, moist heat, injection
Carpal tunnel
sub/obj
-decreased grip strenght
-tinel's sign: tapping the median nerve with the index finger causes pain and tingling
-phalen's sign- patient presses the dorsum of hands together in opposition with fingers pointing downward to elicit tingling
Hip pain
obj/sub
-determine source of pain
-common sources of pain--bursitis, avascular necrosism fx, OA, infection, neoplasms
Knee fx
fx can occur at any age

Sub/obj: trauma, steroid use, sudden swelling, pain, worse with weight bearing, effusion may be present, decreased ROM

Management: immobilization, non-weight bearing, referral to ortho for further evaluation
Knee Pain differentials
medial and lateral collateral ligament injuries-- contact sports

MCL-sudden valgus stress to knee, may have heard a pop, medial knee pain, localized swelling, effusion

LCL-direct blow to medial aspect of knee (varus stress), tenderness over the LCL, joint laxity, small effusion

ACL-pain and almost immediate swelling after sudden cutting, deceleration, or jumping; weight bearing is difficult due to feelings of instability; effusion may be present; pain and tenderness in the poserolateral joint--check for positive anterior drawer and lachman's test

Meniscus tear- pain especially with twisting of the knee, knee is locking or giving away, harder to descend stairs than climbing, knee swelling, tenderness over tibial medial or lateral joint line--positive McMurray test
anterior drawer test--test the ACL
The patient lies supine on with their hips flexed to 45 degrees, his/her knees flexed to 90 degrees and feet flat. The examiner sits on the toes of the tested extremity to help stabilize it. The examiner grasps the proximal lower leg, just below the tibial plateau or tibiofemoral joint line, and attempts to translate the lower leg anteriorly. The test is considered positive if there is a lack of end feel or excessive anterior translation relative to the contralateral side
valgus stress test--tests the MCL
posterior drawer test--tests the PCL
patient lying flat and relaxed, the examiner bends the knee to a right angle. The examiner then places his fingers on the knee joint, and attempts to shift the tibia backwards. As the examiner is placing pressure on the top of the shin bone, he or she can feel the resistance that comes from the PCL. In patients with an injured PCL, the examiner may note excessive translation (movement) of the tibia backwards, and may not feel the normal resistance of the ligament.

The test places stress on the PCL. Both the amount of movement (shifting) of the shin bone, as well as the feel of the endpoint of movement (how solid the ligament feels), offer information about the PCL.

Knees with a damaged PCL may demonstrate more movement and a less firm endpoint during a posterior drawer test.
varus stress test--test the LCL
lachman test--tests the ACL
more accurate than anterior drawer
McMurray--tests for meniscus injury
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