MSK Bonus Questions

Hip

100

A 35-year-old male presents with complaints of hip pain that has been present for the past 6 months. He describes the pain as a deep ache in the groin area, which worsens with activities such as squatting, running, and prolonged sitting. The patient reports that the pain is aggravated by flexing and rotating his hip. On physical examination, the following tests are positive:

• FADIR (Flexion, Adduction, Internal Rotation) test
• FABER (Flexion, Abduction, External Rotation) test

What is the most likely diagnosis based on the patient’s history and test findings?

A) Hip labral tear
B) Hip osteoarthritis
C) Femoroacetabular impingement (FAI)
D) Iliopsoas tendinitis

C) Femoroacetabular impingement (FAI)

Explanation: The patient's presentation and positive FADIR and FABER tests are consistent with femoroacetabular impingement (FAI), a condition where abnormal contact occurs between the femoral head and the acetabulum during hip motion, typically due to structural abnormalities (such as a cam or pincer deformity). The FADIR test, which involves flexion, adduction, and internal rotation, is highly specific for detecting FAI and often reproduces the deep groin pain seen in this condition.

• A) Hip labral tear: Although a labral tear can cause similar symptoms (groin pain, clicking, or instability), FAI is a more likely diagnosis in this case given the structural cause of impingement and the positive FADIR test.
• B) Hip osteoarthritis: While hip osteoarthritis can cause groin pain, it typically presents with stiffness, decreased range of motion, and a history of chronic symptoms. This patient has a more acute onset of symptoms, and FAI is a more likely diagnosis given the test findings.
• D) Iliopsoas tendinitis: This condition causes pain in the hip and groin but is less likely to reproduce pain with internal rotation (as seen with FAI), and it would not typically present with a positive FABER test in the same way.

200

A 27-year-old female presents with persistent hip pain for the past 3 months. She describes the pain as a deep ache in the groin and hip area, which is aggravated by prolonged sitting, pivoting, and twisting motions. The patient reports that she is a competitive dancer and that the pain has worsened with rehearsals. On physical examination, the patient has limited hip range of motion, especially with internal rotation and flexion. The following tests are positive:

• FABER (Flexion, Abduction, External Rotation) test
• Hip Scour test
• FADIR (Flexion, Adduction, Internal Rotation) test

What is the most likely diagnosis based on the patient's history and test findings?

A) Hip osteoarthritis
B) Femoroacetabular impingement (FAI)
C) Hip labral tear
D) Iliopsoas tendinitis

C) Hip labral tear

Explanation: The patient’s presentation, combined with the positive FABER, Hip Scour, and FADIR tests, is most consistent with a hip labral tear. Hip labral tears are often caused by repetitive hip motion, which is common in athletes like dancers. The patient’s groin pain, limited hip internal rotation, and pain with pivoting motions are all indicative of a labral tear. The FABER test and FADIR test can both reproduce the deep hip pain associated with a labral tear. The Hip Scour test assesses for intra-articular hip pathology, and a positive result further suggests a labral tear or other intra-articular hip disorder.

• A) Hip osteoarthritis: Although hip osteoarthritis can cause groin pain, it typically presents with stiffness, decreased range of motion, and a more gradual onset of symptoms, particularly in older individuals. This patient’s age and the mechanism of injury point more toward a labral tear.
• B) Femoroacetabular impingement (FAI): While FAI can lead to labral tears, the history and test results suggest that the primary pathology in this case is a labral tear itself, rather than just impingement.
• D) Iliopsoas tendinitis: Iliopsoas tendinitis may cause hip pain but would not typically result in positive results for FABER, Hip Scour, or FADIR tests. It is also less likely to produce pain with internal rotation and flexion in the same way a labral tear does.

wrist/hand

100

A 38-year-old female presents to physical therapy with complaints of tingling and numbness in her right hand, specifically affecting her thumb, index, and middle fingers. She reports that the symptoms are worse at night and often wake her up. She also mentions that her symptoms worsen with prolonged use of her hands, particularly when typing on a keyboard. On examination, she has positive Phalen's test and Tinel's sign over the carpal tunnel. There is weakness in thumb opposition and atrophy of the thenar eminence.

What is the most likely diagnosis?

A) De Quervain's tenosynovitis
B) Carpal tunnel syndrome
C) Cervical radiculopathy
D) Thoracic outlet syndrome

Answer:

B) Carpal tunnel syndrome

Explanation: The patient's symptoms, including tingling and numbness in the thumb, index, and middle fingers, especially worsening at night and with repetitive hand use, along with a positive Phalen's test and Tinel's sign, are classic signs of carpal tunnel syndrome (CTS). CTS occurs due to compression of the median nerve as it passes through the carpal tunnel at the wrist, leading to sensory changes and motor weakness in the median nerve distribution (thumb, index, and middle fingers).

• A) De Quervain's tenosynovitis: This condition involves inflammation of the tendons of the abductor pollicis longus and extensor pollicis brevis. It typically causes pain on the lateral aspect of the wrist and pain with gripping or thumb movement, not the numbness or tingling associated with CTS.
• C) Cervical radiculopathy: While cervical radiculopathy can cause radiating pain and numbness in the upper extremity, it typically affects multiple nerve distributions (e.g., the C6 or C7 nerve roots) and is not specifically localized to the median nerve distribution as seen in CTS.
• D) Thoracic outlet syndrome: This condition involves compression of the neurovascular bundle (brachial plexus, subclavian artery, and vein) at the thoracic outlet. It causes numbness, tingling, and pain in the upper extremity, but it would not cause the specific sensory deficits and weakness in the thenar eminence typical of carpal tunnel syndrome.

200

A 55-year-old male presents with pain and stiffness in his right hand, particularly at the base of his thumb. He reports difficulty with gripping objects and turning door handles, and he experiences increased pain with activities that require thumb opposition, such as typing and holding a pen. On examination, there is tenderness over the first carpometacarpal joint (CMC), and a positive Grind test is noted. There is no swelling, but the patient demonstrates limited thumb motion and pain at the base of the thumb.

What is the most likely diagnosis?

A) Carpal tunnel syndrome
B) De Quervain's tenosynovitis
C) Osteoarthritis of the first CMC joint
D) Trigger finger

Answer:

C) Osteoarthritis of the first CMC joint

Explanation: The patient’s symptoms, including pain and stiffness at the base of the thumb, difficulty gripping, and pain with thumb opposition, along with tenderness over the first CMC joint and a positive Grind test, are consistent with osteoarthritis (OA) of the first carpometacarpal joint. OA of the first CMC joint is a common condition in older adults and often leads to pain and functional limitations in the thumb, particularly with pinch grip activities.

• A) Carpal tunnel syndrome: Carpal tunnel syndrome typically involves tingling, numbness, and pain in the thumb, index, and middle fingers due to median nerve compression. The patient’s symptoms of localized thumb pain at the CMC joint and lack of sensory changes are not consistent with CTS.
• B) De Quervain's tenosynovitis: This condition involves inflammation of the abductor pollicis longus and extensor pollicis brevis tendons. It typically causes pain and swelling over the radial styloid and pain with thumb extension or radial deviation, but it would not cause pain at the base of the thumb specifically as seen in this case.
• D) Trigger finger: Trigger finger causes snapping or locking of the finger due to flexor tendon inflammation and nodule formation. It is more common in the fingers, not at the base of the thumb, and would not explain the pain at the CMC joint or the positive Grind test.