Anatomy
With knee extension the ACL becomes what?
A. Loose
B. Tight
C. Neither
D. Both
B. Tight
the ACL runs anteroinferomedially to insert onto the tibial. It tenses with knee extension and limits anterior translation of the tibia.
Anterior shoulder dislocations typically occur while the patient's arm is in which position?
A. Abducted, externally rotated
B. Adducted, externally rotated
C. Abducted, internally rotated
D. Adducted, internally rotated
A. Abducted, externally rotated
Tip: the throwing position or Apprehension test position
While performing a knee exam on a patient you flex the hip and knee, externally rotate the ankle, and apply a valgus force to the knee while extending the knee. What structure are you assessing?
A. Medial Meniscus
B. Lateral Meniscus
C. MCL
D. LCL
A. Medial Meniscus
Tip: heel moves toward the meniscus being tested.
A 65 year-old female presents to your clinic with complaints of 4 months of left knee pain. She has tried physical therapy and acetaminophen to no benefit. A corticosteroid injection into the knee provided 3 weeks of relief. Left knee x-rays demonstrate severe medial compartment narrowing, reactive sclerosis, osteophytic changes, and subchondral cysts. What is the next most appropriate step?
A. Knee replacement
B. PRP injection
C. Reassurance
D. Knee MRI
A. Knee replacement
This patient has failed conservative and interventional measures for her severe knee OA, and would be a good candidate for total knee replacement. Regenerative injections such as PRP are most useful before arthritis becomes severe, and likely would not provide significant lasting benefit in her case. Knee MRI would likely provide further information on how bad the knee OA is, and possibly diagnose a meniscal tear, all of which would only further support our conclusion that she would likely benefit from a knee replacement.
A patient presents with complete tear of the acromioclavicular (AC) ligament and partial tear of the coracoclavicular (CC) ligament. What is the Rockwood Classification and recommended treatment?
A. 3 ; surgery
B. 3 ; rehab
C. 2 ; surgery
D. 2 ; rehab
D. Rockwood Grade 2 - Rehab
Grade 1: AC sprain, CC intact
Grade 2: AC torn, CC sprain
Grade 3: AC torn, CC torn (<100% upward displacement of clavicle)
Grade 4: AC/CC torn. Posterior displacement of clavicle
Grade 5: AC/CC torn. >100% upward displacement of clavicle
Grade 6: AC/CC torn. Inferior displacement of clavicle.
The lateral collateral ligament (LCL) of the knee originates on the lateral femoral condyle and inserts on which of the following structures?
A. Fibular head
B. Gerdy's tubercle of the tibia
C. Pes anserine of the tibia
D. Fibular shaft
A. Fibular head
LCL
- origin: lateral femoral condyle
- insertion: fibular head
Clavicle fractures most commonly occur at which portion of the clavicle?
A. There is no difference in rates
B. Distal 1/3
C. Middle 1/3
D. Proximal 1/3
C. Middle 1/3
Just something you have to know
The process of lying the patient supine and abducting and externally rotating their shoulder while providing an anterior-directed force onto the humerus is intended to diagnose which of the following diseases?
A. Posterior shoulder instability
B. GH joint arthritis
C. Anterior shoulder instability
D. AC joint disease
C. Anterior shoulder instability
This question describes the anterior apprehension test, which is a test for anterior shoulder instability. If the test is positive, the patient will experience sudden apprehension that their shoulder is about to dislocate. The AC joint is assessed using the Scarf test. GHJ arthritis shows generalized ROM loss and pain with crepitus. Posterior shoulder instability is diagnosed using the Kim or Jerk tests
A patient develops gradual onset knee pain due to a redundant fold of synovial tissue in the knee that has become thickened and inflamed, leading to knee pain with locking and catching of the knee. The patient has trialed PT and steroid injections with minimal relief. What is a reasonable next step?
A. Surgery
B. Knee Bracing
C. Prolotherapy Injection
D. Pain Management referral
A. Surgery
(plicectomy) - surgical removal of the inflammed or thickened synovial plica. Typically done arthroscopically.
A 21 year old female long distance runner develops gradual onset bilateral medial shin pain. She is currently training for a marathon. She denies trauma. On exam, squeezing the medial and lateral tibial together reproduces her medial shin pain along the tibia. What is the next best step?
A. Physical therapy
B. Reduce mileage
C. Obtain XR
D. Reassurance
C. Obtain XR
This patient most likely presents with bilateral medial tibial stress syndrome (shin splints). For shin splints relative rest, shoe orthotics, gait correction and PT are reasonable treatments, however a tibial stress fracture would present similarly and must be ruled out first. If not found a stress fracture can progress into a larger fracture.
Regarding shoulder ABduction, what are the number of degrees attributed to the scapulothoracic joint versus the glenohumeral joint? (scapulothoracic:glenohumeral)
A. 130:50
B. 60:120
C. 50:130
D. 90:90
B. 60:120
Total Abduction ROM = 180. 60 is from the scapulothoracic joint plus 120 from the GH joint. (1:2 ratio). Essentially the key is the scapula has to move to get full range of motion, if not can lead to shoulder impingement
56 year old female presents as a new consult with shoulder pain for 6 months. Initial shoulder XRs were negative. She has tried PT without benefit. Provocative maneuvers: Positive O'briens ; negative empty can, neers, and hawkins. No weakness or neurologic signs.
What is the next best step?
A. Repeat shoulder XRs
B. Shoulder CT scan
C. Shoulder MRI arthrogram
D. Shoulder MRI
C. Shoulder MR arthrogram
Positive O'brien can be suspicious for a labral tear. MRI arthrogram would better evaluate the labrum than a regular MRI.
You are working a football game with Dr. Penta when 16 year old football player tries to juke his defender. He plants his right foot on the ground and attempts to juke to the left when he experiences sudden-onset right knee pain and swelling. He is unable to walk off the field. On field exam: immediate swelling, diffuse TTP, athlete does not want to attempt AROM, there is pain with PROM, and negative anterior drawer, lachman, varus/valgus, and posterior drawer tests. What is the most likely diagnosis?
A. MCL tear
B. PCL tear
C. ACL tear
D. Quadriceps tendon rupture
C. ACL tear
An athlete attempting a noncontact cutting maneuver with sudden onset knee pain and swelling is classic for an ACL tear. Lachman and anterior drawer are commonly falsely negative due to quadricep muscle spasms.
A 29 year old male presents with bilateral anterior knee pain. Pain is worse with descending stairs. Exam is positive for positive patellar grind test. XR reveals a shallow Medial patellofemoral contour. What should be detailed in the therapy order?
A. IT band stretching; vastus lateralis strengthening
B. IT band strengthening; vastus medialis stretching
C. Vastus medialis strengthening; vastus lateralis stretching
D. Vastus medialis stretching; vastus lateralis strengthening
D. Vasuts medialis stretching; Vastus lateralis strengthening
PFPS most commonly has a laterally tracking patella so typically the correct answer would be medialis strengthening and lateralis stretching.
In this specific case there is XR evidence of a shallower medial patellofemoral contour so could be more medially deviating. Kind of a trick question but good to be aware of.
A 26 year old male falls onto his outstretched hand and sustains a mid-shaft humeral fracture. If you were to find weakness in the limb, which muscle is most likely to be weak?
A. Flexor carpi radialis
B. Extensor indicis proprius
C. Triceps
D. Flexor carpi ulnaris
B. Extensor indicis proprius
Midshaft humeral fractures risk injury to the radial nerve in the spiral groove. Radial innervated muscles include both the triceps and extensor indicis proprius (PIN) but the triceps is innervated prior to the radial groove.
What of the following muscles is NOT a knee internal rotator?
A. Gracillis
B. Sartorius
C. Semitendinosus
D. Biceps femoris
D. Biceps femoris
The biceps femoris is a knee external rotator. The remaining three muscles are part of the Say Grace before Tea mnemonic (muscles that attach to the pes anserine, located on the medial tibia), rendering them all knee internal rotators.
A 36 year-old male suffers a fall onto his outstretched hand. He has immediate shoulder disfigurement which is corrected by a bystander. In the ED, xrays of the shoulder reveal a Hill-Sachs lesion. This lesion can be described as which of the following?
A. Kim lesion
B. Proximal humeral displaced fracture
C. Anterior labral tear
D. Posterolateral humeral head compression fracture
D. Posterolateral humeral head compression fracture
Patient likely had an anterior shoulder dislocation. A hill-sachs lesion is a posterolateral humeral head compression fracture while a Bankart lesion is an anterior labral injury.
You are examining a patient with right knee pain. You have the patient in the seated position (hip and knee flexed). You passively flex the knee beyond 90* and then let it passively drop back into extension. What is the purpose of this test?
A. Diagnose MCL tears
B. Diagnose LCL tears
C. Diagnose meniscal tears
D. Apprehension test for instability
C. Diagnose meniscal tears
*note some sources say to have the patient supine
Bounce Home test - positive test is an inability to fully extend via gravity alone, due to mechanical blockage in the knee
Bounce Home - Sens: 47% ; Spec 67%
McMurrays - Sens 70% ; Spec 71%
Thessalys - Sens 64-66% ; Spec 39-53%
23 year old division 1 basketball player presents with 1 year gradual onset right knee pain. He has trialed oral/topical NSAIDs, 2 rounds of PT, is compliant with HEP, and tried relative rest without improvement in pain. Tenderness localized to the patellar tendon. XRs and MRI are unremarkable. Clinic ultrasound demonstrates a thickened, hypoechoic, wavy appearance of the right patellar tendon with punctate red and blue dots within the tendon on color doppler. He wants to play in the upcoming championship game. What is the most appropriate next step?
A. Recommend patient not play the rest of the season for rest
B. Ultrasound-guided intra-articular steroid injection
C. Ultrasound-guided patellar tendon scraping
D. Orthopedics consult
C. Ultrasound-guided patellar tendon scraping
Ultrasound findings are classic for patellar tendonosis (chronic degenerative changes from overuse). Can lead to neovascularization/neoinnervation of nerves and vessels from Hoffas fat pad into the patellar tendon. Tendon scraping slides a kneed between the fat pad and tendon, cutting these nerves/vessels. If done correctly patients can weight bear and return to activity immediately.
A 40 year old male is water skiing (recreational) when he falls and develops sudden onset left knee pain. On exam, valgus stress testing is positive for laxity and reproduction of knee pain. MRI demonstrates a Grade 3 MCL tear without evidence of avulsion fracture or other ligamentous injury. Neurologic exam is normal. What is the next best step?
A. Knee brace
B. Physical therapy
C. Surgical MCL repair
D. Prolotherapy injection into the MCL
A. Knee bracing
These questions are always a little subjective to the patients circumstances but in general most MCL tears can be treated non-operatively. Start with a knee brace to protect the MCL and facilitate healing, followed by gentle ROM and PT. Surgery is generally reserved for multiple ligament injuries, avulsion fractures, etc. Prolotherapy is generally not appropriate for high grade tears.
The PCL (posterior cruciate ligament of the knee) originates on the femur, and its fibers run in which of the following directions on its way towards the tibia?
A. Postero-infero-laterally
B. Antero-supero-medially
C. Antero-infero-medially
D. Postero-infero-medially
A. Postero-infero-laterally
The PCL runs posteroinferolaterally from the femur toward the tibia. It tenses with knee flexion. It limits translation of the tibia in the posterior direction.
A 57 year-old female presents to your clinic in follow-up for right knee pain. She has tried and failed physical therapy and NSAIDs. Diagnostic ultrasound scan reveals a hypoechoic mass in the posterior knee, located between the semimembranosus and medial head of the gastrocnemius. What is the most appropriate next step?
A. Bracing
B. Color doppler ultrasound
C. Aspiration and steroid injection
D. Surgery
B. Color doppler ultrasound
A refractory Baker cyst is described here. Aspiration with steroid injection under ultrasound guidance is an appropriate intervention. However, this should only be performed after color doppler over the hypoechoic mass is demonstrated to be negative. Positive color doppler flow over the mass would indicate that this is not a cyst, but instead a vascular malformation such as an aneurysm (e.g. popliteal artery aneurysm). Aspiration and steroid injection would not be appropriate for an aneurysm.
A 59 year-old female presents with left knee pain of gradual onset without a history of trauma. She points to the medial knee in a vague, large circle when you ask where the pain is. On exam strength, sensation, and reflexes are intact. Valgus stress testing is negative. Varus stress testing causes medial knee pain. There is pain with resisted hamstring strength. Palpation of the medial tibia below the knee elicits concordant pain. The left medial tibia appears swollen compared to the right. What is the most likely diagnosis?
A. Pes anserine bursitis
B. Hamstring tendonitis
C. LCL sprain
D. Medial meniscus tear
A. Pes anserine bursitis
This patient depicts classic findings of pes anserine bursitis. The pes anserine consists of sartorius, gracilis, and semitendinosus which insert onto the medial tibia below the knee. There is also a bursa here which can become inflamed and distended.
A 32 year old male athlete suffers a medial meniscus tear and notes frequent catching and giving out of the knee. MRI reveals a large tear of the inner 1/3 of the meniscus. What is the most appropriate treatment option?
A. Physical therapy
B. Knee Bracing
C. Surgical resection of the meniscus
D. Surgical repair of the meniscus
C. Surgical resection of the meniscus
Athlete with more frequent mechanical symptoms may warrant earlier consideration for surgery.
Tears of the inner 2/3 of the mensicus are appropriate for surgical resection due to poor blood supply while the outer 1/3 of the mensicus has good blood supply so surgical repair is appropriate.
Patient presents with complete tears of the acromioclavicular (AC) ligament AND coracoclavicular (CC) ligaments. The clavicle is displaced posteriorly. What is the Rockwood classification of the injury and appropriate treatment?
A. Grade 4 ; surgery
B. Grade 4 ; rehab
C. Grade 5 ; surgery
D. Grade 5 ; rehab
A. Grade 4 ; Surgery
Grade 1: AC sprain, CC intact - rehab
Grade 2: AC torn, CC sprain - rehab
Grade 3: AC torn, CC torn (<100% upward displacement of clavicle) - rehab/surgery
Grade 4: AC/CC torn. Posterior displacement of clavicle - surgery
Grade 5: AC/CC torn. >100% upward displacement of clavicle - surgery
Grade 6: AC/CC torn. Inferior displacement of clavicle - surgery