MSK

Question 1

Special test for TOS

Answer 1

These 5 involve palpating radiual pulse and if pulse decreases then positive for arrterial TOS

Adson maneuver
Costoclavicular syndrome (Militarry brace) test
Halstead maneuver
Wright test
Allen test

Roos test (Elevated arm stress test): Arterial TOS, open close hands 3 mins and fatigue

Shoulder girdle passive elevation (Cyriax release test): Cross arms on shoulders, physio lifts arms up, looking for reduction of symptoms

Question 2

Possible complications of a shoulder dislocation

Answer 2

Axillary nerve damage
Axillary artery
brachial plexus (most common the posterior cord)
bankart lesion (damage to the anteroinferior glenoid labrum)
Hill sachs lesion (fracture to the posterolateral humeral head secondary to forceful impact on the anteroinferior labrum)

Question 3

Spectrum of instability

Answer 3

AMBRI (born loose)
Atraumatic etiology, multidirectional with bilateral shoulder findings, rehab for treatment, and rarely inferior capsule shift surgery if required

TUBS Torn loose
Traumatic etiology, unilateral aterior with a bankart lesion responding to surgery (surgery will lead to reductions in ER)

Question 4

Special tests for shoulder dislocation

Answer 4

Anterior instability

• Apprehension test and relocation test
• Apprehension release (surprise test)
• Load and shift test

Posterior instability

• Jerk test
• load and shift test\
• posterior apprehension test

Inferior instability
-Sulcus sign
-feagin test (Examiner position: The clinician holds the patient’s upper extremity at 90
degrees of abduction, with the patient’s forearm over the clinician’s shoulder
and elbow extended.

                   Technique: The clinician uses one hand to apply an inferiorly and slightly 
                     anteriorly directed force while the other hand palpates the edge of the 
                     acromion and the humeral head to feel for displacement anteriorly and 
                    inferiorly.

Question 5

Special tests for SLAP lesions

Answer 5

Compression test of obrian (best test to use) ( positive with resistance to arm in 90 degree flex and internally rotated, and symptoms resolved when repeated with ER)
Biceps load test (Kim test II)
Clunk test

Question 6

Bankaert lesion

Answer 6

Injury of labrum at 3 to 7 o clock
common in overhead athletes and with anterior GH dislocations
presents with clicking or popping
worse with HBB

Question 7

Adhesive capulitis

Answer 7

Idiopathic condition characterized by shoulder pain followed by progressive loss of GH ROM following the capsular pattern (ER>ABD>IR) d/t dense adhesions and capsular thickening

Primrary adhesive capsulitis is idiopathic

Secondary is due to other conditions ex trauma, immobilization, surgery, post stroke, etc.

Has a high correlation with psychosocial issues

Question 8

Stages of adhesive capsulitis

Answer 8

Stage 1

• Gradual onset of pain
• Increase with movement and at night
• Loss of ER ROM with intact RC strength
• Duration: <3 months

Stage 2: “freezing”

• Persistent and more intense pain, even at rest (dull and achy)
• Restricted ROM in all directions
• Duration: 3-6 months

Stage 3 “frozen”

• Pain only with movement, less night pain
• Signiicant adhesions. Hard capsular end-feel in most directions
• Restricted ROM in all directionswith increased scapular compensations
• May present with atropy of deltoid, RC, biceps and triceps d/t disuse
• Duration 9-15 months

Stage 4: " thawing"
-Minimal pain
-Significant capsular restrictions initially, bit get a gradual return of ROM
-Some patients may never regain full ROM
_Duration 15-24 months or longer

Question 9

Special tests for subacromial impingement syndrome

Answer 9

Hawkins kennedy test
Neers impingement test
scapular assistance test

Question 10

Hallmark sign of Subacromial impingement syndrome

Answer 10

Painful arc (60-120 degrees)

Question 11

Special tests for tendinopathy of Biceps and RC muscles

Answer 11

Biceps

• Yergasons
• Speeds

Subscapularis

• Lift off test
• belly press test
• internal rotation lag sign

Infranspinatus
-External rotation lag sign

Teres minor
-Hornblowers sign

supraspinatus

• Empty can
• drop arm test

Question 12

Causes of dynamic scapular winging

Sprcial tests for scapular winging

Answer 12

Serratus anterior weakness, long thoracic nerve damage affecting serratus anterior, spinal accessory nerve (trapezius), C3,C4 trapezius, C5 rhomboids, C7 serratus anterior and rhomboids

Wall push off test
punch out test
scapular load test (manual resistance at 45 degrees abduction and observe scapula for winging)

Question 13

Lateral epicondylosis
Special tests for lateral epicondylosis

Management

Answer 13

Commonly involves the extensor carpii radialis brevis tendon
Commonly known as tennis elbow

Cozens test (Resisted wrist extension)
Mills test ( Passive wrist extension)
Maudsleys test (resisted extension of 3rd MCP)

• Counterforce brace
• Eccentric exercise
• activity modification
• Stretching

Question 14

Medial epicondylosis

Management

Answer 14

Degeneration due to overuse of flexor trndon at the medial epicondykle
Commonly involves the pronator teres, and the flexor carpi redialis tendon
Known as golfers eelbow
Pain with resisted wrist flexion, resisted forarm pronation and passive wrist extension

Eccenteric exercise
Bracing
Stretching
activity mofication

Question 15

Median nerve (C6, C7, C8, and T1)
Peripheral nerve injuries

Answer 15

humerus supracondylar process syndrome
-median nerve entrapped under the ligament of struthers ( on the distal humerus)

pronator syndrome
-Median nerve entrapped between the two heads of the pronator teres muscle

Anterior interosous nerve syndrome
-the anterior interousous nerve, which is a branch of the median nerve is entrapped between the two heads of the pronator teres muscle and characterized as a pinch deformity

Question 16

Ulnar nerve (C7, C8 and T1)

Answer 16

cubbital tunnel syndrome
-Ulnar nerve entrapped between the cubittal tunnel or the two heads of the flexor carpi ulnaris muscle

Special tests

• Tinnels test at the elbow
• cubital tunnel compression test
• Elbow flexion test

Question 17

Radial nerve (C5, C6, C7, C8, and T1)

Answer 17

radial tunnel syndrome

• Entrspment of the posterior interousous nerve (branch of rsadial nerve) in:
  1) Between the 2 heads of the supinator in the arcade of froshe
  2) At the entrance of the radial tunnel anterior to the radial head
  3) Nerve the brachioradialis and the ECRL
  4) Between ulnar half of ECRB tendon and fascia
  5) Distal border of the supinator

Question 18

Complex regional pain syndrome (CRPS)

S & S

Clinical course

Answer 18

Type I: Occurs after injury to tissue, previously known as regional sympathetic dystrophy

Type II: Occurs after injury to a nerve, previously known as causalgia

S & S:

• Severe pain (burning)
• Allodynia/hyperalgesia
• Abnormal blood flow (vasomotor changes)
• Abnormal sweating ( sudomotor changes)
• Abnormal motor function
• Trophic changes (Colour changes, temperature changes, edema, shiny taut skin, abnormal hair and nail growth)

Stage 1: Acute/reversible stage

• typically begins several days after the injury or insidious over several weeks
• characteristics: pain, hyperhidrosis, warmth, erythema, rapid nail growth, edema in distal extremities

Stage 2: dystrophic. or vasoconstriction (Ischemic) stage

• Typically begins 3 months after the injury and lasts 3-6 months
• characteristics: Burning pain, sympathetic hyperactivity, hyperesthesia exacerbated by cold weather, mottling and coldness, brittle nails, osteoporosis

Stage 3: Atrophic stage

• Typically begins 6 months to 1 year after the injury and can last months or years
• characteristics: Pain either decreasing or becoming worse, severe osteoporosis, muscle wasting, and contracturees.

-

Question 19

Most fractured carpal bone and the complications

Answer 19

Scaphoid

• Avascular necrosis
• Non-union of fracture and srtyhritis.

Question 20

Muscle innervation

Radial nerve

Answer 20

Brachioradialis
extensors
supinator
triceps and anconeus

Question 21

Muscle innervation

median nerve

Answer 21

lumbricals 1 and 2
opponens pollicis
abductor pollis brevis
Flexor pollicis brevis

Question 22

Muscle innervation

ulnar nerve

Answer 22

adductor pollicis***
lumbricals 3 and 4
hypothenar muscles
-flexor digiti minimi
-abductor digiti minimi
-opponens digit minimi
-palmaris brevis

interossi (PAD and DABS)

Question 23

Ape hand

Answer 23

Median nerve

• Inability to abdut or oppose the thumb
• Stuck in the same plane as D2-5
• Seen with a low level lesion

Question 24

Hand of benediction

Answer 24

Median nerve

• Inability to flex D1-D3
• D1-D3 remain in extension when trying to actively make a fist
• A higher level lesion

Question 25

Claw hand

Answer 25

Ulnar nerve | -D4 and D5 extend at the MCP, flex at the PIP and DIP when actively trying to make a fist

Question 26

Wrist Drop

Answer 26

Radial nerve | -Inability to extend the wrist or the hand

Question 27

Carpal tunnel syndrome

Answer 27

Compression of the median nerve in the carpal tunnel - The floor is made up of carpal bones, and the roof is the flexor retinaculum - Components are the 4 tendons of the flexor digitorum profundus - r4 tendons of the flexor digitorum superficialis - Median nerve - tendon of the flexor pollicis longus ``` -D/t repetitive hand movements Associated conditions: -RA and other inflammatory disease -Colles fracture (d-t inflammation) -Lunate subluxation (Anterior sublux takes up space) -Hypothyroidism (Excess fluid retention) -Pregnancy (2nd trimester) -DM ``` S & S - Paresthesia of median nerve distribution - Worse with repetitive and sustained wrist movements - nocturnal numbness and pain - relieved by "flicking" the wrist - weakness and clumsiness in hand (Decrease grip strength and drop objects) Special tests - Tinnels test at the wrist - Phalens test - Reverse phalens test - Carpal tunnel compression test - Resisted APB - ULTT median nerve bias Intervention - Activity modification - Wrist splint/brace in neutral - Mobility techniques (nerve mobs, tendon-gliding exercises, jt mobs) Carpal tunnel release surgery - Immobolized for 7-10 days with wrist in slight extension and fingers free to move - During first 10 days post-op avoid wrist flexion past neutral, and finger flexion with wrist flexed. In max protection phase do finger and thumb AROM - Wrist extension - Ulnar and radial deviation with wrist in slight extension - forearm pronation and supimnation - All elbow and shoulder movements - Begin isometrics 4 weeks post-op - Grip and pinch exercises 6 weeks post-op - Sensory reduction, desensitization

Question 28

In severe case of ulnar tunnel syndrome what can happen Special tests for ulnar tunnel syndrome

Answer 28

Claw hand and/or hypothenar muscle atrophy Special tests: - Froments sign: paper between thumb and index finger and uses adductor pollicis to grip paper (ulnar nerve innervation) - Guyon canal compression test - tinnels test - ULTT for ulnar nerve Interventions - Cock-up splint - padded handlebars and gloves, ergonomic aids and equipment - change of hand positions - nerve mobs

Question 29

Finger deformities

Answer 29

Duputryens contracture - Contracture of the palmar fascia - fixed flexion deformity of the MCP and PIP joints - D4 and D5 - skin often adherent to the fascia trigger finger - thickening of the tendon sheath (Notta's nodule) - results in tendon sticking catching, or locking when attemopt to flex finger - Commonly affects D3 and D4 - Often associated with RA mallet finger - DIP stuck in flexion due to rupture of the extensor tendon - Treeated by splinting DIP straight for 6-8 weeks bouchards nodes -OA enlargement of the dorsal surface of the PIP heberdens nodes --OA enlargement of the dorsal surface of the DIP swan neck deformity -flexion of the MCP, hyperextension of the PIP, and flexion of the DIP boutinierres deformity -Hyperextenion of the MCP, and flexion of the PIP, DIP extension ulnar drift

Question 30

With Hip OA is OKC or CKC exercises preferred in acute phase?

Answer 30

OKC, then progress to functional CKC exercises as tolerated

Question 31

Hip OA complications Intra-op Early post-op Late post op

Answer 31

Intra op - malpositioning of prosthesis - femoral fracture - nerve injury - LLD Early post op - Infection - DVT - wound healing problems - pneumomnia - dislocation of the prosthetic joint Late post-op - mechanical loosening of components - atraumatic wearing out of the components

Question 32

Post op THA precautions Posterior/posterolateral Anterior/anterolateral and direct lateral

Answer 32

Posterior/posterolateral - No hip flexion >90 - No adduction past neutral - No Ir past neutral Anterior/anterolateral and direct lateral - No hip flexion >90 - No ER beyond neutral - No hip adduction beyond neutral - No FABER movements - If glute med incised, no resisted or antigravity hip abduction for 6-8 weeks.

Question 33

Hip neuropathies Sciatic nerve Obturator nerve Femoral nerve

Answer 33

Sciatic nerve -Entrapment as the nerve passes under the piriformius muscle Obturoator nerve -d/t uterine pressure and damage during labor Femoral nerve -D/t features of upper femur or pelvis, reduction of congenital dislocation of the hip,, or pressure during a forceps delivery.

Question 34

Special tests for meniscus trears

Answer 34

Mcmurrays test (Most important) Thessalys test Bounce home test Apley's test

Question 35

Special tests for ACL tear

Answer 35

Lachmans test Anterior drawer test pivot shift test

Question 36

Special tests for PCL tear

Answer 36

Posterior drawer test Gofrey (gravity) test Posterior ag sign

Question 37

Infrapatellar fat pad syndrome etiologies Common sign

Answer 37

``` Patella alta inferior patellar tilt anterior pelvic tilt genu recurvatum Hyperextensio n injury ``` camel sign

Question 38

plica syndrome common sign & special tests

Answer 38

Pseudo locking Hughtons plica test mediopatellar plica test patellar bowstring test

Question 39

Patellar subluxation/dislocation structural abnormalities Interventions

Answer 39

**Shallow patellofemoral groove** Patella alta Increased Q angle foot pronation PT management Early immobilization (zimmer splint) for 3-6 weeks crutches until full extension obtained Normalize gait Isometric and ROM (OKC and progress to CKC) Later Progreess to CKC with emphasis on VMO and glute med patellar bracing

Question 40

Contraindications fo myositis ossificans

Answer 40

Passive stetching, massage, and resistive exercises | Only thing that is indicated is AROM

Question 41

Special tests for lateral ankle sprain

Answer 41

``` Anterior drawer test talar tilt (Inversion stress test) ``` ``` Also can do: Ankle lunge test (knee to wall test) Proprioceeption testing(single leg balance) Strength testing (heel raise) ```

Question 42

Special tests for medial ankle sprains

Answer 42

Anterior drawer test Talar tilt test (eversion) External rotation stress test (kleiger)

Question 43

Special tests for high ankle sprain

Answer 43

External rotation stress test (Kleigers test) | Squeeze test

Question 44

Ottawa ankle rules

Answer 44

1) Bony tenderness along distal 6cm of posterior edge of fibula or tip of lateral malleolus 2) Bony tenderness along distal 6cm of posterior edge of tibia/ tip of medial malleolus 3) Bony tenderness at base of 5th ,metatarsal 4) Bony tenderness at the navicular 5) Inability to bear weight both immediately after injury and for 4 steps during initial evsluation

Question 45

3 classes/ causes of shin splints

Answer 45

Periostitis (inflamation of the periosteum of the bone) Compartment syndrome (to much pressure in the fascia stress fractures

Question 46

Plantar fasciitis

Answer 46

overuse of plantar fascia, assess using the windlass mechanism Treat with soft tissue mobs of plantar fascia and calf stretching, and strengthening intrinsic foot muscles

Question 47

Mortons neuroma

Answer 47

Thickening of the fibrous tissue leading to entrapment of the digital nerve of the foot Usually digital nerve of 3rd and 4th toes Assess using mortons test (essentially lateral compression of transverse MTP arch)