A 55 year old male hospital volunteer presents to your clinic with an 8 month history of right anterior hip pain. The patient reports his symptoms have increased significantly over the past 2 months. He reports no symptoms with walking, however, his symptoms are exacerbated with static stance. Further questioning reveals the patient began working for Wal-Mart 10 weeks ago as a greeter. He will stand for 1-2 hours without a break during a typical workday. The patient originally saw his family physician for this condition 7 months ago. His physician suggested that he was overweight, and that going on a “diet” might help. The patient reports he has lost approximately 45 pounds in the last 7 months. The patient is 72 inches tall and weights approximately 210 pounds.
- A physical examination reveals the following data. (+) Trendelenberg sign, (+) Ober’s test, (+) FABER test for pain, (-) Thomas test, (-) Femoral Grind test; MMT Gluteus Medius/Minimus 4/5 with reproduction of symptoms, Gluteus Maximus 4-/5, hip flexors and knee extensors/flexors 5/5. What is the most likely diagnosis?
a. Avascular necrosis of the femoral head
b. Gluteus Medius/Minimus strain
c. Pubofemoral ligament & Y-Ligament sprain
d. Trendelenberg gait
a. Incorrect. We would expect pain to be elicited with the Femoral Grind test and the patient’s aggravating factors would include walking as well as static stance because of the increased compression at the hip joint.
b. Incorrect. The patient does have slight weakness at these muscles. However, the patient is complaining of pain only during static stance. These muscles are not active during bilateral static stance so they are not the source of his pain.
c. Correct. During static stance, stability at the hips is provided entirely by its ligaments and capsule. The key element of this patient’s subjective history was when he reported anterior hip pain with static stance, not walking. Moreover, his symptoms coincide with beginning employment with Wal-Mart as a greeter. The weakness observed at the Gluteal muscles is most likely from a stretch reflex at the anterior hip capsule and ligaments. The Pubofemoral ligament checks extension and abduction while the Y-Ligament checks hyperextension of the hip. If these structures are injured, an inhibitory interneuron is often activated that synapses with the posterior muscles of the hip. By inhibiting these muscles, increased stretch (and further injury) can be avoided at these ligaments. The FABER sign was positive because this test placed a passive stretch on these ligaments. Ober’s sign was positive because it involves placing the patient in hip abduction and extension during the initial phase of the test.
d. Incorrect. This patient’s gait was not assessed. His (+) Trendelenberg sign was most likely due to inhibited Gluteal muscles.
A 55 year old male hospital volunteer presents to your clinic with an 8 month history of right anterior hip pain. The patient reports his symptoms have increased significantly over the past 2 months. He reports no symptoms with walking, however, his symptoms are exacerbated with static stance. Further questioning reveals the patient began working for Wal-Mart 10 weeks ago as a greeter. He will stand for 1-2 hours without a break during a typical workday. The patient originally saw his family physician for this condition 7 months ago. His physician suggested that he was overweight, and that going on a “diet” might help. The patient reports he has lost approximately 45 pounds in the last 7 months. The patient is 72 inches tall and weights approximately 210 pounds.
- Assume this patient was overweight when he saw his physician 7 months ago. Based on your knowledge of the biomechanics at the hip, was this patient’s physician correct in his advice that if he lost weight his pain would resolve?
a. Yes
b. No
a. Incorrect. This patient only complained of pain with static stance. The forces at the hip during static stance is only 0.3 times the body weight. Given this perspective, it is highly unlikely that this patient’s weight was exacerbating his symptoms.
b. Correct.
- What is the “inverted (reverse) action” of the Piriformis muscle?
a. Acts as a hip external rotator, flexor, and abductor beyond 30° of hip flexion
b. Acts as a hip adductor and internal rotator beyond 45° of hip flexion
c. Acts as a hip abductor and internal rotator beyond 60° of hip flexion
d. Acts as a hip adductor and flexor beyond 75° of hip flexion
a. Incorrect. The Piriformis’ primary function is that of an external rotator, flexor and abductor. It is not its inverted action
b. Incorrect.
c. Correct.
d. Incorrect.
A 75 year old female presents to your clinic with a 3 week history of left knee pain of an insidious onset. She reports her pain is increased with activity and decreased with rest, primarily seated in a recliner or laying in bed. Her pain is steadily getting worse without sign of improvement. Radiographs of her left knee, taken at her physician’s office, are without sign of pathology. Prior medical history is significant for osteoporosis and diabetes. She also reports she is a cancer survivor. She reports she increased her daily walking regimen one month ago from 20 minutes a day to 60 minutes a day at the request of her cardiologist. She is taking medication for hypertension, diabetes, osteoporosis, and depression. She states her husband died 5 months ago and she has been severely depressed, however, her medications are improving her mood. She also moved into an assisted-living facility last week at the request of her daughters because she was too depressed to cook and clean for one and is eating more consistently as a result.
- You physical examination of the left knee reveals no deficits in range of motion or strength. Special tests for ligamentous and meniscal pathology are also negative. Gait assessment reveals an antalgic gait on the left. Her ability to balance in left single leg stance is also significantly diminished due to pain. Based on this information, what would the most appropriate next course of action?
a. Perform an evaluation of her left foot and ankle
b. Perform an evaluation of her left hip
c. Perform an evaluation of her lumbar spine
d. Refer her back to her physician for an MRI of her knee
a. Incorrect. While poor biomechanics of the foot and ankle could cause knee pain, the pain at the knee is typically caused by altered biomechanics that results in an overuse pathology. The physical exam of the knee would have elicited this.
b. Correct. The hip is a major source of pain referral to the knee. Often, in cases of avascular necrosis, a complaint of same-sided knee pain is the first sign of pathology at the hip. Also, her primary complaint of symptoms is with weightbearing – typical in the referral of pain from the hip to the knee.
c. Incorrect. The lumbar spine can refer pain, however, rarely is it isolated to the knee. It would also seem likely that a pain referral from the lumbar spine would involve symptoms at the lumbar spine as well.
d. Incorrect. An MRI is an expensive test that is typically used to rule in or rule out a suspected pathology. You do not have a diagnosis to confirm or rule out with an MRI.
Questions 4-5 refer to the case below
A 75 year old female presents to your clinic with a 3 week history of left knee pain of an insidious onset. She reports her pain is increased with activity and decreased with rest, primarily seated in a recliner or laying in bed. Her pain is steadily getting worse without sign of improvement. Radiographs of her left knee, taken at her physician’s office, are without sign of pathology. Prior medical history is significant for osteoporosis and diabetes. She also reports she is a cancer survivor. She reports she increased her daily walking regimen one month ago from 20 minutes a day to 60 minutes a day at the request of her cardiologist. She is taking medication for hypertension, diabetes, osteoporosis, and depression. She states her husband died 5 months ago and she has been severely depressed, however, her medications are improving her mood. She also moved into an assisted-living facility last week at the request of her daughters because she was too depressed to cook and clean for one and is eating more consistently as a result.
5. Let’s assume you eventually evaluated this patient’s left hip. Your physical examination revealed the following.
• Tenderness to palpation over the groin and inguinal ligament
• Pain at end-range of hip internal and external rotation
• Pain and difficulty performing a straight leg raise in supine
• (+) Calcaneal percussion test
• (-) Femoral Grind test
• MMT hip adductors 4+/5 with slight pain
Based on all of the information presented, what is the most likely diagnosis?
a. Femoral stress fracture
b. Hip Adductor strain
c. Osteonecrosis
d. Slipped Capital Femoral Epiphysis
a. Correct. Femoral neck stress fractures are associated with “deep” hip pain, inguinal ligament pain, groin pain, or knee pain. Pain is typically increased with activity and is associated with a change in activity. Recall that this patient changed her daily walking regimen from 20 minutes daily to 60 minutes. This change occurred one week before symptom onset. Common physical examination findings included tenderness to palpation over the groin and inguinal ligament and pain with end-range hip rotation. Patients will often have difficulty and pain while performing a straight-leg raise and the Calcaneal Percussion test is often positive as well. These are due to overuse and not trauma.
b. Incorrect. Hip adductor MMT were strong with slight pain. The slight pain is expected due to the stress fracture. Also, it is very unlikely that the hip adductors would refer pain to the knee – their referral pattern is to the middle of the medial thigh.
c. Incorrect. We would expect a positive Femoral Grind test and pain at the hip with single limb stance.
d. Incorrect. This is seen in adolescent populations.
- If this patient’s pathology was a femoral neck stress fracture, which subcategory would it most likely fall into?
a. Insufficiency fracture
b. Trabecular microfracture
a. Correct. These are typically seen in the elderly populations and are a result of overuse. Predisposing factors include diabetes, osteoporosis, rheumatoid arthritis, and irradiation. Also, femoral neck stress fractures are highly correlated with eating disorders. Recall, this woman also stated she had not been eating very well due to depression.
b. Incorrect.
Questions 7-9 refer to the case below
A 17 year old highschool cross country track runner who averages 35 miles a week reports a 6 month history of right lateral hip pain. Initially, the pain occurred only after running, but is now hurting her continuously throughout the course of the day. She reports pain with right sidelying. Past medical history is significant for left proximal Tibial fracture that was surgically repaired with open reduction internal fixation when she was 12 years old. Physical examination reveals asymmetry at the pelvic landmarks (patient standing) with the left ASIS superior compared to the right. MMT of hip flexors, internal rotators, and extensors is 5/5 without pain; abduction 4+/5 with pain; external rotators 4/5 with pain. Obers and FABER’s tests are positive. Femoral Grind test is negative. Patient demonstrates moderate ITB tightness and tenderness to palpation along the right greater trochanter.
- What would be the most likely diagnosis?
a. Greater Trochanteric bursitis
b. Iliopectineal bursitis
c. SI Joint dysfunction
d. Slipped Captial Femoral Epiphysis
a. Correct. This is an overuse injury. Symptoms are elicited with tests and positions that place stress on the lateral hip structures (FABER’s, Ober’s) and MMT of posterior hip muscles that insert on the Greater Trochanter would be weak with pain. Note, the patient reports the condition has worsened and the pain is now continuous. This is suggestive of a more advanced stage of the inflammation.
b. Incorrect. This condition typically presents more anteriorly where the iliopectinial bursa covers the Iliopsoas and Pectineus muscles. Tenderness to palpation would be elicited over the femoral triangle, not the greater trochanter.
c. Incorrect. FABER’s test is often positive for SI Joint pathology and the SI Joint can refer to the hip. However, this patient has specific pain and tenderness over the Greater Trochanteric bursa.
d. Incorrect. This patient had a negative Femoral Grind test. Also, it is highly unlikely that this patient would be running 35 miles a week with this condition.
Questions 7-9 refer to the case below
A 17 year old highschool cross country track runner who averages 35 miles a week reports a 6 month history of right lateral hip pain. Initially, the pain occurred only after running, but is now hurting her continuously throughout the course of the day. She reports pain with right sidelying. Past medical history is significant for left proximal Tibial fracture that was surgically repaired with open reduction internal fixation when she was 12 years old. Physical examination reveals asymmetry at the pelvic landmarks (patient standing) with the left ASIS superior compared to the right. MMT of hip flexors, internal rotators, and extensors is 5/5 without pain; abduction 4+/5 with pain; external rotators 4/5 with pain. Obers and FABER’s tests are positive. Femoral Grind test is negative. Patient demonstrates moderate ITB tightness and tenderness to palpation along the right greater trochanter.
- Based on her pelvic asymmetries and her prior medical history of a tibial fracture, you decide to assess her leg length in supine. Prior to assessing her leg length, you perform which of the following techniques to align her pelvis?
a. Watson’s Test
b. Weber Test
c. Weber-Barstow Maneuver
d. Wright’s Maneuver
a. Incorrect. This is a test for Scaphoid Instability (Scaphoid-Shift test)
b. Incorrect. This is a test for conductive hearing loss
c. Correct. The patient lies supine with their hips and knees flexed. They raise their buttocks off of the treatment table three times and then straighten their legs for assessment. The examiner then palpates and observes for asymmetry at the medial malleoli
d. Incorrect. This is a test for Thoracic Outlet Syndrome.
Questions 7-9 refer to the case below
A 17 year old highschool cross country track runner who averages 35 miles a week reports a 6 month history of right lateral hip pain. Initially, the pain occurred only after running, but is now hurting her continuously throughout the course of the day. She reports pain with right sidelying. Past medical history is significant for left proximal Tibial fracture that was surgically repaired with open reduction internal fixation when she was 12 years old. Physical examination reveals asymmetry at the pelvic landmarks (patient standing) with the left ASIS superior compared to the right. MMT of hip flexors, internal rotators, and extensors is 5/5 without pain; abduction 4+/5 with pain; external rotators 4/5 with pain. Obers and FABER’s tests are positive. Femoral Grind test is negative. Patient demonstrates moderate ITB tightness and tenderness to palpation along the right greater trochanter.
- You determine that this patient has a short left leg. You suspect this is due to her left Tibial fracture when she was 12. What was the most probable Salter-Harris Classification of that fracture?
a. Type 1
b. Type 2
c. Type 3
d. Type 5
a. Incorrect. This involves a complete separation of the growth plate and the bone. The prognosis is good.
b. Incorrect. This is the most common form of injury involving a fracture through the metaphysis. The prognosis is excellent.
c. Correct. This is an intraarticular fracture of the epiphysis. Open reduction internal fixation is required to stabilize the injury.
d. Incorrect. This involves a crush-type injury. It is very uncommon.
- An increase in femoral anteversion at the hip would be most closely associated with which of the following findings?
a. Lateral femoral torsion and toeing in
b. Lateral femoral torsion and toeing out
c. Medial femoral torsion and toeing in
d. Medial femoral torsion and toeing out
a. Incorrect.
b. Incorrect. This would be associated with femoral retroversion
c. Correct.
d. Incorrect.
Questions 11-12 refer to the case below
A 36 year old male presents to your clinic with right sided groin pain associated with a popping sensation. The patient cannot recall any specific mechanism of injury. He reports he is unable to sit “Indian-style” on the floor while playing with his children. Physical examination reveals negative Femoral Grind test. Placing the patient’s right hip in a position of flexion, external rotation, and abduction and then rapidly moving it into extension, internal rotation, and adduction produces a sharp pain “deep” in the groin area.
- Based on this information, what is the most likely diagnosis?
a. Anterior Acetabular labral tear
b. DJD Hip
c. Iliopectineal Bursitis
d. Legg-Calves-Perthes disease
a. Correct. Acetabular tears are caused by a slipping or twisting injury. The patient will typically not be able to pinpoint an exact mechanism of injury. Pain associated with popping or snapping “deep” within the hip is a common complaint. Limited range of motion into rotation is common (this patient could not sit “Indian-style” on the floor). The special test described above is specific for Anterior Acetabular tears.
b. Incorrect. This would not involve a mechanism of injury, however, patients would most likely have a positive Femoral Grind test and not have snapping or popping associated with their pain.
c. Incorrect. This is associated with anterior hip pain without snapping or popping. It is typically an overuse injury.
d. Not even close. This patient is about 30 years too old for this diagnosis. The hip adduction test is most specific for LCPD. This test involves the examiner passively flexing and adducting the involved hip. If the knee can go past the contralateral ASIS without pain, it is negative for LCPD. It has been thought that radiographs were the best diagnostic tool for this pathology, however, recent studies reveal poor objectivity in radiographic classification of the disease.
Questions 11-12 refer to the case below
A 36 year old male presents to your clinic with right sided groin pain associated with a popping sensation. The patient cannot recall any specific mechanism of injury. He reports he is unable to sit “Indian-style” on the floor while playing with his children. Physical examination reveals negative Femoral Grind test. Placing the patient’s right hip in a position of flexion, external rotation, and abduction and then rapidly moving it into extension, internal rotation, and adduction produces a sharp pain “deep” in the groin area.
- What would be the best treatment option for this patient?
a. Surgical removal of the torn portion of the labrum
b. Strengthening exercises for the muscles crossing the hip joint
c. Anti-inflammatory treatment
d. Stretching exercises
a. Correct. This is the preferred treatment for Acetabular tears
b. Incorrect. This would be a logical choice for DJD
c. Incorrect. This would be a logical choice for Iliopectineal bursitis.
d. Incorrect. This would be a logical choice for LCPD as it is a self-limiting disease.
- You are performing the Supine-to-Longsit test on a patient with suspected leg length discrepancy. When the patient is supine you note the right leg to be longer than the left. When the patient moves into Longsit, the right leg becomes shorter than the left. What do these findings most likely indicate?
a. Right anterior innominate rotation
b. Left posterior innominate rotation
c. Anatomical leg length dysfunction
d. Iliosacral dysfunction
a. Incorrect. According to Magee (Orthopedic Physical Assessment, 3rd ed, pg 448) this would be the correct response. However, this answer is too specific for the limited information presented. The examiner would need to find a positive test for right SIJ hypomobility in conjunction with the above findings in order to be confident that the diagnosis was a right anterior innominate rotation.
b. Incorrect. Again, you would need a positive test for left SIJ hypomobility for this to be the correct diagnosis.
c. Incorrect. A positive test rules out a true anatomical leg length
d. Correct. A positive Supine-to-Longsit test rules out a sacroiliac dysfunction and rules in an iliosacral dysfunction (example: innominate rotation)
Questions 14-16 refer to the case below
A 64 year old male is one day status post right total hip replacement. The surgeon performed the surgery with an posterio-lateral approach and chose an cemented prosthesis. The patient is alert and oriented x3, is on an epidural for pain that is scheduled to be removed the following morning. He rates his current pain at 1/10 on a visual analog scale. You are seeing the patient on your hospital’s acute care floor. His physician plans to discharge him to the rehab floor within the next 48 hours.
- Base on this information, what would this patient’s hip precautions be?
a. No flexion above 60°, adduction beyond midline, and external rotation
b. No flexion above 75°, adduction beyond midline, and internal rotation
c. No flexion above 90°, adduction beyond midline, and internal rotation
d. No flexion above 110°, adduction beyond midline, and external rotation
a. Incorrect. This is the precautions for a posterior surgical approach
b. Incorrect
c. Correct
d. Incorrect
Questions 14-16 refer to the case below
A 64 year old male is one day status post right total hip replacement. The surgeon performed the surgery with an posterio-lateral approach and chose an cemented prosthesis. The patient is alert and oriented x3, is on an epidural for pain that is scheduled to be removed the following morning. He rates his current pain at 1/10 on a visual analog scale. You are seeing the patient on your hospital’s acute care floor. His physician plans to discharge him to the rehab floor within the next 48 hours.
- What would this patient’s weightbearing precautions be?
a. Full weight bearing
b. Non-weight bearing (NWB)
c. Touch down weight bearing (TDWB)
d. Weight bearing as tolerated (WBAT)
d. Correct. Cemented procedures are generally WBAT. Refer to the protocols in your course packet. Cemented procedures only weaken over time. Their fixation is as strong as they are ever going to be day 1 post-op.
Questions 14-16 refer to the case below
A 64 year old male is one day status post right total hip replacement. The surgeon performed the surgery with an posterio-lateral approach and chose an cemented prosthesis. The patient is alert and oriented x3, is on an epidural for pain that is scheduled to be removed the following morning. He rates his current pain at 1/10 on a visual analog scale. You are seeing the patient on your hospital’s acute care floor. His physician plans to discharge him to the rehab floor within the next 48 hours.
- Had this patient’s prosthesis been uncemented, what would his weight bearing precautions have been instead?
a. Full weight bearing
b. Non-weight bearing(NWB)
c. Touch down weight bearing(TDWB)
d. Weight bearing as tolerated(WBAT)
c. Correct. Toe touch weight bearing is the generally accepted protocol guidelines. Again refer to the protocols in your course packet. The reason for more limited weight bearing restrictions is the instability of the prosthesis as healing occurs.
- A 23 year old male presents to your clinic complaining of right thigh and testicular pain that is exacerbated with standing and walking. He reports this pain came on insidiously 3 days ago. Relieving factors include laying supine with the hips and knees flexed. The patient is not taking any medication except Tylenol prn because of a low-grade fever. Physical examination findings include tenderness to palpation at McBurney’s Point, negative Femoral Grind test, and reproduction of symptoms with SI compression test. There is no tenderness to palpation at the right thigh and MMT at the right hip are without noted deficit. Based on this information, what is the most likely diagnosis?
a. Hernia
b. Iliopsoas strain
c. Retrocecal appendicitis
d. SI Joint dysfunction
a. Incorrect. Hernias are not associated with thigh pain or fever
b. Incorrect. Iliopsoas does not refer pain into the testicular area. There would be deficits and/or pain with hip flexor strength testing as well.
c. Correct. Retrocecal appendicitis refers pain to the right thigh and testicle. Appendicitis is associated with insidious onset, low-grade fevers, and patients often find relief by bringing their knees to their chest (as this patient reported). Tenderness to McBurney’s Point is a key finding: it is located between the right ASIS and the umbilicus (over the appendix). The SI Compression test was most likely positive due to the fact that you have to press in the area of McBurney’s Point to perform the test.
d. Incorrect. The SI Joint can refer pain into the groin and proximal thigh. The SI Compression test was most likely positive due to the fact that you have to press in the area of McBurney’s Point to perform the test.
- A 64 year old male reports to you with a referral of right knee osteoarthritis. Upon interviewing him, he informs you that while squatting in his garden, he felt a “pinching sensation” in the back of his knee. Exam reveals an inability to deep knee squat on that side, and painful limited ROM in flexion beyond 90 degrees. Pt is able flex his unaffected leg to 130 degrees. He has tenderness to palpation in the postero-lateral joint line. He has a normal valgus/varus and Lachman’s test. There is pain elicited with Apley’s compression, and is relieved by distraction. Nothing significant is noted with McMurray’s. Based on these findings, do you suspect:
a. The patient’s findings are consistent with osteoarthritis
b. The patient may have a meniscus tear
c. The patient may have strained his bicep’s femoris
d. The patient may have subluxed his patella
a. Incorrect. Sometimes osteoarthritis may limit range of motion, but this patient had a mechanism of injury.
b. Correct. This patient had a common mechanism for someone his age for a posterior horn meniscus tear. Usually stiffness will limit the posterior translation of the meniscus on the tibia, which sets the posterior horn up for getting pinched in the joint.
c. Incorrect. Not a mechanism for a hamstring strain.
d. Incorrect. This patients pain is all posterior and not in the area of the patella retinaculum.
- Why would an anterior cruciate injury be more apt to swell immediately following injury versus a meniscus injury, which could take from 24 to 48 hours to swell?
a. Cruciates are extrasynovial and extracapsular, menisci are intrasynovial
b. Cruciates are extrasynovial and intracapsular, menisci are intrasynovial
c. Cruciates are intrasynovial and extracapsular, menisci are extrasynovial
d. Cruciates are intrasynovial and intracapsular, menisci are extrasynovial
b. Correct. The fact that the cruciates are within the capsule and have a good blood supply would set them up for a quick bleed when injured, and thus immediate swelling. Menisci are bated in synovium, and synovitis-type swelling would occur over a longer period of time. (approximately 24 hours)
Questions 3 – 5 refer to the case below
You are evaluating a patient referred to you from the emergency room. She is a 17 year old female who was struck from behind during an MVA x 1 week ago. She indicated that her R knee struck the dashboard and she felt a “pop”. X-rays in the emergency room were negative for fracture. She notes that her R leg has buckled since on a couple of occasions. During your examination, you observe that she has a positive “sag sign”.
- Given this presentation, what injury do you suspect that she has sustained?
a. Anterior Cruciate Ligament Injury
b. Medial Collateral Ligament Injury
c. Meniscus Injury
d. Posterior Cruciate Ligament Injury
a. Incorrect. This resulted from a hyperflexion mechanism. She also has a posterior sag on exam.
b. Incorrect. No valgus stress
c. Incorrect. No rotary mechanism. Not enough information to completely rule this out, but the mechanism indicated points to something else more obvious.
d. Correct. This can be a typical mechanism for a PCL injury. A posterior sag presentation should immediately raise your suspicion this structure might be involved.
vQuestions 3 – 5 refer to the case below
You are evaluating a patient referred to you from the emergency room. She is a 17 year old female who was struck from behind during an MVA x 1 week ago. She indicated that her R knee struck the dashboard and she felt a “pop”. X-rays in the emergency room were negative for fracture. She notes that her R leg has buckled since on a couple of occasions. During your examination, you observe that she has a positive “sag sign”.
- What would be an appropriate special test to check the integrity of this structure?
a. Anterior Drawer Test
b. Pivot Shift Test
c. Posterior Drawer Test
d. Valgus Stress Test
a. Incorrect. This checks the integrity of the anterior cruciate ligament. You may get a positive finding with this if the posterior elements are disrupted if you begin the test in a degree of post-tibial translation
b. Incorrect. ACL test
c. Correct.
d. Incorrect. This checks the integrity of the medial collateral ligament
Questions 3 – 5 refer to the case below
You are evaluating a patient referred to you from the emergency room. She is a 17 year old female who was struck from behind during an MVA x 1 week ago. She indicated that her R knee struck the dashboard and she felt a “pop”. X-rays in the emergency room were negative for fracture. She notes that her R leg has buckled since on a couple of occasions. During your examination, you observe that she has a positive “sag sign”.
- During your exam, you note laxity present with a Lachman’s test. Does this confirm the patient has a torn anterior cruciate ligament injury?
a. True
b. False
b. Correct. A torn posterior cruciate ligament may cause a degree of posterior translation at the tibofibular joint. So when you begin this test, the tibia may already be posterior translated sot that you feel increased laxity with your line of pull. Thus, giving the impression of a positive test (false positive). It is important to note the quality of the “end feel when performing a Lachman’s.
Questions 6-7 refer to the case below.
A 13 year old male is brought to your clinic by his mother. He has a three-month history of knee pain that is worse with running, jumping, and ascending or descending stairs. His mother notes that he has had a growth spurt of about 2-3 inches over the last year. Your examination findings reveal a tender palpable bump in the area of the tibial tubercle. It is also moderately warm to touch. His ROM appears fine and he has good strength with some mild pain with resisted quadriceps action. He also has moderate tightness of his quadriceps and hamstrings.
- Based on your findings, what is the likely diagnosis?
a. Chondromalacia
b. Osgood Schlater’s Disease
c. Patella Femoral Syndrome
d. Seaver’s Disease
a. Incorrect. This would likely be seen in an older individual unless there was a precipitating trauma.
b. Correct. The palpable tender bump gives this away. This is normally seen in young adolescents who are rapidly growing. The musculature is not keeping up with the long bone growth, thus creating a pull, or apophysitis traction type of inflammation at the quad insertion.
c. Incorrect, This might coexist, but is not the best answer here
d. Incorrect. Similar apophysits condition at the Achilles attachment on the calcaneous.
Questions 6-7 refer to the case below.
A 13 year old male is brought to your clinic by his mother. He has a three-month history of knee pain that is worse with running, jumping, and ascending or descending stairs. His mother notes that he has had a growth spurt of about 2-3 inches over the last year. Your examination findings reveal a tender palpable bump in the area of the tibial tubercle. It is also moderately warm to touch. His ROM appears fine and he has good strength with some mild pain with resisted quadriceps action. He also has moderate tightness of his quadriceps and hamstrings.
- What would be the most appropriate treatment for this patient?
a. Open chain quadriceps strengthening exercises
b. Knee sleeve with donut cutout
c. Phonophoresis; 1.2 watts/cm2 x 6 minutes, 3 x week
d. Quadricep stretching and counterforce brace
a. Incorrect. This would likely increase the symptoms by increasing tension on the quadriceps attachment.
b. Incorrect. May help to some degree with compression, but does not address the underlying mechanics
c. Incorrect. May help decrease inflammation, but again does not address underlying mechanics
d. Correct. Increasing flexibility of the quadriceps would decrease the tension at its insertion, thus decreasing the source of the symptoms. Also a counterforce brace is sometimes helpful in decreasing the tension at the quadriceps insertion when it’s active.
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OCS: Biomechanics49
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OCS: soft tissue injury and repair30
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OCS: bone injury and repair44
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Exercise Physiology44
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Arthritis49
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DVT22
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Complex Regional Pain Syndromes29
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Cryotherapy and moist heat0
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Electrotherapy59
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Iontophoresis, ultrasound, phonophoresis, and laser therapy42
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Stretching21
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Manual Therapy0
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Sports medicine6
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Shoulder128
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AC joint93
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Ankle and Foot99
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Spine52
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Knee109
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Hip81
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Thoracic12
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OCS McGee113
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OCS McGee 238
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SI joint14
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Research39
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Current Concepts48
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Elbow16
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Wrist22
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Test6
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Shoulder McGee65
