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In which phase of throwing does the \"torsional peel-back force\" occur on the biceps-labral complex?
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d. Cocking phase Correct: The cocking phase is where you see the peel-back mechanism affect the biceps-labral complex. See your weekly readings for further insight: Wilk et al., (2005)
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A 16 year old who is the starting pitcher for his high school baseball team is referred for medial elbow pain that began during the beginning of the season during practices and is now limiting the number of throws he can make at each baseball game. He reports occasional paresthesia to the fourth and fifth digits of his throwing hand while throwing. He reports that he has been pitching for 7 years, and that he played year round baseball until starting high school. The elbow is not painful at rest (begins hurting after approximately 10 full speed throws). He has not had imaging performed. Upon examination there is a mild loss of terminal elbow extension (lacks the final 8 degrees). The medial elbow is painful and the pain increases with valgus stress testing although there is not noticeable opening of the humeroradial joint. Varus stress testing at the elbow is not bothersome. Tinel's is negative. Which of the following is the most likely diagnosis for this patient?
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b. Ulnar collateral ligament tear Correct: This condition is associated with repetitive overhead-throwing, particularly adolescent pitching athletes. The repetitive valgus stress placed on the elbow can lead to injury to the ligament. Paresthesia or even associated cubital tunnel syndrome is possible. For a good review on elbow injuries in throwers, review Cain et al., (2003)
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A 16 year old who is the starting pitcher for his high school baseball team is referred for medial elbow pain that began during the beginning of the season during practices and is now limiting the number of throws he can make at each baseball game. He reports occasional paresthesia to the fourth and fifth digits of his throwing hand while throwing. He reports that he has been pitching for 7 years, and that he played year round baseball until starting high school. The elbow is not painful at rest (begins hurting after approximately 10 full speed throws). He has not had imaging performed. Upon examination there is a mild loss of terminal elbow extension (lacks the final 8 degrees). The medial elbow is painful and the pain increases with valgus stress testing although there is not noticeable opening of the humeroradial joint. Varus stress testing at the elbow is not bothersome. Tinel's is negative. Which of the following is least likely to have contributed to pitching related injury at the elbow?
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a. The patient relates he tires quickly so gets pulled in the 5th-6th inning almost every game. Correct: Pitching excessive innings per year is potentially more problematic than not getting playing time.
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With regards to post-op UCL reconstruction, \"improve motion, diminish pain and inflammation, retard muscle atrophy, & prevent joint laxity and instability\" describes the goal of which phase of rehabilitation?
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a. Phase I Correct: This describes the immediate motion phase, or \"Phase I.\" For more information, refer to your weekly readings: Wilk et al. (2004).
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Which of the following surgical procedures involves overlapping and shortening of the subscapularis muscle
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c. Putti-Platt Correct! This procedure divides the subscapularis tendon, overlaps it, and repositions it to achieve anterior capsular stability. This is not performed in throwers due to the risk for range of motion loss.
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An 18 year old male baseball infielder presents with diagnoses of right shoulder multidirectional instability which is confirmed by your clinical testing. He states that he will most likely have a stabilization surgery and would like your opinion on the best procedure for his goal to return to play baseball. You recommend:
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b. Capsular shift to allow for maximal stability Correct: The capsular shift has fallen into favor for MDI, as it will maximize joint stability, but allow for a full return of ROM.
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What portion of the UCL ligament is the primary restraint to stresses induced by baseball pitching?
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b. Anterior bundle Correct: The anterior bundle of the ulnar collateral ligament is the primary restraint to valgus force of the elbow from 30° to 120° of flexion and is subjected to near-failure tensile stresses during the acceleration phase of the throwing motion. For a review on elbow injuries in throwing athletes, review Cain et al. (2003)
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Rehabilitation following shoulder stabilization procedures will vary depending on whether the procedure was performed using an open or arthroscopic technique because:
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c. The subscapularis is detached and reattached during surgery Correct: The subscapularis must be taken down for open stabilization procedures. Hence, you must protect resisted IR, as well as any ROM that would put strain on the healing tissue.
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Which of the following special tests assesses for the presence of posteromedial osteophytes?
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a. Extension overload test Correct: The extension overload test is performed with the patient seated and the shoulder in slight forward flexion. The examiner repeatedly forces the slightly flexed elbow rapidly into full extension while applying a valgus stress. This maneuver attempts to reproduce pain with impingement of the posteromedial tip of the olecranon on the medial wall of the olecranon fossa. A positive finding often indicates the presence of a posteromedial olecranon osteophyte, which may occasionally be palpable at the time of physical examination. For more information, refer to your weekly readings: Cain et al., 2003.
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The subsequent 2 questions will be based on the following scenario: A high-school aged athlete fell on an outstretched arm and immediately complained of elbow pain. The physical therapist is reviewing the Emergency Department notes and notes the presence of a fat-pad sign. The patient was managed with immobilization to protect the injured tissues. The patient now presents in a physical therapy clinic with reduced elbow range of motion, mild pain, and weakness. A fat pad sign at the elbow describes __________.
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c. A radiographic finding indicative of intra-articular fracture Correct: As seen below, the fat pad sign is noted when the ventral fat pad is bowed and dorsal fat pat visible. In this image, the fracture of radius head is not visible directly.
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A high-school aged athlete fell on an outstretched arm and immediately complained of elbow pain. The physical therapist is reviewing the Emergency Department notes and notes the presence of a fat-pad sign. The patient was managed with immobilization to protect the injured tissues. The patient now presents in a physical therapy clinic with reduced elbow range of motion, mild pain, and weakness. The tissue most-likely to have needed protection through immobilization was_________.
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d. Trochlea Correct: This is an intra-articular structure that would result in a positive fat-pad sign, and require immobilization
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As a result of the extreme valgus moment created by the throwing motion, the medial elbow experiences ________ forces and the lateral elbow experiences _________ forces.
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d. Tensile, compressive Correct: As a result of the extreme valgus load involved in the throwing motion, the medial elbow experiences tensile forces and the lateral elbow experiences compressive forces. See Cain et al., (2003) from your weekly readings for further clarification.
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Following anterior stabilization procedure for the shoulder, ___________ are typically delayed for to allow biologic healing of the repaired soft tissue.
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c. Combined abduction and external rotation PROM Correct! These combined motions mimic those which often precede anterior dislocation of the shoulder.
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A \"bucket handle tear of the labrum and the biceps anchor\" describes which type of SLAP lesion?
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d. Type IV Correct: This describes a Type IV labral tear. See Wilk et al. (2005) in your weekly readings for further clarification.
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A 22 y/o male is referred to you for wrist pain. He reports that he fell on his outstretched hand 2 days ago and now has pain with any wrist movement or bearing weight through the involved upper extremity. He reports that he went to the emergency room after his injury, radiographs were taken and he was told they were negative for fracture. Upon examination all wrist motions are painful but he has full active range of motion. Resisted motions are painful but strong. The radial side of the wrist is very tender to palpation, particularly at the hook of the hamate and the anatomical snuff box. Finkelstein's test is particularly painful as is ulnar deviation of the wrist. Which of the following should be of immediate concern?
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a. Scaphoid fracture Correct: Scaphoid fractures are characterized by a mechanism of injury of a fall on outstretched hand and tenderness to the anatomical snuff box. Initial radiographs are often negative. This injury is of particular concern because undiagnosed fracture of the scaphoid can lead to avascular necrosis. Bone scan, CT or MRI can be used to confirm diagnosis.
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A 22 y/o male is referred to you for wrist pain. He reports that he fell on his outstretched hand 2 days ago and now has pain with any wrist movement or bearing weight through the involved upper extremity. He reports that he went to the emergency room after his injury, radiographs were taken and he was told they were negative for fracture. Upon examination all wrist motions are painful but he has full active range of motion. Resisted motions are painful but strong. The radial side of the wrist is very tender to palpation, particularly at the hook of the hamate and the anatomical snuff box. Finkelstein's test is particularly painful as is ulnar deviation of the wrist. You are concerned about the potential for a scaphoid fracture. What would be the most appropriate action to take?
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a. Immobilize the wrist in a thumb spica splint. Discuss your concerns with the referring physician, recommend further imaging and/or consultation with an orthopedic physician. Correct. Suspected scaphoid fractures should be treated as if a fracture is present until ruled out. A thumb spica cast is most appropriate but most physical therapists will not have access to these. Further imaging would be appropriate as well as consultation with an orthopedic physician.
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A 16 year old gymnast was doing her mat routine, when she slipped and fell, landing on on outstretched hand. At the time of injury, she was taped, and continued to tumble. Her initial x-rays were negative after the competition. She was diagnosed in the emergency room with a sprain. Now 4 weeks later, she complains of difficulty with upper extremity weight bearing position. Another x-ray was ordered. What do you see?
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b. Scapholunate instability Correct: This is a PA radiograph of wrist with scapholunate dissociation. Note the wide scapholunate interval (Terry Thomas sign). If you didn't know any of that, at least identify that 1) there is no fracture; and 2) that you can not visualize soft tissue with an x-ray. You can then deduce that the answer is scapholunate instability. Scapholunate injuries, the most common type of the wrist, results from excessive wrist extension and ulnar deviation with intercarpal supination, such as a fall on a pronated hand. Injury to the scapholunate ligament may be partial or complete, depending on the force involved. The injury is common in collision and contact sports or any activity where a fall may occur. After scapholunate ligament disruption, the scaphoid assumes a flexed position and the lunate and triquetrum extend, producing a dorsal intercalated segment instability pattern.
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All of the following are overuse syndromes of the wrist except:
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a. Subluxation of the extensor carpi ulnaris Correct: subluxation of the ECU is caused from sudden volar flexion with ulnar deviation. It is not an overuse injury. If needed, review your weekly readings: Rettig (2004).
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n general, what is the best (or 'safe') position for splinting of the hand after injury for prevention of ligamentous and muscular shortening?
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c. Wrist extended, MCP partially flexed, IP joint extended, thumb palmarly abducted. Correct: this position should help prevent ligamentous shortening and intrinsic tightness. The MCP joints are placed in some degree of flexion because the collateral ligaments are not shortened in this position. The combination of wrist extension and IP joint extension is important to prevent the extrinsic flexors from becoming tight.
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All of the following would be expected findings with cubital tunnel syndrome except ________
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d. + Pinch Grip Test Correct: This finding signifies entrapment of the anterior interosseous nerve, or weakness of the flexor pollicis longus, or a flexor tendon rupture.
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A 16 year old girl comes to you complaining of thumb pain. She was skiing during the weekend and fell, landing on her ski pole. She currently complains of thumb pain. You are suspicious of a fracture, but are uncertain. As such, contact her PCP for x-rays. What does her x-ray reveal?
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d. Bennett's fracture Correct: a Bennett's fracture is the most common of all thumb fractures. It is a fracture-dislocation of the base of the metacarpal. In this injury, a proximal metacarpal fragment maintains its ulnar aspect attachment to the trapezium via the volar ligament. The distal aspect of the metacarpal is supinated and dislocated radially by the adductor pollicis. The proximal aspect of this fragment is pulled proximally by the abductor pollicis brevis and abductor pollicis longus.
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What is the Scaphoid shift test?
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What is the Bunnell-Littler test
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What is the Murphey's Sign
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What is the Finkelstein's Test
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What is the Froment's sign
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A 19 year old NCAA Division I basketball player presents to you in the 3rd quarter of the first round of playoffs. He reports that the ball hit his finger, and that he thinks he dislocated it. Your brief evaluation confirms that indeed he has dislocated his index finger. He reports his pain is 5/10, and that he wants you to relocate it and tape it. Which of the following would be most appropriate?
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b. Immobilize the finger and transport athlete to emergency room Correct: This would be appropriate, especially given the other options. Check your state practice act, as well as the protocol with your team physician, regarding relocation of joints.
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A 16 year old heavyweight wrestler presents to you with wrist pain. Your examination reveals the following: Pain +/- snapping localized to the radioulnar joint exacerbated by forearm rotation The ulnar head is prominent dorsal, with the forearm in pronation, as compared to his contralateral side Positive piano key sign, as well as a positive shuck test Pt has pain with palpation between FCU and ulna styloid What is the most likely diagnosis?
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c. TFCC injury Correct: Ulnar wrist pain and weakness caused by a fall onto an outstretched hand may suggest injury to the triangular fibrocartilage complex (TFCC), which is the primary stabilizer of the distal radioulnar joint. TFCC injury iscommon in gymnasts and in racquetball, tennis, and hockey players.
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The role of the central slip of the dorsal extensor tendon is to:
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c. Extend the PIP joint Correct: This is a basic question that can be made unnecessarily complex. Don't get thrown off by the easy ones. The extensor slip helps to extend the PIP joint. For more info, review your readings: Leggit & Meko (2006)
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Forced flexion to an extended DIP would most likely cause what injury?
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d. Mallet finger Correct: Job well done. See Leggit & Meko (2006) from your readings if you just happened to guess!
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What is a \"Boxer's\" fracture?
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a. Fracture of the neck of the 5th metacarpal Correct: A fracture of the neck of the 5th MC is termed a \"Boxer's\" fracture. Job well done. If this was a lucky guess, go back and review your readings: Leggit & Meko (2006)
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You are performing a sensory exam on an athlete with an acute cervical and right UE injury. You utilize light touch using a cotton swab over the lateral side of the index finger and the medial side of the little finger. Which nerves are you assessing?
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b. Median & ulnar Correct: Sensation along the lateral side of the index finger and the medial side of the little finger is mediated by the median and ulnar nerves, respectively. These areas are reliable because they are unlikely to be altered by variation or by overlapping of adjacent nerves. See Washington University's graphic of hand innervation for more information.
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Which most accurately describes a sports hernia?
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b. The symptoms usually occur gradually over time and are progressive. The pathology usually involves disruption of one or many structures of the posterior inguinal canal/conjoined tendon. They are most commonly found in football players, hockey players and soccer players. Correct: Sports hernias are typically insidious, and are most frequently seen in hockey players. For a good review of sports hernias, review either Swan & Wolcott (2006), or Unverzagt et al., (2008).
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Which most accurately describes the symptoms associated with a sports hernia?
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d. The symptoms usually occur gradually over time, progressive and may be unilateral or bilateral. Correct: Symptoms are insidious, progressive, and tend to be unilateral; however, in approximately 40% of the population, symptoms will progress from unilateral to bilateral. For a good review of sports hernias, review Swan & Walcott (2006), or Unverzagt et al., (2008).
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Which of the following is an indicator that a hamstring strain will require longer rehabilitation?
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b. Injury occurred in the proximal free tendon Incorrect: According to Heiderscheit et al. (2010), \"...injuries involving an intramuscular tendon or aponeurosis and adjacent muscle fibers (biceps femoris during high-speed running) typically require a shorter convalescent period than those involving a proximal, free tendon (semimembranosus during dance and kicking). This finding is consistent with the observation that injuries involving the free tendon require a longer rehabilitation period than those within the muscle tissues.\"
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Which most accurately describes the type of sports performance that causes a sports hernia?
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a. Sports that demand rapid cutting and trunk twisting Correct: it is thought that the shearing forces caused by rapid cutting and twisting contributes to the development of a sports hernia. For an excellent review of hip and groin pain in athletes, review Anderson et al., (2001)
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A therapist goes to call her next patient from the waiting room. This patient is a young male who is 12 years old and overweight. He is presenting with left hip pain. He walks with the left lower extremity externally rotated and appears to be favoring the limb. There is no history of trauma. Based on the presentation,which of the below is the most likely diagnosis?
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d. Slipped Capital Femoral Epiphysis Correct: SCFE typically presents in the adolescent male, often African American, who is overweight. An insideous onset should tip you off. For more about hip examination in the athlete, review Braly et al (2006).
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The most common location for an acetabular labral tear is ____________.
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d. Anterior Correct! Anterior and anterior-superior tears are the most common type of labral tear due to the higher overall forces experienced by this part of the labrum. The femoral head has the least amount of bony restraint anteriorly. For an excellent review of acetabular impingements, review Martin et al. (2006)
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A 5-year-old male presents with an antalgic gait. The patients mother reports that \"He just woke up limping!\" Upon observation, the child is reluctant to move the limb and has pain in both the hip and knee. The most likely explanation for these symptoms is _______.
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b. Transient synovitis Correct! This is the most common cause of hip pain in young children, aged 5-8.
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What are the four types of labral tears?
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c. Radial flap, radial fibrillated, longitudinal peripheral, abnormally mobile Correct: According to Martin et al., (2006), the most common types of acetabular labral tears include the following: 1) radial flap; 2) radial fibrillated; 3) longitudinal peripheral; and 4) abnormally mobile. Job well done.
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A 16-year-old female runner reports a popping sensation when getting up from a chair, and during sprinting. The physical therapist notes tenderness to the femoral triangle and grades iliopsoas strength at a 4/5. The __________ is MOST likely related to her complaints of pain.
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a. Lesser trochanter Correct! This question challenges your knowledge of the femoral triangle. Since weak hip flexion and the illiopsoas are involved, and a likely place for the illiopsoas to be involved with snapping hip is the lesser trochanter, this is the best answer. The femoral triangle is bounded by: (superiorly) the inguinal ligament, (medially) the medial border of adductor longus, (laterally) the medial border of sartorius. Its floor is formed (med to lat) by adductor longus, pectineus, and illiopsoas.
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A soccer athlete reports to the your clinic two days post injury. He reports that he fell on his hip while executing a slide tackle during a game. What is his most likely diagnosis?
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c. Hip pointer Correct: Iliac crest contusion and contusion of the abdominal musculature, commonly known as a hip pointer, occur most often in contact sports. The hip pointer results from a blow to an inadequately protected iliac crest. It tends to produce immediate pain, spasms, and transitory paralysis of the soft tissue.
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The most commonly sited mechanism of injury to the labrum of the hip is:
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a. rotation in a weight-bearing position Correct: Weight-bearing rotation is the most common MOI for acetabular labral injuries. For a good review of acetabular labral tears, see Lewis & Sahrmann (2006)
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A 19 year old collegiate hockey player presents to you 3 days s/p grade II adductor strain. What of the following was his most likely precipitating factor?
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b. Decreased adductor strength Correct: In a recent study of ice hockey players, a player was 17 times more likely to sustain an adductor muscle strain if his adductor strength was less than 80% of his abductor strength (Tyler et al., 2001).
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Common exam findings of an athletic/sports hernia include all of the following except:
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a. All of the answers are common clinical exam findings Correct: According to Swan & Wolcott (2006), all of the answers are common findings associated with athletic/sports hernias.
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All of the following are components of phase one rehabilitation of a grade one hamstring strain except:
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a. Eccentric activation of the hamstring muscle Correct: Eccentric work of the hamstring would come in during phase 2 of rehabilitation, as explained in your readings. See Heiderscheit et al. (2010) for more information.
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How are femoral acetabular impingment, capsular laxity, articular cartilage degeneration, and dyspasia related to labral tears of the hip?
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d. They commonly accompany labral tears Correct: All 4 are associated with labral tears, but we can not assume a cause and effect relationship, or a linear relationship... neither have been substantiated in the literature). For more info, review your readings: Martin et al. (2006).
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A 32-year old male was referred to your therapy department by a family practice physician with a prescription to evaluate and treat including a diagnosis of left knee pain. He had a traumatic onset secondary to a kiteboarding injury resulting in left knee valgus and rotatory stresses while under leg compression. His chief complaint was left knee instability with decreased strength and function. Additional complaints include low back and left hip discomfort. He is an avid snowboarder, mountain biker and kiteboarder. Past medical history includes a T11/12 compression fracture S/P MVA in 1995; Anaphylaxis shock from a bee sting in 1999; Left knee bone bruise and meniscus tear (patient did not recall which meniscus) in 2003 as a result of a snowboarding crash. He is currently taking Ibuprofen per M.D. instruction. Observation reveals no apparent distress or gross gait deviations; no ecchymosis, discoloration, minimal left knee swelling that appears intra-articular and moderate atrophy of the left quadriceps m. He is unable to squat secondary to pain. What is the most likely diagnosis?
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a. Anterior cruciate ligament Grade II sprain, MCL Grade II sprain, medial meniscus tear Correct: The MOI of a valgus stress and rotational injury are consistent with the \"Terrible Triad.\" Additionally, the moderate quad atrophy, instabilty, and intrarticular swelling are consistent with the triad.
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A 32-year old male was referred to your therapy department by a family practice physician with a prescription to evaluate and treat including a diagnosis of left knee pain. He had a traumatic onset secondary to a kiteboarding injury resulting in left knee valgus and rotatory stresses while under leg compression. His chief complaint was left knee instability with decreased strength and function. Additional complaints include low back and left hip discomfort. He is an avid snowboarder, mountain biker and kiteboarder. Past medical history includes a T11/12 compression fracture S/P MVA in 1995; Anaphylaxis shock from a bee sting in 1999; Left knee bone bruise and meniscus tear (patient did not recall which meniscus) in 2003 as a result of a snowboarding crash. He is currently taking Ibuprofen per M.D. instruction. Observation reveals no apparent distress or gross gait deviations; no ecchymosis, discoloration, minimal left knee swelling that appears intra-articular and moderate atrophy of the left quadriceps m. He is unable to squat secondary to pain. What is your next clinical decision?
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a. Recommend to primary care physician to refer to an orthopedic surgeon Correct: The triad of an ACL sprain, MCL sprain, and a meniscus tear necessitates an MRI. It will be important to assess the location, type, and severity of the meniscus tear in particular
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When rehabilitating a patient with excessive lateral pressure syndrome of the patella, open kinetic chain exercises should be performed in what range?
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d. 50-90 degrees of knee flexion Correct: Exercises in this range would not lead to excessive compressive force through the patella. If this was a lucky guess, review your weekly readings: Reinold (2010).
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Based on the current understanding of patellar taping, which of the following is a valid assumption?
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b. An assessment of the patellar tracking is not critical prior to taping Correct! Assessing patellar position has low reliability and recent studies do not support taping's ability to alter or maintain positional changes throughout an exercise session, reducing the need for exact patellar positional assessment.
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Which of the following is not one of the key principles described by Reinhold in the treatment of patellar dysfunctions?
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a. Mobilization of the IT band Incorrect: Mobilization of the IT band is important for laterally tracking patella; however, there are many more reasons why people get patellofemoral pain. Please review Mike Reinold's e-book: Reinold (2010).
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A 33 y/o male is referred to your clinic for knee pain that started 2 weeks ago after an initial injury that occurred during a soccer game. He reports that a 'step and twist' mechanism. He was able to walk off the field and his knee became swollen over the next couple of hours. With ice and rest he is improving but still having pain when he walks prolonged distances and has been unable to return to sports. He has a mild effusion. His range of motion: full extension but has increased pain with flexion at end range. Resisted motions are mildly painful but strong, knee flexion is more painful than knee extension. Functionally squatting is painful. His knee is tender to palpation, particularly along the joint line and he also has pain with patella compression. Given the above scenario what is the most likely diagnosis?
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b. Medial meniscal tear Correct. Key discriminators: 1) Mechanism of injury: step and twist; 2) Effusion that occurs over several hours (as opposed to immediate); 3) Joint line tenderness
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A 33 y/o male is referred to your clinic for knee pain that started 2 weeks ago after an initial injury that occurred during a soccer game. He reports that a 'step and twist' mechanism. He was able to walk off the field and his knee became swollen over the next couple of hours. With ice and rest he is improving but still having pain when he walks prolonged distances and has been unable to return to sports. He has a mild effusion. His range of motion: full extension but has increased pain with flexion at end range. Resisted motions are mildly painful but strong, knee flexion is more painful than knee extension. Functionally squatting is painful. His knee is tender to palpation, particularly along the joint line and he also has pain with patella compression. What would be the most appropriate imaging modality to visualize the integrity of the ligaments and menisci of the knee?
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b. Magnetic Resonance Imaging (MRI) Correct. MRI is the most appropriate modality for imaging soft tissue such as ligaments and menisci.
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A 24 y/o male patient is referred to your clinic the day after an injury while playing intramural Soccer at the local college. He reports that he was running when he lost his balance, landed on his right knee and heard a 'pop'. He was unable to ambulate off the field and had a fairly dramatic effusion within minutes of the injury. He went to the on-campus acute care clinic, where they gave him crutches, instructions to ice his knee and referred him to your clinic. The acute care clinic also took radiographs - which are unavailable but they told the patient there was not a fracture. Upon examination you note that the patient is able to bear weight but that it is painful and he reports a feeling that his knee is going to 'give way'. There is a large effusion present. The patient has normal passive extension but extreme pain with greater than 70 degrees of flexion. Actively the patient is able to flex the knee but is unable to perform a quad set or extend the knee against gravity. A Lachman's test is painful but negative, as are valgus and varus stress tests. You do not perform further testing due to pain. The suprapatellar region is the most tender to palpation and there is a palpable defect just superior to the patella. Given the above scenario what is the most likely diagnosis?
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b. Rupture of the Quadriceps tendon Correct: Ruptures of the quadriceps tendon typically occur with a fall upon a partially flexed knee and result in an effusion and feelings of instability. Other than a palpable defect, inability to actively extend the knee is a key discriminator from other knee injuries.
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A 24 y/o male patient is referred to your clinic the day after an injury while playing intramural soccer at the local college. He reports that he was running when he lost his balance, landed on his right knee and heard a 'pop'. He was unable to ambulate off the field and had a fairly dramatic effusion within minutes of the injury. He went to the on-campus acute care clinic, where they gave him crutches, instructions to ice his knee and referred him to your clinic. The acute care clinic also took radiographs - which are unavailable but they told the patient there was not a fracture. Upon examination you note that the patient is able to bear weight but that it is painful and he reports a feeling that his knee is going to 'give way'. There is a large effusion present. The patient has normal passive extension but extreme pain with greater than 70 degrees of flexion. Actively the patient is able to flex the knee but is unable to perform a quad set or extend the knee against gravity. A Lachman's test is painful but negative, as are valgus and varus stress tests. You do not perform further testing due to pain. The suprapatellar region is the most tender to palpation and there is a palpable defect just superior to the patella. Which of the following is most appropriate?
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b. Physical therapy intervention can begin by attempting to decrease pain and swelling as well as maintaining active and passive range of motion. However, this patient also needs to be seen by an orthopedic physician as soon as possible. Delay in treatment could significantly increase the difficulty of surgery and may compromise the outcome. If an orthopedic consult is not available in a timely manner, having the patient report to an emergency room would not be inappropriate. Correct: It is difficult to determine with clinical examination alone whether a quadriceps rupture is partial or complete. However, given the patient's inability to actively extend the knee there is a high likelihood that the rupture is complete. If the rupture is not surgically repaired there is likely to be significant disability, and delay in surgery would increase the difficulty of the surgery and the likelihood of a good outcome.
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Which of the following is correct regarding anteromedial rotatory instability of the knee?
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d. The anteromedial tibial plateau subluxes anterior to the corresponding femoral condyle Correct: This is reviewed in your weekly readings. See page 583 of Lubowitz et al. (2008).
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Which of the following is not a function of the meniscus of the knee?
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b. Act as primary restraint to excessive varus/valgus force Correct: The meniscus does not play a significant role in restraining varus or valgus force across the knee. Review Heckman et al. (2006) from your readings if this is unclear, or if you just guessed!
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A 21 year old female lacrosse player suffers a hyperextension injury to her knee. The next day, your assessment reveals the following: negative Lachman, negative pivot shift, positive reverse pivot shift, negative varus and valgus at 0 and 30 degrees, and a positive dial test. There is mild effusion about the knee. Which of the following is least likely?
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a. Popliteal artery injury Correct: while the MOI is consistent with a popliteal artery tear, you are seeing her the next day, and she only has mild effusion and swelling. A popliteal artery tear, left to bleed for a day, would be catastrophic.
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Which of the following is true when comparing the jump/landing techniques of female vs. male athletes?
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a. Female athletes land with less knee flexion Correct: Females land with less knee flexion than males. This decreases their ability to absorb shock during landing. See Yu et al. (2005)
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What statement is not true regarding the mechanics of the patellofemoral joint?
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b. The odd facet makes contact with the medial femoral condyle at 20 degrees of flexion Correct: The odd facet makes contact with the medial femoral condyle at 90 degrees of flexion. For an excellent review of patellar mechanics, check out Rob Manske's slides from his recent lecture.
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The classic O'Donoghue's Triad, or \"Unhappy Triad\" was used to describe injury to the cruciates, collaterals, and the meniscus. As we learn more about the knee, we have realized that the original \"unhappy triad\" was pretty rare. Instead, we have learned that the unhappy tried usually includes injury to what 3 structures?
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d. The ACL, lateral meniscus, and the MCL Correct: Originally the \"unhappy triad\" included the ACL, medial meniscus, and the MCL. We have learned that this rarely occurs; instead, injury to the ACL, lateral meniscus, and the MCL is far more common.
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Indications for surgical reconstruction of an injured ACL include all of the following except:
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a. Isolated mid-substance ACL tear Correct: According to your weekly readings (Beynnon et al, 2005), an isolated ACL tear is not necessarily an indication for surgery. The \"mid-substance\" listed in the option is a distractor.
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A skier reports experiencing a knee injury when the downhill ski \"caught an edge\" and forced the foot to externally rotate and move away from the skier's body while the knee was relatively extended. It is one day following the injury and the knee presents with a grade II effusion, loss of both flexion and extension range of motion, and pain is reported during single limb support in gait. Which special test mimics the mechanism of injury and is more likely to produce a positive result?
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c. Slocum's Test Correct! This test can detect anterior and rotary instabilities, which is reflective of the rotational mechanism of ACL injury incurred by many skiers. In order to perform the test, the patient is supine with knee flexed 90 deg. and hip flexed 45 deg. Therapist rotates foot 30 deg. medially to test anterolateral instability or 15 deg. laterally to test anteromedial instability. Therapist stabilizes leg by sitting on foot. Therapist grasps the prox. tibia with hands and places thumb on tibial plateau and administers an anterior directed force to tibia on femur. Positive test is indicated by movement of tibia occurring primarily on lateral side, may be indicative of anterolateral instability
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A skier reports experiencing a knee injury when the downhill ski \"caught an edge\" and forced the foot to externally rotate and move away from the skier's body while the knee was relatively extended. It is one day following the injury and the knee presents with a grade II effusion, loss of both flexion and extension range of motion, and pain is reported during single limb support in gait. The structure most likely injured is the ____________.
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c. ACL Correct! This mechanism describes a valgus rotational injury, which is a common mechanism of ACL injury reported in skiers.
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A skier reports experiencing a knee injury when the downhill ski \"caught an edge\" and forced the foot to externally rotate and move away from the skier's body while the knee was relatively extended. It is one day following the injury and the knee presents with a grade II effusion, loss of both flexion and extension range of motion, and pain is reported during single limb support in gait. The portion of the anterior cruciate ligament most often injured when the knee is in extension is the _________.
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c. Posterior bundle Correct! The posteriolateral bundle of the ACL are most tight in knee extension, the anteriomedial bundle most engaged with knee flexion.
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A skier reports experiencing a knee injury when the downhill ski \"caught an edge\" and forced the foot to externally rotate and move away from the skier's body while the knee was relatively extended. It is one day following the injury and the knee presents with a grade II effusion, loss of both flexion and extension range of motion, and pain is reported during single limb support in gait. The special test most likely to detect an injury of the anterior bundle of the anterior cruciate ligament for this individual is the ______________
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b. Anterior drawer test Correct! Performing this test at 90 degrees of knee flexion will stress the anteriomedial bundle, which is most taut in this range.
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This phase of cartilage healing lasts 4-6 weeks and focuses on decreasing swelling, gradually restoring PROM and weight bearing, and enhancing volitional control of the quads.
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a. Proliferation phase Correct: According to your weekly readings (Reinold et al., 2006), this is indeed termed the proliferation phase. Well done.
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The primary component of articular cartilage is:
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d. Type II collagen Correct: See Lewis et al. (2006) for a good review on the basic science of articular cartilage.
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You are seeing a patient who is 5 weeks s/p ACL reconstruction with a bone-patellar tendon-bone autograft. Which of the following interventions is inappropriate?
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a. Open chain leg extensions between 60 and 30 degrees Correct: OKC knee extension has been shown safe between the ranges of 90-70 degrees. Anything greater than 70 degrees will put increased stress through the patella, and can lead to increased anterior shear of the tibia. See Flemming et al. (2005) for a review of OKC vs. CKC exercises after ACL-R.
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An 26 year old male recently suffered his second non-contact ACL tear on this right LE. His first was reconstructed with an BPTB autograft 4 years ago. The MRI currently reveals a 2x2 cm, grade IV, focal articular cartilage lesion of the medial femoral condyle, a partially torn medial meniscus, as well as a ruptured ACL. The decision was made to perform an arthroscopic meniscus debridement, ACL reconstruction using an allograft, as well as an articular cartilage procedure. Based on this individual's presentation, which articular procedure appears the most appropriate?
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b. Microfracture Correct: Microfracture has been shown to have excellent long term results. Additionally, The microfracture technique is a reasonable first-line approach to the treatment of full thickness chondral defects. This technique does not burn any bridges with regard to future procedures such as a mosaicplasty or an autologous chondrocyte transplant as a second procedure should the microfracture fail. See Lewis et al. (2006) for articular cartilage basic science and treatment options
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An 26 year old male recently suffered his second non-contact ACL tear on this right LE. His first was reconstructed with an BPTB autograft 4 years ago. The MRI currently reveals a 2x2 cm, grade IV, focal articular cartilage lesion of the medial femoral condyle, a partially torn medial meniscus, as well as a ruptured ACL. The decision was made to perform an arthroscopic meniscus debridement, ACL reconstruction using an allograft, as well as an articular cartilage procedure. You inform this patient that the new cartilage will not be the same as the native cartilage. Which of the following accurately depicts the relationship between the native and new cartilage?
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c. The hyaline cartilage is replaced by fibrocartilage, which has decreased resiliance compared to native tissue Correct: The fibrocartilage has inferior stiffness, inferior resilience, and poorer wear characteristics than does normal hyaline or hyaline-like articular cartilage
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An 26 year old male recently suffered his second non-contact ACL tear on this right LE. His first was reconstructed with an BPTB autograft 4 years ago. The MRI currently reveals a 2x2 cm, grade IV, focal articular cartilage lesion of the medial femoral condyle, a partially torn medial meniscus, as well as a ruptured ACL. The decision was made to perform an arthroscopic meniscus debridement, ACL reconstruction using an allograft, as well as an articular cartilage procedure. Now 3 weeks status post surgery, current research supports what activity?
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b. Toe touch weight bearing Correct: Controlled compression and decompression forces observed during weight bearing may nourish the articular cartilage and provide the necessary signals to the repair tissue to produce a matrix that will match the environmental forces. Gentle compression is encouraged; no rotation is allowed, however. See clinical commentary by Reinold & Wilk, 2006.
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An 18 year old male presents to your clinic 6 weeks s/p ACL reconstruction with a bone-patellar-tendon autograft. He reports that he has been working with his athletic trainer from the high-school. At his initial assessment, you find that he has full knee extension, but is limited to 75 degrees knee flexion. He complains of knee pain, especially in his posterior calf and in the popliteal fossa. He has mild-moderate joint effusion. What is the most likely cause of the limited ROM?
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b. Anterior placement of the femoral tunnel Correct: The biggest reason for failure with ACL reconstructions is surgical error. The most likely cause for a loss of flexion includes drilling the femoral tunnel too anterior. A loss of extension can be secondary to anterior placement of the tibial tunnel.
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The ACL experiences the most stress/strain during which range of motion?
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b. 0-50 degrees of flexion Correct: According to your weekly readings (Beynnon et al., 2005) this would be the best answer.
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Reduction of pain and effusion is important in the post operative rehabilitation of an articular cartilage injury primarily because:
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a. Excess pain and effusion inhibits quadriceps activation, which is vital to regain Correct: Elimination of pain and effusion are a vital step in restoring volitional quad control. For more info, review your readings: Reinold et al. 2006.
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Based on the article by Flemming et al. (2005) included in your weekly readings, it is recommended that one should consider which of the following options when rehabilitating an individual s/p ACL reconstruction with an allograft?
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d. Using OKC exercises in combination with CKC exercises because it is shown that they can be incorporate safely and result in an improved outcome Correct: For one thing, the \"allograft\" is a distractor. It doesn't matter what type of graft it is. Otherwise, this was indeed the conclusion of the authors... that OKC and CKC exercises can, and should, be utilized s/p ACL-R
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The most appropriate intervention for a 55 year old runner with Achilles tendonosis is likely to be:
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b. A therapeutic exercise program focusing on stretching the gastroc/soleus complex and heavy-load eccentric exercise. Correct: Both stretching the gastroc/soleus complex and eccentric exercise are appropriate. Eccentric exercise has a growing body of evidence supporting its efficacy over concentric exercise in Achilles tendinopathy. One theory that may explain why eccentric exercise is more effective is that it is thought to counteract the failed healing response that apparently underlies tendinopathy and facilitates tendon remodeling.
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According to your weekly readings, the 3 main factors that decrease the compliance of foot orthoses & bracing in athletes include which of the following?
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b. Discomfort of brace, belief that the brace may have an adverse effect on performance, and possible skin irritation Correct: According to your weekly readings (Gross & Liu, 2003), compliance with bracing & orthoses is decreased secondary to discomfort of the brace, belief that the brace may have an adverse effect on performance, and possible skin irritation.
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The following are all considered critical stress fracture sites:
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a. Anterior tibia, medial malleolus, navicular Correct: According to Wilder & Sethi (2004) from your required readings, these are all critical locations for a stress fracture. Critical stress fractures require special attention due to a higher rate of nonunion, and include the anterior tibia, medial malleolus, talus, navicular, fifth metatarsal, and sesamoids. Noncritical stress fractures in the lower leg, foot, and ankle include the medial tibia, fibula, and metatarsals 2, 3, and 4. Treatment of these stress fractures requires relative rest.
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A 17 year old male football player is referred to your clinic for a syndesmotic ankle injury. Which of the following mechanisms of injury reported during a football injury is most likely to cause a syndesmotic ankle injury?
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a. A direct blow to the lateral knee, with the foot remaining planted on the ground in relative external rotation. Correct: This situation would force a widening of the ankle mortise and potentially rupture the ligamentous structures responsible for stabilizing the distal syndesmotic articulation.
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You are evaluating an individual 2 days s/p syndesmotic ankle sprain. For the first 2 weeks, which of the following non-surgical treatment approaches would be most appropriate?
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c. PRICE, immediate non-weight bearing with crutches, a posterior splint with the ankle positioned in ten degrees plantar-flexion. Correct: The early phase of rehab is designed to hasten tissue healing and prevent further injury to the distal tibiofibular syndesmosis and the surrounding tissues.
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You are evaluating a 19 year old college level cross country runner. His referral is for \"evaluation and treatment of unilateral, chronic shin splints\". He reports that he is not painful at rest or with walking, but has increasing pain starting at 3 miles that forces him to stop running at 4.5 miles. Upon standing, static examination you note that he has a rear-foot with calcaneal varus position that is rigid, with a fairly rigid forefoot valgus. He has genu varum at the knee. His walking gait is non-antalgic and you notice decreased pronation bilaterally. When you have him run until symptoms begin he reports pain along the anterior tibia and just lateral. This area is tender to palpation. He also reports feeling like his foot is tingling. You perform sensation testing and find decreased sensation between the great and second toe on the painful extremity. The pain and paresthesia decrease within 30 minutes after running. What is the most appropriate running shoe for this individual?
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d. A shoe with a curved, slip last that is comfortable when he runs in them at the store Correct. Curved, slip lasted shoes provide flexibility vs. stability. These shoes are often called 'cushioned'. The patients rigid rear-foot varus with forefoot valgus would not be expected to demonstrate adequate subtalar pronation. A flexible shoe would aid with shock absorption and help prevent overuse injuries.
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You are evaluating a 19 year old college level cross country runner. His referral is for \"evaluation and treatment of unilateral, chronic shin splints\". He reports that he is not painful at rest or with walking, but has increasing pain starting at 3 miles that forces him to stop running at 4.5 miles. Upon standing, static examination you note that he has a rear-foot with calcaneal varus position that is rigid, with a fairly rigid forefoot valgus. He has genu varum at the knee. His walking gait is non-antalgic and you notice decreased pronation bilaterally. When you have him run until symptoms begin he reports pain along the anterior tibia and just lateral. This area is tender to palpation. He also reports feeling like his foot is tingling. You perform sensation testing and find decreased sensation between the great and second toe on the painful extremity. The pain and paresthesia decrease within 30 minutes after running. Based upon the information give, what is the most appropriate PT diagnosis for this individual?
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d. Exertional Compartment Syndrome Correct. Exertional compartment syndrome, of the anterior compartment of the leg in this case, occurs when the muscles that are metabolically active during exercise swell during exercise, compressing the neurovascular structures in the compartment. In this case the deep peroneal nerve that runs through the anterior compartment of the leg is being compressed and can cause decreased sensation in the web space between the 1st and 2nd toes. The symptoms typically improve with rest after exercise. Other signs might be pain with stretch or a taut feeling compartment. Impairment based therapeutic exercise, activity modification, running gait instruction and shoe selection may help in some cases.
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As part of your required readings, you reviewed Nawoczenski & Janisse (2004) as they discussed foot orthoses in rehabilitation. According to the authors, should individuals with pes planus be provided an orthoses? If so, what is the best orthoses to prescribe them?
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c. Yes, an orthoses is indicated. Provide them with an over the counter full length insole with added medial support Correct: According to your readings, (Nawoczenski & Janisse, 2004) an orthoses is indicated. They should be provided an over the counter full length insole with added medial support. You will want to make sure you have a good command of foot orthotics prior to taking this exam, and so know specific orthotic modifications well
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You are the physical therapist for a collegiate women's Rugby team. A team member sprained her ankle during practice yesterday. She reports a plantar flexed and inversion mechanism of injury, with immediate effusion. She was able to walk off of the field and is able to bear weight with pain although she has a fairly dramatic antalgic gait if she tries to walk without crutches. With testing she has near full passive range of motion with pain at end ranges and a positive anterior drawer and inversion stress test. She is tender over the anterior lateral malleolus and along the ATFL insertion and the base of the fifth metatarsal. She is not tender at the medial malleolus or the navicular. She is neurovascularly intact. According to the Ottawa ankle rules, which of the following is correct?
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a. This patient needs radiographs. In addition to an AP/lateral and mortise view of the ankle an AP/lateral and oblique view of the foot should be taken. Correct: Bony tenderness at the base of the fifth metatarsal is sufficient reason to order radiographs. This set of views of the foot are the most appropriate to image a possible Jones fracture (fracture of the base of the fifth metatarsal)
question
You are the physical therapist for a collegiate women's Rugby team. A team member sprained her ankle during practice yesterday. She reports a plantar flexed and inversion mechanism of injury, with immediate effusion. She was able to walk off of the field and is able to bear weight with pain although she has a fairly dramatic antalgic gait if she tries to walk without crutches. With testing she has near full passive range of motion with pain at end ranges and a positive anterior drawer and inversion stress test. She is tender over the anterior lateral malleolus and along the ATFL insertion and the base of the fifth metatarsal. She is not tender at the medial malleolus or the navicular. She is neurovascularly intact. After radiographs and an evaluation with the team orthopedic physician the patient was found to have a fracture in Zone 2 of the proximal fifth metatarsal. Which of the following statements is correct regarding the orthopedic management of this injury?
answer
d. Acute fractures in zone 2 are at risk of mal or non-union. Most cases will be able to be treated non-surgically with cast immobilization for 6-8 weeks, but early internal fixation may be considered for some patients, such as the athlete in this scenario. Correct. Mismanagement of a fifth metatarsal fracture may result in metatarsalgia with a plantar callus or chronic lateral foot pain.
question
Which best describes Tarsal Tunnel syndrome?
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a. A complex of symptoms caused by compression neuropathy of the tibial nerve or its branches. Correct: The tibial nerve or its branches (medial plantar nerve or first branch of the lateral plantar nerve) can be compressed posterior to the medial malleolus. The compression can be from a variety of sources - usually unknown. The symptom complex caused by this compression (vague burning pain to the medial ankle, tenderness and usually + Tinel's sign, sometimes paresthesia or sensory disturbance to the tibial nerve distribution on the plantar foot) is referred to as tarsal tunnel syndrome.
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A 50 year old runner complains of Achilles pain over the past 12-18 months. He presents to your clinic reporting that after performing intervals last week, his Achilles pain has increased substantially. His examination reveals 4-/5 PF MMT with marked pain, swelling, moderate hypertrophy of the Achilles tendon, and point tenderness along the distal 1/4 of the Achilles tendon. Which of the following best describes his condition?
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a. Achilles tendonosis Correct: Tendonosis is common in tendonous injuries lasting >6-12 months. The tendon is actually degenerative, not not undergoing an active inflammation. The treatment of a tendonitis is very different then that of a tendonosis. See Rees et al. (2009) for more about tendonopathy.
question
Your required readings included an article by Gross & Liu (2003) regarding ankle bracing. The general consensus of the authors is that ankle bracing:
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a. Is generally successful in reducing ankle sprains Correct: Ankle bracing has been shown time and time again to help reduce ankle sprains, especially in chronic sprainers. While it is not perfect, it has certainly been shown to be cost effect. Any questions, go back and review your required readings: Gross & Liu, 2003.
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A 16 y.o. competitive gymnast presents with a complaint of acute central low back pain. Her pain is worsened with the combined movements of extension, ipsilateral rotation, and side bending of her lumbar spine. She denies any LE pain or motor weakness. Her symptoms began following an increase in the intensity of her training 3 weeks ago. Pt reports pain is becoming so intense she is unable to perform a back bend. What is the most likely diagnosis?
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a. Spondylolysis Correct: Spondylolysis is common in gymnasts, and typically stems from repeated hyperextensions. For a good review of pediatric \"spondy\" injuries, review Herman et al. (2003)
question
You are working on the sideline of a football game, and observe helmet to helmet contact between two players. You noticed that, just prior to contact, one player looked down and then struck the other player. The player you observed immediately comes to the sideline complaining of pain in the shoulder, arm, and hand. A sensory examination reveals decreased sensation over the lateral right arm and into the thumb and index finger. You conduct a thorough examination of the cervical spine, and fail to identify any signs of cervical fractures, instability, or ligamentous laxity. You diagnose the individual with a \"burner.\" Within 30 minutes, the athlete reports that his symptoms have resolved. Which of the following is most consistent with his type of injury?
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d. Neuropraxia Correct: A neuropraxia is a transient episode of motor and/or sensory paralysis. In football players, it typically involves the C5/C6 nerve roots. Of note, there is no disruption of the nerve or its sheath with neuropraxia. This is often called a \"grade I\" burner, and will typically resolve in minutes to hours. Sometimes, however, symptoms can persist for up to 6-8 weeks.
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According to Richardson et al (1997) the global muscles of the core include all of the following muscles except:
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b. Transversus abdominis Correct: Panjabi et al (1989) suggested that global muscles play an important role in stabilization due to their ability to efficiently produce stiffness in the entire spinal column, as compared to local muscles acting on only a few levels. The global muscle system appears to be most limited in its ability to control segmental shear forces. See the following from Faries & Greenwood (2007).
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According to Wainner et. al (2003), which of the following statements is true regarding the test-item cluster for diagnosing cervical radiculopathy?
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a. If at least three of the items in the cluster are present, there is a high suspicion for cervical radiculopathy. Correct: The test item cluster consists of: + upper limb tension test A, + Spurling's test, + Distraction test, and cervical rotation < 60 degrees to the ipsilateral side. With the presence of 3 of the test items the + likelihood ratio is 6.1, dramatically increasing the post-test probability of a cervical radiculopathy (diagnosed by needle EMG as the gold standard) being present. See User's guide to the MS exam p. 100 or Wainner et al. Spine 2003. (Wainner et al. Spine 2003)
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When differentiating between C6 nerve root compression and median nerve entrapment, which of the following will indicate a C6 nerve root compression?
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d. Decreased biceps tendon reflex Correct! This deep tendon reflex does not receive any contribution from the Median nerve and so is able to differentiate between these two conditions.
question
It is hypothesized that core strength is more important to the female athlete as compared to the male athlete because:
answer
b. Females have overall decrease in total extremity strength Correct: According to SPTS's Home Study Course, \"Rehabilitation Concerns for the Female Athlete\" (2005), core stability may even be more vital for the female athlete due to her overall decreased total extremity strength as compared to her age-matched male participant (UE's 40-75%, LE's 60-80%).
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When performing a neurological screening examination on a collegiate rower with neck pain and a report of numbness/tingling to the hand (1st three digits) you record the following findings: Strength: bilaterally WNL upper and lower extremities. Sensation: intact and bilaterally symmetrical to light touch upper and lower extremities. Deep Tendon Reflexes: Brachioradialis Reflex: R = 2+; L = 2+ Biceps Brachii Reflex: R = 2+; L = 2+ Triceps Reflex: R = 2+; L = 2+ Patellar Reflex: R = 3+; L = 3+ Achilles Reflex: R = 3+; L = 3+ Hoffman's Reflex: present bilateral Babinski Reflex: Toes downward bilateral The patient does not report any other neurological signs (such as headaches, dizziness, etc.), denies any history of head trauma and has a normal gait. He has plain films that revealed mild DJD of his c-spine and no other imaging. The above presentation is most consistent with which of the following diagnoses?
answer
c. Cervical myelopathy Correct. Hoffman's Reflex is an upper motor neuron sign, as is hyperreflexia. It is not uncommon to have hyperreflexia of the lower extremities only with cervical myelopathy. The babinski reflex is not present with toes going down - but may be a false negative.
question
Which of the following best describes a positive prone instability test?
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a. The patient lies prone with the body on the examination table and legs over the edge with feet resting on the floor. The test is positive if pain provoked with posterior to anterior pressure to the lumbar spine in the resting position subsides when the pressure is repeated while the patient is lifting the legs off of the floor. Correct: Note also that the test cannot be performed if the provocative posterior to anterior pressure is not painful at 1 or more segments. The PIT is part of a clinical prediction rule developed by Hicks et al. (2005). Alone it has a sensitivity of .72 (-LR .48) and specificity of .58 (+LR of 1.7). (Flynn - User's Guide - 2007)
question
According to the evidence, which of the following tests have been shown to be useful in the identification of patients with ligamentous instability of the cervical spine?
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c. Sharp-Purser test Correct: Validated in a rheumatoid arthritis population with a gold standard of an atlanto-dens interval greater than 3mm on full flexion and extension lateral radiographs, the Sharp-purser test has a + likelihood ratio of 17.3. With these diagnostic properties the presence of this test would result in an extreme increase in the post-test probability of ligamentous instability. It is moderately good for helping to rule out ligamentous instability (-LR of .32, sensitivity of .69). For more on Likelihood ratios see the EBP Section.
question
How does the internal oblique work eccentrically?
answer
b. contralateral rotation, extension, and contralateral flexion Correct: A proper understanding of local and global musculature, and their function, is vital for this exam.
