The Physio Notebook

A Guidebook for Diastasis Recti By Veronica Kirigo Introduction Chapter One Chapter Two Chapter Three Chapter Four Conclusion 3 4 6 8 9 11 Contents Hi, I’m Veronica Kirigo Licensed Physiotherapist Women’s Health AdvocateINTRODUCTION I am a licensed physiotherapist under the Physiotherapy Council of Kenya, deeply committed to helping individuals move, heal, and thrive through evidence- based physiotherapy. My passion lies in women’s health, particularly in raising awareness and providing practical, science-backed solutions for conditions like diastasis recti, pelvic floor dysfunction, and postpartum rehabilitation. With a background in clinical practice, education, and advocacy, I believe that knowledge is power—and that every woman deserves access to accurate, professional guidance about her body. I have seen firsthand how conditions like diastasis recti and pelvic dysfunction can impact confidence, daily function, and overall well-being, often due to misinformation or lack of awareness. That’s why I am dedicated to bridging the gap between research, healthcare, and the everyday experiences of women by translating complex medical concepts into clear, actionable advice. My approach to physiotherapy is holistic and patient-centered. I combine my clinical expertise, hands-on experience, and continuous professional development to provide care that is not only effective but also empowering. Whether through one-on-one consultations, educational workshops, online content, or advocacy, my mission is to equip women with the tools they need to take control of their health—without fear or confusion. Beyond my clinical work, I am actively involved in health education and awareness initiatives, working to create conversations around women’s health that are open, informed, and free from stigma. By integrating evidence-based practice, clinical experience, and a passion for education, I strive to be a trusted voice in women’s health, ensuring that every woman has the support and knowledge she needs to feel strong, capable, and confident in her body HTTPS://KIRIGO.CO.KE/ CHAPTER ONEDiastasis Recti (DR) is a condition characterized by the separation of the rectus abdominis muscles, commonly referred to as the 'six-pack' muscles. This separation occurs due to the stretching of the linea alba, a band of connective tissue that connects the left and right sides of the abdominal muscles. The linea alba plays a crucial role in maintaining core stability, and when weakened, it can lead to reduced support for the spine and pelvic structures. Although DR is most commonly associated with pregnancy due to the natural expansion of the abdomen, it can also occur in other populations. Men who engage in improper weightlifting techniques, individuals with obesity, and those who experience frequent abdominal strain due to chronic coughing, constipation, or heavy lifting may also develop this condition. Athletes, particularly those involved in high-impact sports or excessive abdominal training without proper core activation, are at risk as well. Understanding DR and its implications is essential for anyone looking to enhance their core strength, prevent complications, and restore functional movement. Left untreated, DR can contribute to poor posture, lower back pain, hernias, and inefficient core engagement. This guide, written from a physiotherapist’s perspective, aims to educate you on DR by covering its causes, symptoms, treatment approaches, and evidence-based recovery strategies. Through proper education, assessment, and individualized rehabilitation plans, individuals can take proactive steps to regain core function and overall well- being. The information in this book is designed to provide clear, actionable strategies to help readers take control of their recovery and promote optimal core health. Introduction to diastasis recti The abdominal wall is composed of multiple muscle groups that work together to support posture, breathing, and movement. The rectus abdominis runs vertically from the rib cage to the pelvis and is divided by the linea alba. The integrity of the linea alba is essential for abdominal strength and function. When this connective tissue becomes overstretched, the muscles lose their ability to provide proper support to the core, resulting in Diastasis Recti. Beneath the rectus abdominis lies the transverse abdominis (TrA), a deep core muscle that acts like a natural corset, providing stability to the spine and pelvis. The TrA works in coordination with the internal and external oblique muscles, which contribute to rotational and lateral movements. Additionally, the pelvic floor muscles play an essential role in supporting the abdominal wall and maintaining intra-abdominal pressure. The abdominal wall is not just about muscles; it also contains fascia, nerves, and blood vessels that contribute to overall function. The fascia surrounding the core muscles helps transmit forces across the body, ensuring efficient movement and stability. If these connective tissues become overly stretched or weakened, as seen in DR, they can compromise movement mechanics and lead to compensatory patterns that may result in further dysfunction. By understanding the anatomy of the abdominal wall, you can appreciate why certain rehabilitation exercises focus on deep core activation rather than traditional abdominal workouts like sit-ups. Strengthening the transverse abdominis and pelvic floor muscles is a key component of recovering from DR and preventing its recurrence. Anatomy of the Abdominal Wall Pregnancy and Hormonal Changes During pregnancy, the growing uterus stretches the abdominal muscles and connective tissue, often leading to DR. The body produces hormones like relaxin and progesterone, which help loosen ligaments and connective tissues in preparation for childbirth. While these hormones are essential for pregnancy, they also contribute to the weakening of the linea alba, increasing the risk of DR. Many women experience some degree of DR by the third trimester, though its severity varies. Factors that may increase the likelihood of developing DR during pregnancy include multiple pregnancies, carrying large babies, excessive weight gain, and poor core strength before or during pregnancy. Women with a shorter torso may also be at higher risk since the abdominal wall has less space to expand. Improper Core Exercises Exercises that place excessive pressure on the abdominal wall, such as traditional crunches, sit-ups, and heavy lifting without proper technique, can exacerbate or cause DR. When the deep core muscles are not engaged correctly, intra- abdominal pressure increases, straining the linea alba and potentially worsening the separation. Athletes, fitness enthusiasts, and postpartum individuals attempting to regain core strength may unknowingly perform exercises that aggravate DR. It is crucial to learn safe, core-friendly exercises that promote proper muscle activation and minimize excessive stress on the midline. Chronic Straining Chronic straining from heavy lifting, persistent coughing, or constipation can place repetitive pressure on the abdominal wall, increasing the risk of DR. Conditions such as obesity and frequent bloating can also contribute to excessive abdominal pressure, weakening the linea alba over time. Poor posture and improper breathing mechanics can further exacerbate the problem. When individuals fail to engage their deep core muscles during everyday activities, they create movement compensations that put unnecessary strain on the abdominal wall, potentially leading to or worsening DR.Causes and Risk Factors of diastasis recti Signs and Symptoms of Diastasis Recti (DR) Diastasis recti is not always painful or immediately obvious, especially in the early stages. However, there are key signs and symptoms that can alert someone to the presence of this condition. Understanding these can help individuals seek proper assessment and intervention early on. 1. Visible Bulge or “Doming” of the Abdomen One of the most noticeable signs of DR is a visible bulge or a raised ridge running vertically down the midline of the abdomen, particularly noticeable during movements that engage the core—such as sitting up from a lying position, coughing, or lifting something heavy. This bulge, often referred to as “doming” or “coning,” is caused by the separation of the rectus abdominis muscles and the thinning of the connective tissue (linea alba) between them. This weakened midline lacks the tension needed to hold the abdominal contents in place, allowing them to push outward. �� Note: This symptom is often most visible when lying flat and attempting to lift the head or shoulders without proper core activation. 2. Lower Back Pain The abdominal muscles, especially the deep core muscles, play a critical role in stabilizing the spine. When the rectus abdominis is separated and the core is weakened, this stability is compromised. The lower back muscles may overcompensate for the lack of support, leading to discomfort, tightness, or even chronic pain in the lumbar region. Poor spinal support also increases the risk of strain during everyday movements like lifting a child, bending, or even standing for long periods. �� Think of your core as a canister—if one side is weak or compromised, pressure and support become unbalanced, putting strain on other areas like your back. 3. Poor Posture and Spinal Misalignment DR can significantly affect posture. As the core muscles weaken and the midline loses integrity, it becomes harder to maintain an upright, aligned position. This may result in an anterior pelvic tilt (where the pelvis tilts forward), increased lumbar lordosis (excessive inward curve of the lower back), or a forward head posture. Over time, poor posture can lead to muscle imbalances, joint pain, and reduced efficiency in body mechanics. �� Postural changes due to DR may not always be obvious at first, but they can gradually contribute to feelings of fatigue, imbalance, and discomfort. 4. Core Weakness and Functional Limitations A hallmark symptom of DR is general core weakness. Individuals may notice difficulty with tasks that previously felt easy—such as standing from a low chair, lifting groceries, or carrying a child. This is because the separation compromises the synergy between abdominal muscles, reducing intra-abdominal pressure and affecting the body’s ability to generate strength and stability. Common complaints include: Difficulty bracing or “engaging” the core Trouble maintaining balance, especially during dynamic movements Early fatigue during physical activity Reduced control during exercises like planks or leg lifts �� This weakness isn’t just physical—it often leads to a lack of confidence in movement, which may cause people to avoid activity and lose further strength. 5. A Feeling of "Looseness" or Gap in the Abdominal Wall Many individuals with DR describe a sensation of looseness or “emptiness” in the abdominal area. This may be felt when pressing on the belly—particularly along the linea alba between the belly button and the pubic bone. In more advanced cases, there may be a noticeable gap between the two halves of the rectus abdominis muscles (often measured in finger widths by a trained professional). This lack of tension not only affects physical strength but can create an unsettling sense of instability, especially when moving quickly or shifting directions. �� This physical gap can vary in width and depth depending on posture, muscle engagement, and time since onset (e.g., postpartum period). Additional Symptoms That May Be Present: Pelvic floor dysfunction (e.g., incontinence, pelvic heaviness) due to core-pelvic floor imbalance Bloating or digestive discomfort—some individuals report abdominal distension after meals or throughout the day Hernias in severe cases, where abdominal contents push through the weakened midline Emotional impact, including body image concerns or frustration over limited progress with traditional core workouts Why These Signs Matter These signs and symptoms are not just cosmetic or inconvenient— they reflect a deeper imbalance in the body’s functional system. Without proper rehabilitation, DR can continue to impact quality of life, posture, movement patterns, and overall physical confidence. Early recognition, proper education, and guided physiotherapy interventions are key to restoring strength, function, and body awareness. CHAPTER TWO Understanding Postpartum Abdominal ChangesThe Postpartum Body: A Natural Transition Pregnancy initiates one of the most transformative processes in a woman’s body, requiring immense structural and functional adaptations to accommodate the growing baby. After childbirth, many women experience abdominal changes, leading to concerns about persistent belly bulge, core weakness, or even discomfort. Despite the cultural pressure to "snap back" after pregnancy, see Amber Ray after birthing Africanah, postpartum recovery is a gradual process that varies from woman to woman. Some may find their stomach returning to near pre-pregnancy form within a few months, while others may struggle with lingering abdominal separation, skin laxity, or core instability for longer. This chapter explains the physiological mechanisms behind these postpartum abdominal changes, the role of muscles, connective tissues, and hormonal influences, and why some women experience more persistent abdominal concerns than others. The Role of the Uterus and Abdominal Muscles During pregnancy, the uterus expands up to 500 times its original size, pushing other organs out of the way and stretching the abdominal wall. This pressure and expansion cause significant stretching of the abdominal muscles and skin. After delivery: The uterus gradually shrinks back to its original size over 6-8 weeks through a process called involution. The abdominal muscles, which were stretched for months, may take much longer to regain their strength and tone. The connective tissue (linea alba) between the abdominal muscles may remain stretched, causing a condition called diastasis recti (abdominal separation). The extent of these changes depends on various factors, including: Number of pregnancies – Women with multiple pregnancies may experience more pronounced changes. Baby size – Carrying larger babies or twins increases abdominal muscle strain. Genetics – Some women naturally have more elastic connective tissue, allowing for better recovery. Activity level – Engaging in core-strengthening exercises before and during pregnancy can help prevent severe muscle separation. 1. The Role of Muscles in Core Support The core is more than just your "abs." It's a dynamic system made up of deep and superficial muscle layers that work together to stabilize the spine, pelvis, and internal organs. These include: Rectus Abdominis: Commonly known as the “six-pack” muscle, it stretches vertically from the rib cage to the pubic bone. During pregnancy, it naturally separates to accommodate the growing uterus. Transverse Abdominis (TrA): This is the deepest abdominal muscle, wrapping around the torso like a corset. It plays a major role in stabilizing the spine and pelvis and maintaining internal pressure. Its function is crucial during pregnancy and recovery. Obliques (Internal and External): These muscles help with rotation, side bending, and postural support. They also contribute to breathing and trunk stability. Pelvic Floor Muscles: These form the base of the core and help manage intra- abdominal pressure while supporting pelvic organs. During vaginal delivery, these muscles may stretch or tear, further altering core stability. �� Together, these muscles work like a supportive cylinder. When any part weakens—especially the TrA and pelvic floor—the entire system struggles to function well. 2. Connective Tissue: The Linea Alba and Fascia Linea Alba: A fibrous band of connective tissue that runs from the sternum to the pubic bone. It connects the left and right sides of the rectus abdominis. During pregnancy, hormonal and mechanical factors cause it to stretch and thin. Fascia: This connective tissue surrounds and links all abdominal muscles. It’s responsible for transmitting force across the core, maintaining posture, and coordinating movement. After childbirth, the quality of this tissue plays a large role in recovery. Some women may have a linea alba that regains tension, while others experience lingering laxity and separation. �� Think of the fascia like elastic—some stretches bounce back easily, while others remain overstretched and need guided rehab to regain tension. 3. Hormonal Influences on Core Tissues Relaxin: This hormone increases during pregnancy to soften ligaments and connective tissues, allowing the pelvis and abdomen to expand. However, it can also make tissues more prone to overstretching. Estrogen & Progesterone: These also affect connective tissue and fluid retention. Their levels drop sharply postpartum, which may influence tissue healing. Oxytocin & Prolactin: While essential for bonding and breastfeeding, these can also impact fatigue and energy availability for recovery, especially when sleep-deprived. ��️ Every woman’s hormonal profile is different. This partially explains why some bounce back quickly and others require longer, more structured rehab. 4. Why Some Women Experience More Persistent Issues Recovery after childbirth is not one-size-fits-all. Several factors influence the severity and persistence of abdominal concerns like DR: Genetics: Some women naturally have more elastic connective tissue or smaller abdominal separation. Pregnancy Factors: Carrying multiples, large babies, or having closely spaced pregnancies increases abdominal strain. Delivery Type: Vaginal delivery, C-section, or assisted birth each impact different muscles and tissues. Lifestyle & Movement Patterns: Lifting toddlers, returning to exercise too quickly, or poor posture can delay healing. Core Activation Strategies: Lack of awareness on how to properly engage the TrA or over-reliance on superficial muscles can hinder recovery. �� Education is key—understanding your body empowers you to take the right steps toward healing. HTTPS://KIRIGO.CO.KE/ Diastasis Recti in pregnancy: What Causes Diastasis Recti? Hormonal Changes: During pregnancy, the hormone relaxin is released to loosen ligaments and connective tissues in preparation for birth. This makes the linea alba more vulnerable to excessive stretching. Excessive Pressure on the Abdominal Wall: As the baby grows, constant outward pressure stretches the connective tissue, especially in women with a weaker core before pregnancy. Repetitive Incorrect Movements: Poor posture, improper core exercises, or straining (e.g., incorrect lifting techniques) during or after pregnancy can worsen separation. Multiple Pregnancies or Close Pregnancies: Repeated stretching of the abdominal wall without sufficient recovery time can weaken the linea alba over time. C-sections and Surgical Trauma: While diastasis recti occurs whether a woman has a vaginal or cesarean delivery, surgical incisions can further weaken abdominal function and impact healing. Pre-existing Core Weakness: Women who have weak core muscles before pregnancy are more likely to experience severe separation. CHAPTER THREEHTTPS://KIRIGO.CO.KE/ Assessment and Diagnosis of Diastasis Recti Early and accurate identification of Diastasis Recti (DR) is key to creating a tailored recovery plan. This chapter explains how individuals can check for signs on their own and why professional evaluation by a physiotherapist offers deeper insight into core function and healing needs. 1. Self-Check Method A quick, safe way to assess yourself at home: Step-by-step self-assessment: 1.Lie on your back with knees bent, feet flat on the floor. 2.Place one hand behind your head and the other hand on your abdomen, fingers pointing downward at the midline (above the belly button). 3.Gently lift your head and shoulders slightly off the ground as if doing a small crunch—just enough to engage the abdominals. 4.Press your fingers down into your midline: Start just above the belly button, then below it. Check for any gap or softness where your fingers sink in. Count how many fingers fit in the gap. Interpreting your findings: A gap of 1-2 finger widths may be considered normal in postpartum individuals and can resolve naturally. A gap of 2.5 fingers or more, especially with doming, softness, or discomfort, may indicate Diastasis Recti. If the tissue feels very soft or squishy, that may point to weakened fascia, needing attention. �� Note: A self-check gives you a general idea, but should not replace professional evaluation 2. Professional Physiotherapy Evaluation Seeing a trained physiotherapist ensures a comprehensive assessment that looks beyond the surface: ✅ Detailed Gap Measurement: Physiotherapists use palpation or tools like calipers or ultrasound to measure: Inter-rectus distance (the horizontal gap between muscles) Depth of the separation, indicating how compromised the connective tissue is ✅ Core Muscle Function Test: Assesses how well deep core muscles (like the transverse abdominis and pelvic floor) activate Tests for coordination between breathing and core engagement Identifies compensatory patterns (e.g., holding breath, gripping with superficial muscles) ✅ Functional Movement Screening: Looks at how your core behaves during daily movements: Getting up from bed Lifting objects Sitting or standing posture Breathing and abdominal bracing Identifies risk for pelvic floor issues, low back pain, or poor movement mechanics ✅ Screening for Associated Issues: Pelvic floor dysfunction (incontinence, heaviness) Pelvic girdle or SI joint instability Low back pain or hip tightness Posture-related tension in the thoracic spine, rib cage, or diaphragm �� The goal is not just to measure a gap, but to understand how your core is functioning as a whole. 3. When to Seek Professional Help You should consider seeing a physiotherapist if: You notice a gap larger than two fingers months after delivery You experience doming/bulging of your tummy during movement You have persistent back pain, pelvic pain, or heaviness You plan to return to exercise after pregnancy You’ve had more than one pregnancy or a C-section You want a safe, guided core recovery plan OTHER ASSESSMENTS AND KEY POINTS Ultrasound Imaging For greater precision, musculoskeletal ultrasound can be used to visualize the separation and thickness of the linea alba. It offers: Objective measurement Visualization of muscle activation and healing over time Better assessment of subtle cases or deeper separations Tailoring the Recovery Plan An accurate assessment lays the foundation for an individualized recovery journey. Based on findings, the physiotherapist can: Design Core-Safe Exercises: Programs start with deep core and pelvic floor activation exercises before progressing to more dynamic movements. Address Breathing Mechanics: Proper breathing supports intra- abdominal pressure regulation, crucial for healing. Correct Movement Patterns: Teaching strategies like log-rolling to get out of bed or modifying lifting techniques to prevent excessive intra- abdominal pressure. Monitor Progress: Regular reassessments ensure that exercises are appropriately challenging without compromising healing. Educate on Daily Activities: Helping clients understand how posture, baby-carrying, or workout routines impact their core health. Red Flags During Assessment Sometimes, assessments reveal signs that require special attention or referral, such as: Hernias (a visible bulge that doesn't reduce) Severe pelvic floor dysfunction Significant pain or dysfunction not improving with early intervention In such cases, a multidisciplinary approach involving physicians, surgeons, or specialized pelvic health physiotherapists may be necessary. Key Takeaway: Early and accurate identification of Diastasis Recti enables clinicians to intervene before significant complications arise. A thoughtful, individualized treatment plan—rooted in careful assessment—sets the stage for safe recovery, improved core function, and long-term well-being. CHAPTER FOURHTTPS://KIRIGO.CO.KE/ Treating diastasis recti Early and accurate identification of Diastasis Recti (DR) is key to creating a tailored recovery plan. 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Set boundaries and allocate specific time slots for research and evaluation to avoid getting overwhelmed or sacrificing your content creation and client acquisition efforts. Strive for a balance that allows you to stay updated on emerging trends without compromising your core responsibilities as a UGC Creator. - OLIVIA WILSON Lorem ipsum dolor sit amet, adipiscing elit, sed do eiusmod tempor incididunt labored et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud all exercitation ullamco laboris nisi ut aliquip a ex ea com consequat. Duis aute irure dolor in reprehenderit in. Voluptate velit esse am cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat nonoad proident, sunt in culpa qui officia deserunt mollit anim. Lorem ipsum dolor sit amet, en adipiscing elit, sed do eiusmod temporals incididunt labore et dolore. Ut enim ad minimn veniam, quis en nostrud exercitation ullamcon laboris nisi ut aliquip ex ea com consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse lore cillum dolore eu fugiat nulla. Excepteur sint occaecat cupidatat non all proident, sunt in culpa qui officia deserunt mollit anim. But perspiatis unde omnis iste natus error sit voluptatem accusanti. CONCLUSION WWW.REALLYGREATSITE.COM @REALLYGREATSITE Embrace Your Journey

Scoliosis can be classified as structural or functional. Which one of the following is not characteristic of functional scoliosis? 

A) Can be due to muscle spasm 

B) Can be secondary to a herniated disc 

C) Can be due to senile changes in person’s spine 

D) Can be postural musculoskeletal 

C) Senile changes in a person’s spine result in the acquired type of structural scoliosis, which is not reversible. 

All other answer choices are characteristic of functional scoliosis and are reversible Which finger is commonly affected in Dupuytren’s contracture?

 A) The index finger 

B) The middle finger

 C) The ring finger 

D) The pinky finger 

C) Dupuytren’s contracture most commonly involves the ring finger. This condition appears in the fourth to sixth decade of life and is more severe in males of northern European descent. The pathophysiology results in collagen type III hyperproliferation affecting the palmar fascia. 

Treatment includes serial triamcinolone injections in early stages, collagenase injections, and surgery. Idiopathic brachial plexitis, usually preceded by a viral illness, is called: 

A) Thoracic outlet syndrome 

B) Erb’s palsy 

C) Guillain-Barré syndrome 

D) Parsonage-Turner syndrome D) Parsonage-Turner syndrome commonly affects the suprascapular nerve, axillary nerve, and/ or long thoracic nerve, and can be mistakenly attributed to an athletic event because of its idiopathic nature. Its classic presentation is acute onset of pain lasting 1 to 2 weeks and a delayed onset of weakness. B) In lateral ankle sprains, the ligaments within the lateral ligament complex are injured in a predictable sequence as forces increase: anterior talofi bular ligament, calcaneofi bular ligament, then posterior talofi bular ligament. Which ligament is most commonly injured in lateral ankle sprains? A) Calcaneofibular ligament B) Anterior talofibular ligament C) Tibionavicular ligament D) Posterior talofibular ligament What is a Smith’s fracture? A) Fracture of the distal radius with dorsal displacement B) Fracture of the distal ulna with dorsal displacement C) Fracture of the distal radius with volar displacement D) Fracture of the distal ulna with volar displacement C) Smith’s fracture is when the distal radius becomes fractured and the distal fragment is displaced toward the palm (volar). It is also called a reverse Colle’s fracture because in a Colle’s fracture the distal radial fragment is displaced dorsally. A) The anterior hip dislocation precautions are different from the posterior hip dislocation precautions: no hip extension, bridging, prone lying, or hip external rotation beyond neutral. When the patient is supine, keep the hip flexed to approximately 30° by placing a pillow under the patient’s knees or by raising the head of the bed. Which position should be avoided after total hip arthroplasty using an anterior approach? A) Bridging B) Adduction crossing midline C) Sitting on regular toilet seat D) Cross legs Which condition/injury is not considered an absolute contraindication for return to play? A) Atlantoaxial instability noted on lateral flexion-extension x-rays B) Fused C1 to C2 segments C) A two- to three-level spinal fusion with normal exam D) An acute spinal fracture C) Answers A, B, and D are all absolute contraindications to return to play. A two- to three-level spinal fusion with normal exam is considered a relative contraindication. A one-level fusion with normal alignment and physical exam has no restriction whereas a fusion extending more than three levels is an absolute contraindication for return to play. B) Rheumatoid arthritis is the most common cause of elbow joint destruction and occurs in most patients who have polyarticular involvement. What is the most common cause of nontraumatic elbow joint destruction? A) Osteoarthritis B) Rheumatoid arthritis C) Repetitive valgus stress injury D) Gout Intrinsic factors contributing to the development of tendinitis include all of the following except: A) Age B) Genetic predisposition C) Poor training technique D) Muscle imbalance/weakness C) Age, muscle imbalance (weakness), anatomic malalignment, and genetic predisposition are all intrinsic factors that contribute to the development of tendinitis. Extrinsic variables include training errors, environmental factors, and equipment. B) The elbow articulations allow the elbow two degrees of freedom: fl exion-extension and pronation-supination. The normal elbow moves from 0° (full extension) to 135° to 150° of fl exion. Pronation is approximately 70° to 90°, and supination is approximately 80° to 90°. The articulations of the elbow joint: A) Allow 3 degrees of freedom B) Allow 2 degrees of freedom C) Allow normal range of motion (ROM) of -10° extension to 120° flexion D) Allow 30° to 40° of pronation Which of the following is not true regarding steroid injection for carpal tunnel syndrome (CTS)? A) It is indicated for mild to moderate CTS B) It can be used in conjunction with splinting and physical therapy C) Caution should be used when injecting patients with diabetes D) Is preferable to surgery in patients with severe CTS D) Steroid injection can be considered in patients diagnosed (by nerve conduction studies [NCV]/ electromyogram [EMG]) with mild to moderate CTS. Care is taken to avoid piercing the median nerve. The needle is directed at an angle of 30°. Surgery is usually required in severe CTS, especially if abnormal spontaneous potentials are noted in the abductor pollicis brevis (APB) muscle. D) There are five treatment phases in sports rehabilitation: the first phase is to resolve the pain and inflammation; the second phase is to restore ROM; the third phase is to strengthen; the fourth phase is proprioceptive training; and the last phase involves sports/task- specific activities. Identify the final treatment phase of sports rehabilitation: A) Resolving pain and inflammation B) Restoring range of motion (ROM) C) Strengthening D) Sports/task-specific activities Mechanisms proposed for superior labrum anterior to posterior (SLAP) lesions include: A) Falling on an outstretched arm B) Underhand throwing motion C) Repetitive overhead reaching D) Repetitive resistant elbow extension A) SLAP lesions occur as a result of falling on an outstretched arm causing a traction and compression injury related to the fall. Overhead throwing motion in the deceleration phase can also cause a SLAP lesion by causing traction on the superior labrum by the biceps muscle. The cocking phase of the overhead throw causes a torsional peeling-back stress to the glenoid labrum leading to a SLAP lesion. A) Osteochondritis dessicans is characterized by fragmentation of the bone and cartilage overlying the capitellum in the elbow. This condition often occurs in teenage boys involved in throwing sports because of the valgus stress on the elbow. It is often mistakenly confused with Panner’s disease, which has more to do with a circulatory problem affecting the bone in the elbow and occurs in children 5 to 12 years of age. Which portion of the humerus is most commonly affected in osteochondritis dessicans? A) Capitellum B) Medial epicondyle C) Lateral epicondyle D) Greater tubercle Shoulder extension involves the use of all of the following muscles except: A) Pectoralis major, sternocostal portion B) Teres major C) Biceps brachii D) Posterior deltoid D) Shoulder extension involves the use of the posterior deltoid, latissimus dorsi, teres major, long head of triceps, and sternocostal portion of the pectoralis major C) Choices (A) and (B) are paired with the incorrect nerves. Choice (D) is responsible for lateral winging of the scapula. Medial winging of the scapula is caused by which of the following nerve injuries? A) Weakness of serratus anterior due to spinal accessory nerve injury B) Trapezius weakness due to long thoracic nerve injury C) Serratus anterior weakness due to long thoracic nerve injury D) Trapezius weakness due to spinal accessory nerve injury Which is the most common site for compartment syndrome? A) Anterior compartment of the lower leg B) Superficial posterior compartment of the lower leg C) Lateral compartment of the lower leg D) Deep posterior compartment of the lower leg A) The most common site of compartment syndrome is the lower leg. The anterior compartment is the most frequently affected, followed by the lateral compartment and the deep posterior compartment. D) MTSS, also known as shin splints, is a common type of overuse injury that results from chronic traction on the periosteum at the periosteal-fascial junction along the posteromedial border of the tibia. The main predisposing factor is hyperpronation. Pain may improve with exercise but may worsen afterward. Rest is the fi rst priority in management of MTSS. Return to activity should be gradual. Which statement is true regarding medial tibial stress syndrome (MTSS or shin splints)? A) This is a type of overuse injury that results from chronic traction on the periosteum at the periosteal-fascial junction along the anterolateral border of the tibia B) The main predisposing factor is hypersupination C) Patient should continue normal activity D) Pain may improve with exercise but worsens afterward Most patients with a grade II ankle sprain will present with: A) Pain in the ankle with no ligamentous injury B) Mild sprain of the anterior talofibular ligament and negative ankle drawer test C) Disruption of the anterior talofibular ligament, sprain of the calcaneofibular ligament, and positive ankle drawer test D) Disruption of the anterior talofibular ligament, the calcaneofibular ligament, and the lateral ligament complex, with a positive ankle drawer test C) It is important to rule out a fracture of the fibula and/or the fifth metatarsal. Mild sprain of the anterior talofibular ligament and negative ankle drawer test is considered a grade I ankle sprain. Disruption of the anterior talofibular ligament, the calcaneofibular ligament, and the lateral ligament complex with positive ankle drawer test is considered a grade III ankle sprain. A) The pivot shift test is the most specific test to diagnose an ACL tear. Under anesthesia, the specificity approaches 100%. Lachman’s test is usually considered the most sensitive test for an ACL tear. Ege’s test is used for diagnosis of a meniscal injury. Which test is the most specific test to diagnose an anterior cruciate ligament (ACL) tear? A) Pivot shift B) Lachman test C) Anterior drawer sign D) Ege’s test Which ligament is affected in Gamekeeper’s thumb? A) Tear of the ulnar collateral ligament of the thumb metacarpophalangeal (MCP) B) Rupture of the flexor digitorum profundus (FDP) tendon C) Rupture of the extensor tendon from the distal phalanx D) Tear of the triangular fibrocartilage complex A) Gamekeeper’s thumb is an injury to the ulnar collateral ligament of the thumb-MCP joint resulting in joint instability. Usually, the mechanism of injury is a forced radial deviation of the thumb or from a ski pole injury. Patients may describe pain and decreased grip strength at this location. There may be appreciable laxity of the MCP. A palpable mass at the location of the ulnar collateral ligament is called a Stener lesion, where the adductor pollicis aponeurosis falls under the torn collateral ligament. B) The patellofemoral joint is under high levels of compression during stair climbing owing to significantly increased quadriceps activity Which activity will most likely aggravate patellofemoral pain syndrome? A) Ambulation B) Climbing stairs C) Stationary cycling D) Swimming Which nerve injury results in medial scapular winging? A) Spinal accessory nerve B) Axillary nerve C) Suprascapular nerve D) Long thoracic nerve D) Long thoracic nerve injury or palsy will result in serratus anterior weakness. The long thoracic nerve originates from the C5-C7 nerve roots, and travels below the brachial plexus and clavicle before ultimately innervating the serratus anterior muscle. The serratus anterior muscle works to protract the scapula and cause its upward rotation, pulling it forward against the rib cage. In medial scapular winging, the scapula comes away from the chest wall medially. Forward flexion of the shoulder is often weaker and limited to 90° relative to the unaffected side. Injury to the spinal accessory nerve results in lateral scapular winging. B) The ACL, MCL, and medial meniscus are structures that are damaged in the unhappy triad. This usually occurs in contact sports, usually with valgus stress and rotation of the knee. Lateral meniscus tears can also be seen with ACL and MCL injuries. O’Donoghue’s triad (the unhappy triad) consists of tears of which of the following? A) Anterior cruciate ligament (ACL), medial collateral ligament (MCL), and lateral meniscus B) ACL, MCL, and medial meniscus C) ACL, MCL, and lateral collateral ligament (LCL) D) ACL, MCL, and posterior collateral ligament (PCL) Where is the lesion if a patient presents with isolated infraspinatus weakness and atrophy? A) The suprascapular notch B) The C5 nerve root C) The spinoglenoid notch of the scapula D) The upper trunk of the brachial plexus C) The suprascapular nerve is commonly compressed at the level of the suprascapular notch, resulting in deep, boring shoulder pain along the superior scapula and weakness of shoulder abduction and external rotation. If nerve entrapment occurs at the level of the spinoglenoid notch, then the only appreciable fi nding may be isolated atrophy and weakness of the infraspinatus muscle. Pain is not so prominent at this level because the sensory fibers have already exited. C) Injury to the long thoracic and spinal accessory nerves causes weakness of the serratus anterior and trapezius muscles, respectively, and are most commonly associated with scapular winging. Patients present with symptoms of pain in the upper back or shoulder, muscle fatigue, and weakness with the use of the shoulder. Initial management includes immobilization to prevent overstretching of the weakened muscle. Scapula winging is caused by an injury to which one of the following nerves? A) Radial nerve B) Suprascapular nerve C) Long thoracic nerve D) Axillary nerve The primary function of tendon is to: A) Transmit the force generated by a muscle to bone B) Attach bone to bone C) Be primary joint stabilizers D) Provide nutrition to bone A) Tendons consist of dense, regularly arranged collagen fibers meshed with elastin and a proteoglycan/glycosaminoglycan ground substance. The primary function of the tendon is to transmit the force generated in muscle to the bone allowing for the generation of movement of the extremities. A) Eversion injuries are not as common as inversion injuries but can cause damage to the deltoid ligament. The anterior talofibular ligament, calcaneofibular ligament, and posterior talofibular ligament can be injured in inversion injuries. Ankle eversion injuries often injure the: A) Deltoid ligament B) Anterior talofibular ligament C) Calcaneofibular ligament D) Posterior talofibular ligament Rotator cuff tears are characterized by: A) Symptoms similar to rotator cuff tendinitis B) Pain at night with side-lying on the affected side C) Examination findings of supraspinatus weakness, external shoulder rotator weakness, and positive drop arm test D) All of the above D) A full thickness tear can cause immediate functional impairments. The pain quality can be described as dull and achy, and symptoms are similar to those of rotator cuff tendinitis. The greatest limitation is difficulty performing overhead activities. A) Seizures can occur within seconds of the insult and do not warrant treatment. They are uncommon and are not associated with structural brain injury or long-term risks. The athlete should not necessarily be eliminated from the sport. Which of the following is true regarding impact seizures after a mild head injury? A) Do not require treatment B) Occur commonly C) Are associated with structural brain injury D) Always indicates that the patient should stop participating in that sport In Erb’s palsy, what part of the brachial plexus is affected? A) The lower trunk (C8-T1) B) Both upper and lower trunks C) Middle trunk (C7) D) The upper trunk (C5-C6) D) In Erb’s palsy, the upper trunk of the brachial plexus is affected (C5-C6) resulting in shoulder abduction, elbow flexion, and forearm supination weakness. It is the most common brachial plexopathy seen in newborns. C) Patients must be asymptomatic before starting the stepwise approach, which goes from light aerobic activity to sport-specific training to non–contact drills to full contact practice to game play. The patient is able to progress as long as they are asymptomatic in all steps. When is it safe for a patient to return to play after a concussion is diagnosed? A) Patient can return to the game once they are asymptomatic B) Neuroimaging must confirm that there is no structural damage C) Patient must follow a stepwise approach and will be cleared once asymptomatic in all steps D) Patient is able to play as long as there was no loss of consciousness Shoulder impingement may result from: A) C6 radiculopathy B) Loss of competency of the biceps tendon C) Loss of competency of scapula- stabilizing muscles D) Thoracic outlet syndrome C) Impingement can result from extrinsic compression or as a result of loss of competency of the rotator cuff and/or scapula-stabilizing muscles. The biceps tendon also passes within the space. The impingement interval, which is the space between the undersurface of the acromion and the superior aspect of the humeral head, is maximally narrowed when the arm is abducted. C) It is important to identify and prevent sudden cardiac death during physical activity. Conditions such as hypertrophic cardiomyopathy, arrhythmias, coronary artery anomalies, ruptured aortic aneurysms, and commotio cordis are some examples of dangerous and life-threatening conditions. Which of the evaluations below is the most important part of the physical evaluation of an athlete? A) Nephrology evaluation B) Pulmonary evaluation C) Cardiovascular evaluation D) Neurologic evaluation A 22-year-old football player presents with right knee pain. His history reveals that he received a posteriorly directed force to his bent knee. Physical examination reveals a positive posterior drawer sign. What injury has the patient most likely sustained? A) Patello-femoral syndrome B) Anterior cruciate ligament (ACL) injury C) Posterior cruciate ligament (PCL) injury D) Medial collateral ligament (MCL) injury C) This injury can occur when there is a force to a flexed knee. PCL injuries can also be seen in motor vehicle collisions. Isolated PCL injury rehabilitation is focused on quadriceps strengthening and closed kinetic training. A) When there is shoulder instability, there are recurrent episodes of subluxation where the humeral head partially comes out of the socket. Anterior instability is more commonly seen than posterior instability, hence dislocations also more commonly occur anteriorly. With recurrent anterior dislocations (where the humeral head remains fully out of socket), the anterior glenoid labrum may become torn or even avulsed off of the glenoid rim (called a Bankart lesion). Choice (B) describes a Hill- Sachs lesion; choice (C) is a SLAP lesion; and choice (D) describes the setting of thoracic outlet syndrome. What is a Bankart lesion? A) Tear or avulsion of the anterior glenoid labrum B) Compression fracture of the posterior humeral head C) Injury to the superior glenoid labrum and biceps tendon (long head) D) Compression of the brachial plexus and/or subclavian vessels as they exit between the superior shoulder girdle and first rib A positive Froment’s sign hints to which nerve being injured? A) Median nerve B) Radial nerve C) Ulnar nerve D) Musculocutaneous nerve C) Froment’s sign is performed by asking the patient to pinch a piece of paper between his or her index finger and thumb while the examiner tries to pull the paper away. If the patient flexes the first interphalangeal joint, suggesting adductor pollicis weakness, the test is considered a positive Froment’s sign and indicates possible ulnar nerve palsy D) Boutonnière deformity is seen in patients with rheumatoid arthritis and is a consequence of disruption of the central slip of the extensor tendons with volar migration of the lateral bands. This results in hyperflexion of the proximal interphalangeal (PIP) joint. Treatment in early stages includes splinting of the PIP joint in extension. What causes Boutonnière deformity? A) Ruptured flexor digitorum profundus (FDP) tendon B) Thickening and nodule formation in the flexor tendon sheath C) Median nerve entrapment D) Rupture of the central slip and volar migration of lateral bands Compression of which nerve is commonly misdiagnosed as lateral epicondylitis? A) Posterior interosseous nerve (PIN) B) Anterior interosseous nerve C) Median nerve D) C8/T1 nerve roots A) The PIN is a deep branch of the radial nerve, which if compressed may present with lateral elbow pain. The PIN usually gets compressed by a fibrous band located between two heads of the supinator muscle (the radial tunnel). Patients may present with symptoms similar to lateral epicondylitis, but remain refractory to treatment. In such situations, an electromyogram (EMG)/nerve conduction study (NCS) should be sought to evaluate for PIN compression. D) Little League elbow is suspected in a throwing athlete between the ages of 9 and 12 with medial elbow pain and a recent history of throwing. There is tenderness over the medial epicondyle and pain with resisted fl exion of the wrist and valgus stress testing of the elbow. There may also be a slight elbow fl exion contracture. The pathology is irritation and inflammation of the growth plate on the medial epicondyle. Little League elbow: A) Involves the lateral elbow region B) Is an acute dislocation of the elbow C) Occurs most commonly between the ages of 13 and 15 D) Occurs in athletes complaining of medial elbow pain Tennis elbow typically: A) Is an acute lesion, lasting less than a few weeks B) Presents with pain and tenderness over the medial epicondyle C) Does not affect grip strength D) Can occur as a result of a poor tennis backhand stroke D) Tennis elbow is commonly known as lateral epicondylitis. Patients present with pain and tenderness over the lateral epicondyle as well as over the extensor tendon. There is pain with resistance to wrist and third digit extension. Occasionally, grip strength testing elicits pain. Acutely, there will be inflammatory responses to tension overload placed in the tendon-bone junction. Lateral epicondylitis typically lasts longer than a few weeks. It is caused by a poor backhand stroke in tennis, although this is not always the cause. D) Swan neck deformity is characteristic of rheumatoid arthritis. The deformity may start at the MCP, PIP, or DIP joint. If the fl exor tendon at the MCP joint tightens, this may result in hyperextension at the PIP joint. Alternatively, if the PIP volar capsule becomes lax secondary to tenosynovitis, the PIP joint will hyperextend causing swan necking of the remaining joints. More commonly, however, stretching or disruption of the distal extensor mechanism results in a mallet finger deformity, which leads to eventual PIP hyperextension. What describes a swan neck deformity? A) Hyperextended metacarpophalangeal (MCP) and distal interphalangeal (DIP) joints, and flexion deformity at the proximal interphalangeal (PIP) joint B) Synovitis at the ulnar styloid with resultant disruption of the ulnar collateral ligament C) Hyperextension of the MCP and DIP joints with flexion of the PIP joint D) MCP and PIP joint hyperextension with flexion deformity at the DIP joint Which bone is most commonly affected in a wrist fracture? A) Lunate B) Capitate C) Distal radius D) Scaphoid D) Scaphoid fractures can be missed but should be suspected in patients with radial wrist pain after trauma. The scaphoid and triquetrum are the most common wrist fractures. Scaphoid and lunate fractures are highly susceptible to avascular necrosis. D) The menisci appear to transmit approximately 50% of the compressive load through range of motion (ROM) of 0° to 90°. The contact area is increased, protecting articular cartilage from high concentrations of stress. The circumferential continuity of the peripheral rim of the meniscus is integral to meniscal function. Partial meniscectomy, or bucket-handle tearing, will still preserve meniscal function as long as the peripheral rim is intact. Conversely, if a radial tear extends to the periphery and interrupts the continuity of the meniscus, the load-transmitting properties of the meniscus are lost. The tibial femoral contact area is decreased by up to 75% in postmeniscectomy knees. This decrease results in a 235% increase in contact stresses after total meniscectomy. The peripheral outer 1/3 of a meniscus is well vascularized, and the inner 2/3 poorly vascularized. Therefore, no surgical repair is needed for the inner 2/3 of a meniscus tear. The meniscus also plays an important role in proprioception of the knee joint. Which of the following statements is not true regarding the meniscus? A) Partial meniscectomy for bucket-handle tearing will still preserve most of the meniscal function as long as the peripheral rim is intact B) The peripheral outer 1/3 of a meniscus is well vascularized, and the inner 2/3 poorly vascularized C) One of the important roles the meniscus plays is in proprioception of the knee D) The tibial-femoral contact area is decreased by up to 25% after total meniscectomy In sports, which knee ligament is the most commonly injured? A) Anterior cruciate ligament (ACL) B) Posterior cruciate ligament (PCL) C) Lateral collateral ligament (LCL) D) Medial collateral ligament (MCL) D) The MCL is the most common knee ligament injury in sports. It is usually caused by a valgus force to the knee joint, causing stretching or tearing of the MCL. Isolated complete tears of the MCL can be treated nonoperatively D) Plantar fasciitis is caused by inflammation of the plantar fascia. Increased tension on the plantar fascia, such as pes cavus, pes planus, obesity, tight Achilles tendon, or bone spurs can lead to chronic inflammation. Treatment options are mostly conservative, including modalities, nonsteroidal anti-inflammatory drugs (NSAIDs), orthotics or shoe modification (heel pads, cushion, and lift), as well as Achilles tendon and plantar fascia stretching. Anesthetic/corticosteroid injection is effective. Injection from the medial side of the heel helps avoid injection into subcutaneous tissue or fascial layer, which may cause fat pad atrophy/necrosis and fascia rupture. Nighttime dorsiflexion splints may be used if other conservative measures fail. Which statement is not true regarding plantar fasciitis? A) Increased tension on the plantar fascia leads to chronic inflammation B) Heel spurs may contribute to its etiology C) A tight Achilles tendon is frequently associated with plantar fasciitis D) Night plantar flexion splints are not indicated Heberden’s nodes are found in which condition? A) Rheumatoid arthritis B) Psoriatic arthritis C) Osteoarthritis D) Gout C) Heberden’s nodes are swellings of the distal interphalangeal joints seen in osteoarthritis. Contents of these swellings are gelatinous hyaluronic acid. These growths arise in the chronic phase of osteoarthritis. C) Typical radiographic features of osteoarthritis include joint space narrowing, osteophyte formation, and subchondral cysts. Periarticular osteopenia/osteoporosis and soft tissue swelling are typically seen in rheumatoid arthritis. Pencil-in-cup deformity is a finding in psoriatic arthritis. What radiographic finding is typical of osteoarthritis? A) Periarticular osteopenia B) “Pencil-in-cup” deformity C) Subchondral cysts D) Soft tissue swelling Which joint is most commonly dislocated among pediatric patients? A) Shoulder B) Hip C) Elbow D) Proximal interphalangeal (PIP) joint C) The most commonly dislocated joint in children is the elbow. The elbow is the second most commonly dislocated joint in adults. D) Four muscles (infraspinatus, supraspinatus, subscapularis, and teres minor) form the rotator cuff. The insertion point of these four muscles is subject to repetitive microtrauma and impingement between the acromion and greater tuberosity of the humerus. Impingement syndrome, supraspinatus syndrome, and bursitis are terms commonly used. Neer’s test will be positive in the setting of impingement. Hawkins’ test can also be performed to further confirm impingement. Drop arm test is used to detect rotator cuff tears. O’Brien test can be used to detect superior labrum anterior to posterior (SLAP) lesions or acromioclavicular (AC) joint abnormalities. Apley scarf test is also used to detect AC joint pathology. Which provocative test is useful in detecting rotator cuff impingement? A) Drop arm test B) O’Brien test C) Apley scarf test D) Neer’s test What is the most common cause of adhesive capsulitis? A) Diabetes B) Female gender C) Hypothyroidism D) Idiopathic D) Adhesive capsulitis is usually an idiopathic condition resulting in the loss of both active and passive range of motion (ROM) of the shoulder. It most commonly affects middle- aged adults (40–60 years). Associated risk factors include female gender, diabetes (most common risk factor), and hypothyroidism, among other conditions. None of the aforementioned risk factors have been determined to be primary causes of this condition. Adhesive capsulitis is divided into three stages: freezing stage, frozen stage, and thawing stage. B) Static and dynamic stabilizers contribute to shoulder joint stability. Static stabilizers are glenoid, labrum, articular congruity, glenohumeral ligaments and capsule, and negative intraarticular pressure. The dynamic stabilizers are rotator cuff muscles/tendons, biceps tendon, and periscapular muscles. Which of the following is a static stabilizer of the shoulder joint? A) Biceps tendon B) Labrum C) Supraspinatus muscle D) Subscapularis muscle The cruciate ligaments are important knee structures which lie: A) Inside the joint capsule, and within the synovial cavity as well B) Outside the synovial cavity but within the fibrous joint capsule C) Outside the fibrous joint capsule D) Outside the synovial cavity and fibrous joint capsule B) The cruciate ligaments lie outside the synovial cavity but within the fibrous joint capsule. A) Ipsilateral Horner’s syndrome (dropping eye, pupillary constriction, and increased skin temperature or fl ushing) indicates that the block was adequate. What is a sign that the stellate ganglion was successfully blocked? A) Ipsilateral Horner’s syndrome B) Increased paresthesias C) Anesthesia in the limb D) Increased pain symptoms What is the most common pathological “mass” to occur in the wrist joint? A) Madelung’s deformity B) Ganglion cyst C) Heterotopic ossification D) Giant cell tumor of tendon sheath B) The most common “mass” to occur in the wrist is a ganglion cyst. It is essentially a “ballooning-out” of the joint lining and the fl uid inside is synovial fl uid. Ganglion cysts most commonly occur on the dorsal aspect of the wrist (usually from the scapholunate joint). On physical examination, the cyst may transilluminate. They can be evaluated by MRI, while x-rays will often be normal. Observational management is indicated for asymptomatic cases. If the cysts interfere with activity, aspiration may be warranted. Ganglion cysts tend to recur at a rate of 20%, while recurrence rate drops to less than 10% following excision A) Sports rehabilitation can be categorized into five phases: (1) resolving the pain and inflammation, (2) restoring range of motion, (3) strengthening, (4) proprioceptive training, and (5) sports/ task-specific activities. Immobilization is generally avoided as it can limit range of motion (which can cause contractures and atrophy) What is the final (last) phase of sports rehabilitation? A) Sports/task-specific activities B) Immobilization C) Restoring range of motion (ROM) D) Strengthening In patients younger than 20 years who have had a shoulder dislocation, what is the rate of reoccurrence? A) 10% B) 50% C) 75% D) 90% D) Approximately 90% of patients under 20 years of age will dislocate their shoulder again after a prior dislocation. Individuals age 20 to 40 years old carry a moderate risk of dislocation and there is an approximate 10% rate for dislocation in patients over 40 years. B) Clavicle fractures are one of the most common bony injuries. The most common location is the middle 1/3 (80%), 15% occur in the distal 1/3, and 5% occur in the proximal 1/3. What portion of the clavicle is most commonly fractured? A) Distal 1/3 B) Middle 1/3 C) Proximal 1/3 D) Distal 1/3 and proximal 1/3 fractures are equally most common Thomas’ test is used to assess: A) Lumbar lordosis B) Hip flexion contracture C) Sacroiliac joint dysfunction D) Iliotibial band contracture B) Thomas’ test is used to assess for a hip flexion contracture. With the patient supine, flex one hip to obliterate the lumbar lordosis. The angle between the affected thigh and the table reveals the fixed flexion contracture of the hip. Ober’s test is used to assess for an iliotibial band contracture. A) Mallet finger is usually caused by forced flexion of the distal phalangeal joint. Jersey finger is avulsion of the flexor digitorum profundus from the distal phalanx. It usually occurs in the fourth fi nger. Trigger fi nger is thickening of the proximal portion of the fl exor tendon sheath which may cause the fi nger to get “stuck” in fl exion. Coach’s finger is an interphalangeal dislocation that usually dislocates dorsally Rupture of the terminal extensor tendon of the distal phalanx causing loss of active extension is called: A) Mallet finger B) Jersey finger C) Trigger finger D) Coach’s finger or jammed finger The test of choice when looking for labral pathology is: A) MRI B) CT scan C) X-rays D) Magnetic resonance (MR) arthrogram D) MR arthrogram is the test of choice when evaluating for labral pathology. B) De Quervain’s tenosynovitis is a condition in which infl ammation causes thickening and stenosis of the synovial sheath surrounding the fi rst dorsal compartment of the wrist. This produces pain with tendon movement. On examination, there may be appreciable thickening of the fibrous sheath and Finkelstein’s test will be positive. Nonoperative management is indicated in most cases. Splinting with a thumb spica splint is applied such that pinching is possible. Steroid injection can help for symptomatic relief, and surgery may be indicated for decompression in refractory cases. Which splint is appropriate for De Quervain’s tenosynovitis? A) Nocturnal wrist splint B) Thumb spica splint C) Dynamic extension splint D) Flexor tendon splint The popliteus muscle performs an important action of unlocking by: A) Internally rotating the femur on the tibia during an open chain movement B) Externally rotating the tibia on the femur during an open chain movement C) Externally rotating the femur on the tibia during a closed chain movement D) Internally rotating the tibia on the femur during a closed chain movement C) During the last 20° of extension of the knee, the femur slightly internally rotates on the tibia to lock the knee joint in place in the closed chain, or the tibia slightly externally rotates on femur in the open chain, which is also called the screw-home mechanism. In the closed chain, the popliteus can externally rotate the femur to unlock the knee for flexion. D) Congenital torticollis occurs in approximately 1 per 250 live births, with 75% involving the right side. The most common cause is fi brosis of the sternocleidomastoid. The presence of a cervical hemivertebra is less common. On physical examination, a nontender enlargement in the sternocleidomastoid is noted. A newborn is holding his head with his chin rotated toward the left and the ear approximating the right shoulder. Which muscle is primarily implicated? A) Left cervical paraspinal B) Right cervical paraspinal C) Left sternocleidomastoid D) Right sternocleidomastoid Lateral epicondylitis most commonly affects which muscle or muscles? A) Extensor carpi radialis brevis and extensor digitorum communis B) Pronator teres, flexor carpi radialis, palmaris longus, flexor carpi ulnaris, and fl exor digitorum superficialis C) Triceps muscle D) Biceps tendon A) The pronator teres, flexor carpi radialis, palmaris longus, flexor carpi ulnaris, and flexor digitorum superficialis are affected in medial epicondylitis. The triceps muscle is affected in posterior elbow tendonitis. The biceps tendon is affected in bicipital tendonitis. C) The most powerful forearm supinator is the biceps brachii. This muscle has two proximal attachments. The short head attaches to the coracoid process, whereas the long head attaches to the supraglenoid tubercle of the scapula. The distal attachment is at the radial tuberosity and bicipital aponeurosis into fascia of the forearm. The biceps brachii is innervated by the musculocutaneous nerve, and this muscle is best tested when the forearm is placed in flexion and supination Which muscle is the most powerful forearm supinator? A) Supinator muscle B) Pronator teres muscle C) Biceps brachii muscle D) Brachioradialis muscle D) Trigger finger is defined as the triggering, snapping, or locking of the finger as it is flexed and extended. This is due to localized inflammation or nodular swelling of the flexor tendon sheath, which inhibits the normal tendon glide. Typically, the thumb, middle, and ring fingers of the dominant hand in middle- aged women are most commonly affected. C) The true leg length should be measured from anterior superior iliac spine to medial malleolus. Apparent leg length discrepancy should be assessed if no true leg length discrepancy exists by measuring from a nonfixed point (eg, umbilicus) to a fixed point (eg, medial malleolus), which may be associated with pelvic obliquity The true leg length should be measured between: A) Greater trochanter and lateral malleolus B) Umbilicus and lateral malleolus C) Anterior superior iliac spine (ASIS) and medial malleolus D) Anterior inferior iliac spine and medial malleolus The differential diagnosis of trigger finger includes all of the following except: A) Dupuytren’s disease B) Ganglion of the tendon sheath C) Rheumatoid arthritis D) Phalange fracture B) A second trauma can be relatively minor, but the body’s response can be fatal. It is believed that the brain’s autoregulation becomes impaired from the first injury leading to engorgement within the cranium. This leads to increased intracranial pressures and possible herniation of the medial temporal lobes through the tentorium or herniation of cerebellar tonsils through the foramen magnum. A) Frozen shoulder often follows a period of prolonged shoulder immobilization and results in a decreased range of motion (ROM) of the shoulder. Thickening and contraction of the capsule occurs around the glenohumeral joint. Risk factors include diabetes. It is more commonly seen in middle-aged women. Adhesive capsulitis or frozen shoulder: A) Results from thickening and contraction of the capsule around the glenohumeral joint B) Is more commonly seen in middle-aged men C) Has risk factors including psoriasis D) Is more frequently noted in colder climates Second impact syndrome occurs when a patient: A) Sustains a physical injury at the same time as a concussion B) Sustains a brain injury before the previous concussion symptoms have resolved C) Sustains a second concussion after previous concussion symptoms have resolved D) Sustains a medical condition after a concussion B) Scaphoid fractures are the most common carpal bone fractures. The usual mechanism of injury (as is the case with most carpal fractures) is a fall on outstretched hands. Patients will have tenderness in the anatomical “snuffbox” area and decreased range of motion (ROM). Fracture of the middle 1/3 of the scaphoid bone (known as the waist) is most common. This bone has retrograde blood supply, making it particularly susceptible to malunion or avascular necrosis following a fracture. It is for this reason that a low threshold of suspicion is maintained for scaphoid fractures, and immobilization is usually initially prescribed if there is high clinical suspicion (despite negative x-rays). C) Anterior glenohumeral stability is evaluated by the apprehension test. Hill-Sachs lesion accounting for greater than 30% of the articular surface may cause shoulder instability. A notch occurs in the posterior lateral aspect of humeral head owing to recurrent impingement Hill-Sachs lesion of the shoulder: A) May be associated with posterior dislocations B) May cause shoulder instability if it accounts for 10% of the articular surface C) Is a compression fracture of the posterolateral aspect of humeral head caused by abutment against the anterior rim of the glenoid fossa D) Is evaluated by Speed’s test What is the usual mechanism of a scaphoid fracture? A) Axial compression and hyperextension of the wrist B) Fall onto outstretched hands C) Direct blow to the scaphoid bone D) End-on blow of the fi st, as in boxing C) Additional studies are not usually necessary. If crystal-induced or septic bursitis is suspected, aspiration of the bursal fluid is usually indicated. Plain radiographs may demonstrate an olecranon spur in about 1/3 of cases. D) The quadrangular space of the shoulder is bordered by the teres minor, teres major, long head of the triceps muscle, and medial border of the humerus. It is an area of potential compression of the posterior humeral circumfl ex artery or axillary nerve, especially in athletes who engage in overhead activities (throwing athletes, tennis players, swimmers). Patients will present with pain and paresthesias of the posterior lateral shoulder What structures are found within the quadrangular space? A) The circumflex scapular artery B) The femoral nerve, artery, and vein C) Processus vaginalis, spermatic cord, and ilioinguinal nerve D) Axillary nerve, posterior circumfl ex artery, and humeral artery The diagnosis of aseptic non-inflammatory olecranon bursitis: A) Is based on plain radiographs, demonstrating an olecranon spur in all cases B) Requires aspiration of bursal fluid in all cases C) Is usually straightforward and based on characteristic appearance on physical examination D) Is made only with MRI D) Internal snapping hip syndrome is caused by a tight iliopsoas tendon snapping over the iliopectineal prominence of the pelvis, or less commonly, acetabular labral tear or loose body in the hip joint. A tight iliotibial band or gluteus maximus snapping over the greater trochanter causes external snapping hip syndrome. C) The rotator cuff muscles include the teres minor, supraspinatus, infraspinatus, and subscapularis muscles. These muscles are dynamic stabilizers of the shoulder. The rotator cuff muscles include all of the following except: A) Teres minor B) Supraspinatus C) Rhomboids D) Infraspinatus Internal snapping hip syndrome is caused by: A) A tight iliopsoas tendon snapping over the lesser trochanter B) A tight iliotibial band snapping over the greater trochanter C) A tight gluteus maximus snapping over the greater trochanter D) An acetabular labral tear or loose body in the hip joint A) Adson’s test is performed by locating the radial pulse of the affected arm and asking the patient to turn their head toward the affected shoulder. The arm may be abducted and externally rotated as part of the maneuver. If the radial pulse diminishes on the affected side, this is positive for possible thoracic outlet syndrome. Thoracic outlet syndrome is the compression of the neurovascular structures in the neck, usually by a cervical rib or first rib and scalene muscles B) Approximately 30% of the humeral head articulates directly with the glenoid fossa. A fibrocartilaginous complex called the labrum surrounds the glenoid fossa, effectively increasing the total contact of the humeral head with the glenoid to 70%. This allows for the stabilization of the glenohumeral joint and prevents anterior and posterior humeral head dislocation The glenohumeral joint (shoulder girdle complex) involves articulation of the humeral head with the glenoid fossa and the labrum. Approximately what percentage of the humeral head articulates with the glenoid fossa? A) 15 B) 30 C) 50 D) 70 What is the Adson’s test used for? A) To detect thoracic outlet syndrome B) To check for adequate blood perfusion to the hand C) To detect anterior instability of the shoulder joint D) To detect symptoms of carpal tunnel syndrome (CTS) C) De Quervain’s affects the abductor pollicis longus and extensor pollicis brevis tendons. It can be seen with overuse in sports with gripped equipment such as golf and racquet sports. The patient usually has pain with resisted thumb extension. Finkelstein’s test can be positive. A) Individual flexor tendons for each digit of the hand are housed within a flexor tendon sheath. The tendon sheath has areas of thickening called annular and cruciate pulleys that function to stabilize the tendon. In stenosing tenosynovitis (trigger finger), the proximal pulley becomes inflamed and thickened with concurrent nodular enlargement of the tendon itself. As the inflamed tendon passes through the thickened pulley, it occasionally becomes stuck, locking the finger in flexion. This condition usually affects the middle or ring fingers. Therapy includes local steroid injection or surgery. A finger locked in flexion, especially in the morning, is typical of which condition? A) Trigger finger B) Mallet finger C) Jersey finger D) Boutonnière deformity De Quervain’s stenosing tenosynovitis is inflammation of the fi rst dorsal compartment, which includes which of the following? A) Abductor pollicis longus and opponens pollicis B) Extensor pollicis brevis and opponens pollicis C) Abductor pollicis longus and extensor pollicis brevis D) Adductor pollicis longus and opponens pollicis A) The scaphoid is the most commonly fractured carpal bone (70%). It is subject to osteonecrosis because of its poor blood supply. Clinical features of a scaphoid fracture include tenderness in the anatomical snuff box. Complications include collapse of carpal bones, especially scapholunate instability. A) The proximal tibiofibular joint is located between the lateral tibial condyle and the fibular head and has been construed as the “fourth compartment” of the knee joint. It is a synovial joint and communicates with the knee joint in approximately 10% of adults. It is a source of lateral knee pain that is often overlooked. The proximal tibiofibular joint: A) Is a source of lateral knee pain that is often overlooked B) Is located between the lateral tibial condyle and the fi bular head, and has been construed as the “third compartment” of the knee joint C) Is not a synovial joint D) Communicates with the knee joint in approximately 90% of adults A fall or blow on a hyperextended (dorsiflexed) wrist can cause osteonecrosis of which bone? A) Scaphoid B) Lunate C) Triquetrum D) Pisiform A) O’Brien’s test evaluates for labral abnormalities. The shoulder is flexed to 90° with the elbow fully extended. The arm is then adducted 15° and the shoulder is internally rotated with the patient’s thumb pointing down. Downward force is applied to the arm against resistance. The shoulder is then externally rotated with the palm facing up and the examiner applies downward force on the patient’s arm, which the patient is instructed to resist. A positive test is indicated by pain during the first part of the maneuver with the patient’s thumb pointing down. The pain is lessened when the patient resists a downward force with the palm facing up. B) Injuries caused by forcible abduction of the thumb are associated with injury to the ulnar collateral ligament of the first metacarpophalangeal joint (MCP). Skiers are at risk owing to falling while holding a ski pole. Gamekeeper’s thumb involves an injury to the following structure: A) Medial collateral ligament B) Ulnar collateral ligament C) Transverse carpal ligament D) Triangular fibrocartilage complex O’Brien’s test evaluates for: A) Labral abnormalities B) Bicipital tendinitis C) Stability of the glenohumeral joint D) Thoracic outlet syndrome C) Neer’s impingement sign is performed by bringing the arm in extreme forward flexion with the humerus externally rotated. Hawkins’ test is also used to assess for impingement sign. The arm is forward flexed to 90° and medially rotated. A positive sign elicits pain during movement. Speed’s test is used to assess for bicipital tendonitis. Finkelstein’s test is used to assess for De Quervain’s, and; Tinel’s test is used to evaluate for nerve irritability. D) Sudden impact to the front of the tibia with the knee flexed (as in a motor vehicle accident) is the most frequent cause of a PCL injury. Hyperflexion is the most common cause of PCL injuries in athletes. What is the most common cause of posterior cruciate ligament (PCL) injury? A) Hyperextension of the knee B) Rotation of femur on fixed lower leg C) Hyperflexion of the knee D) Dashboard injury Test(s) to evaluate for shoulder impingement syndrome include: A) Finkelstein’s test B) Speed’s test C) Neer’s sign D) Tinel’s test D) Q angle is the angle formed by a line drawn from the anterior superior iliac spine (ASIS) to the central patella, and a second line drawn from the central patella to the tibial tubercle. Normally, Q angle is 14° for males and 17° for females. An increased Q angle is a risk factor for patellar subluxation. The Q angle is increased by genu valgum, increased femoral anteversion, external tibial torsion, a laterally positioned tibial tuberosity, or a tight lateral retinaculum. A) The surgical neck is called so because of frequent fractures which occur here. This area lies below the head and tubercle and is narrow. The anatomical neck is located at the junction point of the head with the shaft, and is between the head and tubercles. What is the most common site for humeral fractures? A) Surgical neck B) Anatomical neck C) Midshaft D) Humeral head The Q angle is increased by; A) Genu varum B) Decreased femoral anteversion C) Internal tibial torsion D) Tight lateral retinaculum B) Muscle comprises 40% to 45% of the total body weight. B) MRI of both hips is indicated to assess for a diagnosis of AVN of the femoral head. MRI is most sensitive to early changes with a low signal intensity noted on T1 imaging. The most sensitive imaging study to detect early changes in avascular necrosis (AVN) of the femoral head is: A) CT B) MRI C) Bone scan D) X-ray Which of the following constitutes the largest tissue mass in the body (40%–45% of the total body weight)? A) Bone B) Muscle C) Skin D) Blood C) Pain with resisted wrist extension and supination as well as pain with passive wrist flexion are seen in lateral epicondylitis. Once diagnosed, it is important to identify the behavior causing the problem, and to modify it. Pain with wrist flexion and pronation, as well as pain with passive wrist extension, is seen in medial epicondylitis A) The ACL originates at the lateral femoral condyle, travels through the intercondylar notch, and attaches to the medial tibial eminence. Its primary function is to limit anterior tibial translation, or prevent backward sliding of the femur. It limits internal rotation of the femur when the foot is fixed. The ACL loosens in flexion and tightens in full extension. ACL pathology leads to increased pressures on the posterior menisci. Which statement is true regarding the anterior cruciate ligament (ACL)? A) It prevents backward sliding of the femur B) It limits external rotation of the femur when the foot is fixed C) It tightens in flexion and loosens with full extension D) Its deficiency leads to increased pressures on the anterior menisci A 35-year-old male plumber presents with right elbow pain. You diagnose right lateral epicondylitis. What would be expected on physical exam? A) Pain with passive wrist extension B) Pain with resisted wrist fl exion and pronation C) Pain with resisted wrist extension and supination D) Pain with resisted wrist extension and pronation D) Cozen’s test is performed with the examiner stabilizing the patient’s elbow and his or her thumb over the extensor tendon origin along the lateral epicondyle. With the opposite hand, the examiner provides resistance as the patient tries to extend and radially deviate the wrist. Pain over the lateral epicondyle indicates a positive test. D) The phases of throwing in order are: wind up, early cocking, late cocking, acceleration, and follow-through. During late cocking there is significant valgus stress on the elbow joint, with maximal stress on the medial collateral ligament (MCL). The elbow also experiences a significant degree of valgus stress during acceleration, but not as much as late cocking. During which phase of throwing is the elbow joint placed under the most valgus stress? A) Follow-through B) Wind-up C) Early cocking D) Late cocking What provocative maneuver is used to test for lateral epicondylitis? A) Empty can test B) Valgus stress test C) Elbow flexion test D) Cozen’s test B) The serratus anterior protracts the scapula and holds it against the thoracic wall. The other choices refer to the pectoralis minor (A), levator scapulae (C), and subscapularis (D). C) Recurrent anterior shoulder dislocations can lead to a compression fracture of the posterolateral humeral head known as a Hill-Sachs deformity. Radiographic evaluation with anterior-posterior views and Stryker notch view are used. In the Stryker notch view, the patient is supine with a cassette placed under the involved shoulder. The palm of the affected arm is placed on top of the head with the fingers pointing posteriorly, and the elbow pointing upward toward the ceiling. The x-ray beam is centered over the coracoid process with the beam directed 10° towards the head. Which radiographic view is used to visualize the humeral head for possible Hill-Sachs lesion? A) Scapular Y view B) West point view C) Stryker notch view D) Lateral view Injury to the long thoracic nerve affects the function of serratus anterior, which functions primarily to: A) Stabilize the scapula by drawing it inferiorly and anteriorly against the thoracic wall B) Protract the scapula and hold it against the thoracic wall C) Elevate the scapula and tilt the glenoid cavity by rotating the scapula D) Medially rotate and adduct the arm; helps hold the humeral head in the glenoid cavity D) The dorsal portion of the annulus fibrosis is innervated by the medial branch of the segmental spinal nerves. A) Saturday night palsy, honeymooner’s palsy, or radial nerve mononeuropathy usually presents with wrist and fi nger drop. It may present with numbness and paresthesias of the forearm and wrist as well. Acute compression of the radial nerve typically occurs at the spiral groove. What physical exam finding will be observed in “Saturday night palsy”? A) Marked wrist and finger drop B) Atrophy of abductor pollicis brevis (APB) C) Weak elbow extension D) Painless weakness and atrophy of hand intrinsic muscle All of the following are correct regarding the intervertebral disc except: A) The pressure obtained in the sitting position is double the pressure when the patient stands B) The interior of the disc has no nociceptive innervation C) The fibrous outer ring (annulus fi brosis) is held taut by the pressure in the central nucleus pulposus D) The dorsal portion of the annulus fi brosis has no nociceptive innervation B) Kienböck’s disease is a consequence of traumatic or repetitive microtrauma to the lunate leading to osteonecrosis. Patients present with pain, stiffness, and wrist dysfunction. Physical examination reveals local tenderness over the lunate, limited range of motion (ROM), and decreased grip strength. Radiographs may show lunate sclerosis and degeneration of adjacent joints in later stages. In later stages, wrist fusion may be indicated. D) Clinical features of Kienböck’s disease include pain over the dorsal aspect of the wrist, directly over the lunate. The mechanism is hypothesized to be an idiopathic loss of blood supply to the lunate, causing avascular necrosis. The disease is correlated with repetitive stress or fracture. Risk factors include short ulnar variance and poor vascular supply. In later stages, the collapse of the lunate results in multiple degenerative changes at the wrist. Kienböck’s disease involves which of the following features? A) Osteonecrosis of the scaphoid B) “Pencil-in-cup” deformities C) Heberden’s and Bouchard’s nodules D) Osteonecrosis of the lunate What is Kienböck’s disease? A) Scaphoid bone fracture B) Avascular necrosis (AVN) of the lunate bone C) Ulnar deviation of the wrist D) Intra-articular fracture affecting the carpometacarpal joint