Section 10. Musculoskeletal Problems
MULTIPLE CHOICE
1. One of the initial steps in assessing patients with musculoskeletal complaints is to determine
whether the complaint is articular or nonarticular in origin. Which of the following is an
example of an articular structure?
A.
Bone
B.
Synovium
C.
Tendons
D.
Fascia
2. You have detected the presence of crepitus on examination of a patient with a musculoskeletal
complaint. Additionally, there is limited range of motion (ROM) with both active and passive
movement. These findings suggest that the origin of the musculoskeletal complaint is:
A.
Articular
B.
Inflammatory
C.
Nonarticular
D.
Noninflammatory
3. Which of the following signs or symptoms indicate an inflammatory etiology to
musculoskeletal pain?
A.
Decreased C-reactive protein
B.
Hyperalbuminemia
C.
Morning stiffness
D.
Weight gain
4. Which of the following statements concerning the musculoskeletal examination is true?
A.
The uninvolved side should be examined initially and then compared to the
involved side.
B.
The part of the body that is causing the patient pain should be examined first.
C.
When possible, the patient should not be asked to perform active ROM exercises
to avoid causing pain.
D.
Radiographs should always be obtained prior to examination so as not to cause
further injury to the patient.
5. You are performing muscle strength testing on a patient presenting with musculoskeletal pain
and find that the patient has complete ROM but cannot move it above gravity. Which numeric
grade of muscle strength would you give this patient?
A.
1
B.
2
C.
3
D.
4
6. Mrs. Gray is a 55-year-old woman who presents with tightness, pain, and limited movement
in her right shoulder. She denies any history of trauma. Her examination reveals a 75%
reduction in both active and passive ROM of the right shoulder. Mrs. Gray also is
experiencing tenderness with motion and pain at the deltoid insertion. Her medical history is
significant for type 1 diabetes mellitus and hypertension. Her social history reveals that she is
a secretary and that she is right-handed. Based on her examination and medical history, you
suspect adhesive capsulitis, or “frozen shoulder.” Which clue in Mrs. Gray’s history supports
this diagnosis?
A.
History of hypertension
B.
Her affected shoulder is also her dominant arm.
C.
Her history of type 1 diabetes
D.
Her work as a secretary predisposes her to repetitive motions.
7. Jennifer is an 18-year-old woman who comes to the emergency room after a fall during a
soccer game. Jennifer explains that she fell on her left side and kept her arm out straight to
break her fall. She has been experiencing severe pain and limited ROM in her left shoulder.
The clinician has diagnosed Jennifer with a dislocated shoulder. Which of the following
statements are true concerning shoulder dislocation?
A.
Anterior dislocations are not painful, and ROM is normal.
B.
There is a risk of neurovascular and neurosensory trauma, so the clinician should
check for distal pulses.
C.
X-rays are the only diagnostic testing appropriate to assess a dislocation.
D.
Most traumatic dislocations are posterior.
8. Fred has been diagnosed with a trigger finger of the ring finger. Which of the following
management strategies is appropriate?
A.
Surgical removal of the tendon sheath
B.
NSAIDs
C.
Local anesthetic injection into the tendon sheath
D.
Splinting
9. Mrs. Anderson is a 35-year-old woman who has been recently diagnosed with carpal tunnel
syndrome. She has two young children and asks the clinician what the chances are that they
also will develop carpal tunnel syndrome. Which of the following responses would be correct
regarding the risk of developing carpal tunnel syndrome?
A.
Carpal tunnel syndrome commonly occurs in families. Genetic factors are thought
to account for about one-half the risk of developing carpal tunnel.
B.
People with occupations that require repeated flexion extension of the wrist, use of
hand tools that require forceful gripping, or use of hand tools that vibrate are at
risk for developing carpal tunnel.
C.
An underlying musculoskeletal disorder must be present for a person to develop
carpal tunnel.
D.
Carpal tunnel syndrome only occurs in the presence of a hormonal imbalance.
10. Which of the following statements is true regarding the treatment of carpal tunnel syndrome?
A.
The goal of treatment is to prevent flexion and extension movements of the wrist.
B.
Splints are not used in carpal tunnel syndrome, because they restrict complete
movement of the fingers and wrist.
C.
Corticosteroid injections are encouraged in the treatment of carpal tunnel
syndrome.
D.
Treatment that encourages fluid retention, to keep the joints lubricated, is an
emphasis of treatment.
11. Sam is a 25-year-old who has been diagnosed with low back strain based on his history of
localized low back pain and muscle spasm along with a normal neurological examination. As
the clinician, you explain to Sam that low back pain is a diagnosis of exclusion. Which of the
following symptoms would alert the clinician to the more serious finding of a herniated
nucleus pulposus or ruptured disc?
A.
Morning stiffness and limited mobility of the lumbar spine
B.
Unilateral radicular pain symptoms that extend below the knee and are equal to or
greater than the back pain
C.
Fever, chills, and elevated erythrocyte sedimentation rate
D.
Pathologic fractures, severe night pain, weight loss, and fatigue
12. The clinician has instructed Sirius, a 23-year-old patient with low back strain, to use NSAIDs
to manage his symptoms of pain and discomfort. Which of the following statements would be
most appropriate when teaching Sam about the use of NSAIDs?
A.
“You should start with the lowest dose that is effective in managing your pain,
because long-term use of NSAIDs can result in gastrointestinal (GI) disorders such
as ulcers and hemorrhage.”
B.
“You should start with the lowest dose that is effective in managing your pain to
avoid developing tolerance to the medication.”
C.
“You should take the maximum recommended dose of NSAIDs so that you will
not need to take narcotics to control your pain.”
D.
“It is important to take NSAIDs on an empty stomach in order to increase
absorption.”
13. Janet is a 30-year-old who has recently been diagnosed with a herniated disc at the level of
L5-S1. She is currently in the emergency room with suspicion of cauda equina compression.
Which of the following is a sign or symptom of cauda equina compression?
A.
Gastrocnemius weakness
B.
A reduced or absent ankle reflex
C.
Numbness in the lateral foot
D.
Saddle area anesthesia
14. Which of the following statements is true concerning the management of the client with a
herniated disc?
A.
Muscle relaxants and narcotics can be used to control moderate pain but should be
discontinued after 3 weeks of use.
B.
An epidural injection is helpful in reducing leg pain that has persisted for at least 3
weeks after the herniation occurred.
C.
Intolerable pain for more than a 3-month period is an indication for surgical
intervention.
D.
Most disc hernias require opioids for long term pain relief.
15. John is a 16-year-old boy who presents to the emergency room after hurting his knee in a
football game. He described twisting his knee and then being unable to extend it completely.
John tells the clinician that he heard a pop when the injury occurred and has been
experiencing localized pain. The clinician suspects a meniscal tear. Which test would be most
appropriate to assess for the presence of a meniscal tear?
A.
Valgus stress test
B.
McMurray circumduction test
C.
Lachman test
D.
Varus stress test
16. The clinician suspects that a client has patellar instability. In order to test for this, the client is
seated with the quadriceps relaxed, and the knee is placed in extension. Next the patella is
displaced laterally, and the knee flexed to 30°. If instability is present, this maneuver displaces
the patella to an abnormal position on the lateral femoral condyle, and the client will perceive
pain. Testing for patellar instability in this way is known as:
A.
Apprehension sign
B.
Bulge sign
C.
Thumb sign
D.
Lachman sign
17. The clinician is caring for Diane, a 22-year-old woman who presents with an injured ankle.
Diane asks the clinician if she will need an x-ray. The clinician explains to Diane that an x-ray
is not always necessary for an injured ankle and that the decision to obtain radiographs is
dependent on the examination and Diane’s description of her injury. Which of the following
clues in Diane’s examination or history would alert the clinician to the need for obtaining
radiographs?
A.
Ability to bear weight immediately after the injury
B.
Development of minor ankle swelling after the injury
C.
Slight bruising over the injury site 2 days after injury
D.
Crepitation with palpation or movement of the ankle
18. Mr. Jackson is a 65-year-old man recently diagnosed with osteoarthritis. The clinician has
explained to Mr. Jackson that the goals for managing osteoarthritis include controlling pain,
maximizing functional independence and mobility, minimizing disability, and preserving
quality of life. Mr. Jackson explains to the clinician that his first choice would be to use
complementary therapies to control his condition and asks what therapies are most effective in
treating osteoarthritis. What would be the most appropriate response from the clinician?
A.
“Complementary therapies should be considered only if surgical interventions are
not successful.”
B.
“I am unfamiliar with the available complementary therapies for osteoarthritis and
prefer to discuss more mainstream treatments, such as NSAIDs and physical
therapy, to manage your condition.”
C.
“I would be happy to discuss all the treatment options available to you.
Complementary therapies, such as acupuncture, acupressure, and tai chi, are being
studied for use in the treatment of osteoarthritis and acupuncture can be used and is
safe and well tolerated.”
D.
“It would be crazy to use complementary therapies to treat such a serious
condition.”
19. Chris is a 28-year-old male who complains of lower back pain that began 3 days ago. The
pain is worse when he stands or bends, and it is somewhat relieved when he sits. The clinician
performs the straight-leg raise test and it is negative. Plain film x-ray is positive. Which
diagnosis is most likely?
A.
Osteoarthritis
B.
Spinal stenosis
C.
Scoliosis
D.
Muscle strain
20. A clinician has performed a synovial fluid analysis and the results are as follows: visual
analysis: turbid and yellow, viscosity: decreased, 52,000 white blood cells (WBCs) per mm3,
polymorphonuclear leukocytes (PMNs): 75%, protein: 5 g/dL. Which of the following
conditions could this result be attributed to?
A.
Rheumatoid arthritis
B.
Osteoarthritis
C.
Gout
D.
Septic arthritis
21. Normal estrogen function is important for preventing osteoporosis in both men and women.
Estrogen works to prevent osteoporosis in which of the following ways?
A.
By increasing the erosive activity of osteoclasts
B.
By promoting osteoclastogenesis
C.
By inhibiting osteoclast apoptosis
D.
By increasing the activity of osteoblasts
22. Which of the following tests is considered the gold standard for definitively diagnosing
osteoporosis?
A.
Bone alkaline phosphatase levels
B.
Urinary N-telopeptide assay
C.
Bone mass density measurement by densitometry
D.
Magnetic resonance imaging
23. What is the recommended daily calcium intake for men 70 years and younger?
A.
500 mg/day
B.
750 mg/day
C.
1,000 mg/day
D.
1,500 mg/day
24. Mrs. Allen is a 60-year-old woman who has been diagnosed with osteoporosis. She is very
concerned about the risk of breast cancer associated with hormone replacement therapy and is
wondering what other treatments are available to her. The clinician explains that
bisphosphonates are another class of drugs used in the prevention and treatment of
osteoporosis. What teaching should the clinician give Mrs. Allen in regard to taking
bisphosphonates?
A.
Taking bisphosphonates can result in hypercalcemia, so calcium intake should be
decreased while taking this class of drugs.
B.
There is potential for upper GI irritation, so these medications are contraindicated
in people with abnormalities of the esophagus or delayed esophageal emptying.
C.
This class of drugs can be taken at any time of the day without regard to meals.
D.
This class of drugs should be taken with orange juice to increase absorption.
25. Which of the following medications is appropriate to treat Paget’s disease?
A.
Boniva
B.
Fosamax
C.
Reclast
D.
Forteo
26. Which of the following statements concerning fibromyalgia is true?
A.
Muscle pain that is caused by the development of trigger points within the muscle
cannot occur concurrently with fibromyalgia.
B.
A cause of myalgia can be fibromyalgia.
C.
Bursitis cannot coexist with pain from fibromyalgia.
D.
Fibromyalgia is an inflammatory musculoskeletal disorder.
27. One of the most frequent presenting signs/symptoms of osteoporosis is:
A.
Goiter
B.
Abnormal serum calcium
C.
Elevated urine biochemical markers
D.
Bony fracture
28. Mrs. Thomas was seen in the office complaining of pain and point tenderness in the area of
her elbow. The pain has increased following a day of gardening 1 week ago. A physical
finding that differentiates the diagnosis and is most consistent with lateral epicondylitis
(tennis elbow) is:
A.
Ecchymosis, edema, and erythema over the lateral epicondyle
B.
Pain at the elbow that radiates into the forearm and pain and weakness with
gripping objects
C.
Inability to supinate and pronate the arm
D.
Inability to flex or extend the elbow against resistance
29. A clinician is examining a vertebral fracture, and the examination and diagnostic findings
have shown a compression of the anterior column that includes both endplates. What type and
subtype are these?
A.
Compression fracture, type A
B.
Burst fracture, type B
C.
Seat-belt type injury, level two
D.
Fracture-dislocation, shear
30. Which of the following would lead the clinician to suspect a tumor when paired with low back
pain?
A.
Minor trauma with sneezing in elderly with osteoporosis
B.
History of spinal procedure
C.
Sudden loss of bowel or bladder function
D.
Unintended weight loss >10% of body weight in 6 months
31. A 70-year-old female fell 2 weeks ago and developed immediate pain in her left elbow on the
lateral epicondyle. She thought she just bruised it, but is now worried because it has not
improved. She has used Tylenol® and ice at home, and that has helped slightly. During your
examination, you find she has moderate swelling and ecchymosis, but no overtly obvious
deformity. Her ROM is uncomfortable and severely diminished due to the pain. No crepitus is
heard or felt. Her fingers are warm; her pulse is strong; and capillary refill is less than 2
seconds. What should you do?
A.
Make an immediate referral for an orthopedic surgical evaluation without further
assessment.
B.
Tell her that it takes time for these bruises to improve, so she should be patient.
C.
Prescribe a splint for her left wrist and begin corticosteroid injections.
D.
Send her to the emergency room for reduction of this obvious wrist fracture.
32. Debbie is a 43-year-old female being evaluated for a wrist injury. The clinician is assessing
for median nerve compression by having Debbie maintain forced flexion of her wrist for 1
minute with the dorsal surface of each hand pressed together. Which of these tests did the
clinician just perform?
A.
Allen’s test
B.
Phalen’s test
C.
Tinel’s sign
D.
Finkelstein’s test
33. In which of these athletes is posterior impingement syndrome most commonly seen?
A.
Cross country runner
B.
Swimmer
C.
Soccer player
D.
Ballet dancer
34. The clinician is assessing Sally’s diffuse hip pain. How should the clinician begin the
examination?
A.
Begin the range-of-motion examination with an assessment of the motion that
causes pain.
B.
Physical examination of the hip must first assess its position at rest.
C.
The patient should move the hip prior to radiographic studies to determine whether
they are necessary.
D.
Flexion and extension of the affected hips’ extremity should only be performed
with the knee straight.
35. Felice is a 66-year-old female who complains that walking and prolonged standing causes
pain and weakness in her legs and buttocks. She expresses that she has short-term relief when
she leans on the shopping cart. When she sleeps on her back, she sometimes wakes up in the
night in pain. Which of the following diagnoses is most likely?
A.
Multiple sclerosis
B.
Herniated lumbar disc
C.
Lumbar spinal stenosis
D.
Cervical spondylosis
36. Which of the following is a risk factor for overuse syndrome with tendonitis?
A.
Body mass index <18
B.
Hypothyroidism
C.
Rheumatoid arthritis
D.
Cardiac disease
37. Which diagnostic test is the diagnostic gold standard for patients that have tendonitis and have
failed conservative treatment?
A.
Plain x-ray films
B.
Magnetic resonance imaging (MRI)
C.
Computed tomography (CT) scan
D.
Surgical exploration
38. Connie is a 63-year-old seamstress who presents with pain at the base of her right thumb on
abduction and extension of her right thumb. She also complains of pain on the radial side of
her right wrist with lifting. Which of these diagnostic tests will help to determine if she has de
Quervain’s tenosynovitis?
A.
Allen’s test
B.
Phalen’s maneuver
C.
Tinel’s sign
D.
Finkelstein’s test
39. Gladys has begun taking Prolia for osteoporosis. Which of the following should be included in
teaching about this medication?
A.
This medication is an oral pill daily.
B.
This medication decreases the risk of infection.
C.
It is contraindicated in the event of hypocalcemia.
D.
A drug holiday every 8 months is recommended.
40. Willow is a 67-year-old female and her bone mineral density is more than 1 SD below the
young adult reference mean. What is her diagnosis?
A.
Normal bone mineral density
B.
Osteopenia
C.
Osteoporosis
D.
Severe osteoporosis