A 33-year-old male marathon runner presents with knee pain. Which of the following tests is positive ...

The answer to question 1  ANS: A
Tears or disruptions of the meniscus sheath of cartilage are associated with OA in older persons and with athletic activities in younger persons. There is typically a sudden onset of pain and swelling over the lateral or medial joint line as well as locking and painful popping. Onset often follows a twisting injury. Point tenderness is present over the joint line, with mild effusion. A positive McMurray's test is often present.

The answer to question 2  ANS: A
De Quervain's tenosynovitis involves irritation of a tendon located on the radial side of the wrist, near the thumb. With overuse, the tissues surrounding the tendon sheath hypertrophy, causing pressure on the tendon and making it difficult to move. The pain is usually limited to the radial aspect of the wrist and area immediately around the base of the thumb. Pain increases with use of the hand, such as with gripping maneuvers. Other symptoms include swelling, decreased sensation, and limited ROM with a locking sensation with thumb motion. The Finkelstein maneuver (Fig. 14.7) is used to diagnose De Quervain's disease. A positive test results in pain, which is often severe. Patients who can repeatedly open and close the fist with smooth thumb motion are unlikely to have De Quervain's.

The answer to question 3  ANS: B
There are many potential causes of hip pain. Among adults, the most common cause is OA with degenerative changes. In younger patients, the cause is often strain of the muscles or tendons. In comparison to other joints, the hip is often difficult to assess, in part because much of the joint and its periarticular structures lie deeper than those of other joints.

The answer to question 4  ANS: A
Also known as pulled elbow or toddler's elbow, nursemaid's elbow involves the head of the radius slipping under the annular ligament in children, usually between 1 and 4 years of age. The condition occurs when traction is applied to the young child's hand or wrist. There is a history of sudden onset of pain associated with sudden immobility of the affected arm as the child protects the elbow. The parent may be able to identify a situation in which the child's hand was held and traction applied. The child may have moved in an opposite direction or injury could occur while pulling the arm through clothing. There is no associated swelling or inflammation. Examination is otherwise normal with the exception of resistance to attempts to move the arm, elbow, and, possibly, wrist. There may be tenderness along the upper margin of the radius.

The answer to question 5  ANS: A
Carpal tunnel syndrome causes a range of neurological symptoms, including pain, paresthesia, and weakness. Frequently, nighttime pain is an early symptom. There may be a swelling at the wrist related to inactivity or flexion at night. The pain and/or paresthesias typically involve the anterior aspects of wrist, medial palm, and first three digits on the affected hand. However, pain may radiate up the forearm to the shoulder with numbness and tingling along the median nerve. Over time, hand weakness often develops. Pain and paresthesia are often relieved by the patient shaking the affected hand in a downward fashion; this is called the flicking sign. A positive Tinel's sign is elicited by tapping on the median nerve at the carpal tunnel, causing pain and tingling along the median nerve. Phalen's maneuver reproduces the pain after 1 minute of wrist flexion against resistance.

The answer to question 6  ANS: C
Unlike the other conditions affecting the shoulder, glenohumeral instability is most common in young patients who are physically active. The instability can result in displacement of the humeral head in various directions. The patient will experience sudden onset of pain and be unwilling to move the arm. The displacement may follow an acute injury/trauma or may be associated with specific movements or overuse. A positive apprehension test suggests glenohumeral instability. This can be somewhat validated by performing the relocation test, in which the apprehension test is immediately followed by placing mild anterior pressure on the arm paired with external rotation.

The answer to question 7  ANS: D
Acute shoulder syndromes frequently arise from inflammation. Most frequently, the capsule of the glenohumeral joint, supraspinatus tendon, and the subacromial bursa are involved. When patients present with shoulder pain, always consider the possibility of cardiac, cervical neck, or gastrointestinal cause. Cardiac pain commonly radiates to the left shoulder. Cervical spine degeneration and osteoarthritis frequently causes right- or left-sided shoulder pain. Gastrointestinal disorders, such as cholecystitis, frequently cause pain radiation to the right shoulder.