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A 62-year-old male treated for hypertension and hyperlipidemia complains of nagging right knee pain that is
w orse in the evening. The pain has been present for several months and it seems to limit his physical
activities. His blood pressure is 160/ 100 mmHg and his heart rate is 70/min. His BMI is 32 kg/m 2, and
palpation of the knee reveals a cool joint w ith bony tenderness. His blood cholesterol level is 200 mg/dl and
his serum uric acid level is 9.0 mg/dl. W hich of the follow ing additional findings is likely on further examination
of the right knee?

A. Soft tissue sw elling [17%]

B. Painful tibial tuberosity [6%]
C. Palpable popliteal mass [4%]
v D. Bony crepitus [60%]
E. Subcutaneous nodules [ 12%]

Explanation: User ld:

This question requires one to be able to diagnose osteoarthritis (OA) from the clinical history alone. In
general, patients w ith OA lack significant physical and laboratory findings, so the diagnosis is generally based
on the physician's overall clinical impression. OA most often affects the knee, hip, spine and fingers, and is
often monoarticular. In the setting of a painful knee, there are six classic criteria used to establish the
diagnosis of OA. These include age > 50, minimal or no morning stiffness, bony tenderness, bony
enlargement, crepitus on active motion and no w armth of the joint. In the case of a painful knee w hich meets
at least three of these criteria, the sensitivity and specificity for OA are 95 and 69 percent, respectively. The
above patient's age, lack of morning stiffness, cool knee, and bony tenderness make OA the most likely
diagnosis. The patient is also obese, w hich is an additional risk factor for knee and hip OA. Of the answer
choices provided, bony crepitus w ould be the most likely additional finding. The uric acid level in this patient is
mildly elevated, w hich is non-specific. In the setting of acute rather than slow ly progressive monoarticular
arthritis, an elevated uric acid level might suggest gout.

(Choice A) Osteoarthritis is a noninflammatory arthritis, so joint effusions and soft tissue sw elling are minimal.

(Choice B) Pain at the site of the tibial tuberosity may indicate enthesitis, defined as inflammation at the site
of tendon insertion into bone. This occurs in spondyloarthropathies such as ankylosing spondylitis.

(Choice C) A palpable popliteal mass suggests a Baker cyst, w hich most commonly affects patients w ith
rheumatoid arthritis.

(Choice E) Subcutaneous nodules are commonly associated w ith rheumatoid arthritis, and appear at sites of
repetitive trauma, such as the extensor surfaces of the forearm. Nodular protrusions at the DIP and PIP in OA
result from bony enlargement and are know n as Heberden and Bouchard nodes, respectively.

Educational objective:
There is a lack of physical exam findings and laboratory values specific for osteoarthritis (OA). Therefore, the
diagnosis of OA is often made based upon the overall clinical impression and supplemented by radiographic
findings. There are six criteria used to establish the diagnosis of OA in the setting of a painful knee: age > 50,
crepitus, bony enlargement, bony tenderness, and lack of w armth/morning stiffness. If three or more criteria
are met, the specificity for OA is 69 percent.

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A 63-year-old painter presents w ith pain in his right shoulder for the past few w eeks. He experiences pain
w hen he tries to reach for objects and he is unable to lift his arm above his head. He denies trauma to the
shoulder, fevers, chills and w eight loss. Vital signs are w ithin normal limits. On exam, the physician raises
the patient's arm w hile asking him to relax the shoulder. At 60 degrees, the patient begins to shrug his
shoulder and complain of pain. In spite of the pain, his range of motion is normal. A lidocaine injection into the
shoulder leads to a significant decrease in pain upon lifting the arm . W hich of the follow ing is most likely
responsible for his current condition?

A. Rotator cuff tear (14%]

B. Adhesive capsulitis [18%]
.; C. Rotator cuff impingement [59%]
D. Crystal arthritis [2%]
E . Bacterial infection (0%]
F. Cervical radiculopathy (5%]
G. Vascular compression [1 %]

Explanation: User ld:

Patients w ith rotator cuff tendonitis complain of shoulder pain aggravated by activities such as reaching or
lifting the arm over the head. The condition results from repetitive activity above shoulder height and is most
common in middle-aged and older individuals. For this reason, painters are particularly prone to developing
rotator cuff tendonitis. Impingement is present in all patients w ith rotator cuff tendonitis. It is confirmed on
physical exam by performing the Neer test (passive motion of the arm above the head). Pain and guarding
during the Neer test confirms impingement. To distinguish rotator cuff tendinitis from other forms of rotator
cuff pathology, lidocaine is injected into the joint. Improved range of motion and pain relief after the injection
corroborates the diagnosis of rotator cuff tendonitis. MRI is used for definitive diagnosis.

(Choice A) Rotator cuff tear may result from trauma (e.g. falling on an outstretched arm) or as the end result
of chronic impingement and tendonitis. Similar to patients w ith rotator cuff tendinitis, patients often complain
of pain upon reaching and lifting the arm over the head. How ever, w eakness of the shoulder is more common
in rotator cuff tears, and symptoms do not improve w ith lidocaine injection.

(Choice B) Adhesive capsulitis, or frozen shoulder, is an idiopathic condition characterized by pain and
contracture. This condition presents w ith an inability to lift the arm above the head. Even after injection of
lidocaine, the arm still cannot be lifted above the head due to fibrosis of the shoulder capsule.

(Choices D & E) The shoulder is not a common site of crystal or septic arthritis. The knee is more
commonly involved in these highly inflammatory conditions. They present w ith a hot, sw ollen, tender joint.
These conditions are confirmed by synovial fluid analysis.

(Choice F) Cervical radiculopathy typically presents w ith pain of the neck and arm. Paresthesias of the arm
are present in 80% of patients. W eakness may affect the shoulder, elbow or w rist depending on the cervical
root(s) involved . Movement at the neck exacerbates symptoms.

(Choice G) Vascular compression may occur in thoracic outlet syndrome. This most commonly presents
w ith a combination of numbness, w eakness and sw elling due to compression of the subclavian vessels and
low er trunk of the brachial plexus. A w eakened radial pulse and reproduction of symptoms w ith specific arm
movements supports the diagnosis.

Educational objective:
Rotator cuff tendonitis caused by impingement is most common in middle-aged and older patients w ho
perform repetitive arm movements above the head. It presents w ith pain w hen lifting the arm . It may be
differentiated from rotator cuff tear and frozen shoulder by injection of the joint w ith lidocaine. In the case of
isolated rotator cuff tendonitis, any pain and limitation of motion is resolved by the injection.

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A 27 -year-old male presents to the physician's office because of pain on the medial side of the tibia just below
the knee. The pain does not radiate and is continuous. He relates the onset of his pain to falling on the
Lab Values Notes Calculator

ground w hile playing football two w eeks ago. He denies fever, malaise and w eight loss. His past medical
history is not significant. On examination, a w ell-defined area of tenderness is present on the upper tibia
below the medial knee joint. There is no redness, w armth or sw elling. His gait is normal. A valgus stress test
has no effect on his pain . X-ray of the knee and tibia show s no abnormalities. W hich of the follow ing is the
most likely cause of his current symptoms?

~ A. Anserine bursitis [39%]

B . Prepatellar bursitis (15%]
C. Medial collateral ligament strain [33%]
D. Medial compartment osteoarthritis [2%]
E. Patellofemoral syndrome (1 0%]

Explanation: User ld:

The patient described is most likely experiencing anserine bursitis. The anserine bursa is located
anteromedially over the tibial plateau just below the joint line of the knee. Inflammation of the anserine bursa
can be the result of an abnormal gait, overuse or trauma. Patients typically present complaining of localized
pain over the anteromedial tibia; the pain is often present overnight as pressure from the knees making
contact w ith one another w hile the patient lies on their side can exacerbate the pain . Examination reveals a
w ell-defined area of tenderness over the medial tibial plateau just below the joint line. A valgus stress test
does not aggravate the pain indicating that disease of the medial collateral ligament is absent. X-ray of the
tibia is normal in this condition. Treatment is w ith rest, ice and maneuvers to reduce pressure on the bursa .
Corticosteroid injections into the bursa are also helpful.

(Choice B) Prepatellar bursitis presents w ith pain and sw elling directly over the patella . Examination show s
cystic sw elling over the patella w ith variable signs of inflammation. The most common cause is trauma.

(Choice C) Medial collateral ligament injury presents w ith pain along the medial joint line and is aggravated by
w alking . It is caused by valgus stress applied on the lateral aspect of the knee w hen it is partially flexed. The
knee pain in this condition is aggravated by valgus stress testing.

(Choice D) Medial compartment osteoarthritis presents w ith pain of medial joint line typically in patients older
than 40. Other clinical features include morning stiffness of less than 30 minutes, crepitus and bony
tenderness on examination. X-ray of the knee show s narrow ing of the joint space and osteophyte formation.
Anserine bursitis may accompany medial compartment osteoarthritis due to the chronic gait abnormality
caused by the arthritic pain .

(Choice E) Patellofemoral syndrome is a common overuse pain syndrome of the knee. Patients present w ith
peripatellar pain w orsened by activity or prolonged sitting (due to sustained flexion) and may also complain of
crepitus w ith motion of the patella .

Educational objective:
Anserine bursitis presents w ith sharply localized pain over the anteromedial part of the tibial plateau just below
the joint line of the knee. Valgus stress test fails to reproduce the pain, thereby ruling out damage to the
medial collateral ligament, and radiographs are classically normal.

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A 23-year-old w oman comes to the physician with right foot pain that started 5 w eeks ago and is sharp and
localized to the forefoot. She recalls no trauma or other inciting event. The patient is an avid runner and is
currently training for a long-distance race. The pain has been w orsening over the past w eek and prevents her
from doing her daily running activities. She takes no medications. She does not use tobacco, alcohol, or illicit
drugs. She is not sexually active, and her last menstrual period w as 8 w eeks ago. Her temperature is 37 C
(98.6 F), blood pressure is 100/60 mm Hg, pulse is 68/min, and respirations are 12/min. Her body mass
index is 15 kg/m2. Examination show s normal range of motion, no erythema or bruising, and tenderness to
palpation along the second metatarsal bone on the dorsal surface of the right foot. Which of the following is
the most likely diagnosis?

A. Morton neuroma [13%1

B. Plantar fasciitis [6%1
.; C. Stress fracture [76%1
D. Tarsal tunnel syndrome [2%1
E. Tenosynovitis [3%1

Explanation: User ld:

Clinical features of stress fracture

• Prior stress fracture

• Repetitive activities (eg, running, gymnastics)
• Inadequate calcium & vitamin D intake
Risk factors • Decreased caloric intake (especially in women)
• Female gender, menstrual irregularities
• Decreased bone density

• Recently increased physical activity

Clinical • Insidious onset of localized pain that increases with activity
p resentatio n • Pain can progress to occur with less strenuous activity or at rest
• Physical examination shows point tenderness at site of injury
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This patient has acute w orsening of right foot pain consistent with a stress fracture, which most commonly
occurs in athletes (up to 15% incidence in runners) and non-athletes who suddenly increase their activity.
Bone responds to mechanical stress by remodeling, but an abrupt increase in intensity, duration, or frequency
of physical activity (without adequate rest) causes repeated tension or compressive stress to the bone. This
can lead to microfractures that eventually coalesce within the cortical bone. Female runners with the "female
athlete triad" (ie, oligo-/amenorrhea, decreased caloric intake, and osteoporosis) are more likely to develop
stress fractures. This patient's menstrual irregularities and low body mass index make this more likely.

Pain in the forefoot involving the metatarsal bones is usually due to a stress fracture, arthritis, bursitis, or
Morton neuroma. A stress fracture usually causes sharp and localized pain over a bony surface (most
commonly the 2nd, 3rd, or 4th metatarsals) that w orsens with palpation of the area . Local sw elling may also
be seen . Arthritis typically occurs in the metatarsal-phalangeal joints and is not localized to a single bony
surface. Bursitis is usually caused by w earing poor-fitting shoes for an extended period, leading to
inflammation between the metatarsal heads. This patient's bony tenderness over the foot is consistent with a
stress fracture, which should be managed with rest.

(Choice A) Morton neuroma is associated with pain between the third and fourth toes on the plantar surface

I
and with a clicking sensation (Mulder sign) that occurs when simultaneously palpating this space and
squeezing the metatarsal joints.

(Choice B) Plantar fasciitis causes burning pain in the plantar (not dorsal) area of the foot that w orsens with
the first steps in the morning. The pain decreases as activity increases during the day but usually w orsens at
the end of the day with prolonged w eight bearing. It is common in runners with repeated microtrauma who
develop local point tenderness on the plantar aspect of the foot.

(Choice D) Tarsal tunnel syndrome is due to compression of the tibial nerve as it passes through the ankle.
It is usually caused by a fracture of the ankle bones. Patients develop burning, numbness, and aching of the
distal plantar (not dorsal) surface of the foot/toes that sometimes radiate up to the calf.

(Choice E) Tenosynovitis is an inflammation of the tendon and its synovial sheath . It is usually seen in the
hands and w rists, often due to overuse or following a bite or puncture w ound. Patients have pain and
tenderness along the tendon sheath, particularly with flexion and extension movements.

Educational objective:
Stress fractures are common in patients who suddenly increase their physical activity, especially in female
runners with the female athlete triad (oligomenorrhea, osteoporosis, and decreased caloric intake). Typical
symptoms include localized pain to palpation and possible sw elling.

References:

1. High-risk stress fractures: evaluation and treatment.

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MQ# Main Division Sub Division Topic

! 1 - [4586) Medicine Rheumatology/Orthopedics & Sp... Osteoarthritis

! 2-[3168) Medicine Rheumatology/Orthopedics & Sp... Rotator Cuff Impingement

! 3- [3303) Medicine Rheumatology/Orthopedics & Sp... Anserine Bursitis

! 4- [2329) Medicine Rheumatology/Orthopedics & Sp... Foot Pain/Surgery

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