Tendinopathies — MCQs
Best initial treatment for acute calcific tendinitis of shoulder?
Test for De-quervain's tenovaginitis -
In combined tendon and nerve injuries, the preferred sequence of repair is:
Tennis elbow is -
Finkelstein's test is done for diagnosis of:
A 40-year-old man was repairing his wooden shed on Sunday morning. By afternoon, he felt that the hammer was becoming heavier and heavier. He felt pain in the lateral side of the elbow and also found that squeezing water out of sponge hurt his elbow. Which of the muscles are most likely involved-
A 52-year-old female complains of increasing pain in the right shoulder. She is also finding it increasingly difficult to do overhead abduction of the affected joint. She had been diagnosed as a diabetic 20 years back and is on treatment since then. What is the most likely cause of her clinical condition?
Which of the following statement(s) is/are true?
Identify the true statement regarding the clinical examination given in the image:
With reference to frozen shoulder, consider the following statements: 1. It is associated with diabetes and heart disease. 2. It may follow minor trauma. 3. Its differential diagnosis are infection and fractures. 4. Treatment of choice is surgery. Which of the statements given above are correct?
Tendinopathies Indian Medical PG Practice Questions and MCQs
Question 1: Best initial treatment for acute calcific tendinitis of shoulder?
- A. Surgical Removal
- B. Steroid Injection
- C. Ultrasound Therapy
- D. NSAIDs and Physical Therapy (Correct Answer)
Explanation: ***NSAIDs and Physical Therapy*** - **NSAIDs (Nonsteroidal Anti-Inflammatory Drugs)** are the first-line treatment for acute pain and inflammation associated with calcific tendinitis. - **Physical therapy** helps maintain joint mobility, reduce stiffness, and strengthen surrounding muscles, preventing chronic issues. *Surgical Removal* - **Surgical removal** of calcium deposits is typically reserved for cases that are refractory to conservative treatments after several months or for severe, disabling symptoms. - It is an **invasive procedure** and not the initial approach for acute presentation. *Steroid Injection* - **Corticosteroid injections** can provide temporary pain relief by reducing inflammation, but they do not address the underlying calcium deposits. - Repeated injections can have adverse effects on tendon health and are generally considered after **NSAIDs** have failed. *Ultrasound Therapy* - **Ultrasound therapy** may be used as an adjunct treatment to help break down calcium deposits or to reduce inflammation, but it is not typically the sole initial treatment. - Its effectiveness is **variable**, and it is often combined with other modalities like NSAIDs and physical therapy.
Question 2: Test for De-quervain's tenovaginitis -
- A. Phalen test
- B. Cozen test
- C. Kanavel's sign
- D. Finkelstein test (Correct Answer)
Explanation: ***Finkelstein test*** - The **Finkelstein test** is performed to diagnose **De Quervain's tenosynovitis**, which involves inflammation of the **abductor pollicis longus** and **extensor pollicis brevis** tendons. - The test involves making a fist with the thumb tucked inside the fingers, followed by **ulnar deviation** of the wrist. Pain along the **radial styloid** is a positive sign. *Phalen test* - The **Phalen test** is used to diagnose **carpal tunnel syndrome**, which is compression of the **median nerve**. - This test involves holding the wrists in maximal **flexion** for 30-60 seconds, which exacerbates median nerve symptoms like **numbness** and **tingling**. *Cozen test* - The **Cozen test** is used to diagnose **lateral epicondylitis**, also known as "tennis elbow." - It involves resisted **wrist extension** and **radial deviation** with the elbow extended, causing pain at the **lateral epicondyle**. *Kanavel's sign* - **Kanavel's signs** (pain on passive extension, uniform swelling, flexed posture of digit, tenderness along the tendon sheath) are clinical indicators for **flexor tenosynovitis** in the hand. - These signs suggest a severe infection of the **flexor tendon sheath**, requiring urgent surgical intervention.
Question 3: In combined tendon and nerve injuries, the preferred sequence of repair is:
- A. Tendons should be repaired before nerves
- B. Nerves should be repaired before tendons (Correct Answer)
- C. None of the above
- D. Tendons should not be repaired simultaneously with nerves
Explanation: ***Nerves should be repaired before tendons*** - Nerve repairs are **more delicate** and require precise microsurgical technique with minimal tension - Repairing nerves first allows optimal **anatomical positioning** and coaptation without interference from tendon manipulation - Tendon repair involves **greater tissue handling and tension**, which could disrupt a freshly repaired nerve if done first - This sequence is the **standard teaching** in hand surgery (Green's Operative Hand Surgery, Campbell's Operative Orthopaedics) - Once nerves are secured, tendons can be repaired with the necessary tensioning without risk to neural structures *Tendons should be repaired before nerves* - This would subject the **fragile nerve repair to mechanical stress** during subsequent tendon manipulation - Tendon repair requires **forceful suturing and tensioning** that could displace or damage a previously repaired nerve - This sequence makes nerve repair technically more difficult as tendons may obstruct access *Tendons should not be repaired simultaneously with nerves* - While the exact sequence matters, both structures are typically repaired **in the same surgical setting** - The statement is confusing as "simultaneously" could mean same surgery (which is done) versus same moment (which is avoided) - Modern practice favors complete repair in one operation when possible *None of the above* - There is a well-established preferred sequence in combined tendon and nerve injuries - The principle of nerve-before-tendon repair is supported by surgical literature and clinical practice
Question 4: Tennis elbow is -
- A. Lateral Epicondylitis (Correct Answer)
- B. Radial head subluxation
- C. Ulnar collateral ligament injury
- D. Medial Epicondylitis
Explanation: ***Lateral Epicondylitis*** - **Tennis elbow** is the common term for **lateral epicondylitis**, an overuse injury causing pain on the **outer side of the elbow**. - It is typically caused by repetitive wrist extension and supination movements, leading to **tendinopathy** of the **extensor carpi radialis brevis** muscle origin. *Radial head subluxation* - This condition, commonly known as **nursemaid's elbow**, involves the displacement of the **radial head** from the annular ligament. - It is usually caused by a sudden pull on an outstretched arm, typically in young children, and presents with immediate pain and refusal to move the arm. *Ulnar collateral ligament injury* - An injury to the **ulnar collateral ligament (UCL)**, often seen in overhead throwing athletes, is sometimes called **"Tommy John injury"**. - It involves damage to the ligament on the **inner side of the elbow** and can lead to instability and pain during throwing motions. *Medial Epicondylitis* - This condition, known as **golfer's elbow**, involves pain on the **inner side of the elbow**. - It is caused by overuse of the forearm flexor muscles that originate from the **medial epicondyle**, due to repetitive wrist flexion and pronation.
Question 5: Finkelstein's test is done for diagnosis of:
- A. Trigger finger (stenosing tenosynovitis)
- B. Acute compartment syndrome
- C. De quervain's tenosynovitis (Correct Answer)
- D. Carpal tunnel syndrome
Explanation: ***De Quervain's tenosynovitis*** - **Finkelstein's test** is the classic physical examination maneuver used to diagnose **De Quervain's tenosynovitis**. - The test involves pain elicited when the patient makes a **fist with the thumb tucked inside** the other fingers, and then ulnar deviates the wrist. *Trigger finger (stenosing tenosynovitis)* - While it is also a tenosynovitis, **trigger finger** affects the flexor tendons of the digits and is characterized by painful clicking or locking. - Diagnosis is clinical, based on observing the **finger catching or locking** during attempted extension. *Acute compartment syndrome* - This is a limb-threatening condition involving increased pressure within a muscle compartment, often due to trauma. - Diagnosis is based on **clinical signs** (pain out of proportion, pallor, paresthesia, pulselessness, paralysis) and **intracompartmental pressure measurements**. *Carpal tunnel syndrome* - This condition results from compression of the **median nerve** within the carpal tunnel, causing numbness, tingling, and weakness in the hand. - Diagnostic tests include **Tinel's sign** (tapping over the median nerve) and **Phalen's maneuver** (wrist flexion), not Finkelstein's test.
Question 6: A 40-year-old man was repairing his wooden shed on Sunday morning. By afternoon, he felt that the hammer was becoming heavier and heavier. He felt pain in the lateral side of the elbow and also found that squeezing water out of sponge hurt his elbow. Which of the muscles are most likely involved-
- A. Triceps brachii and anconeous
- B. Biceps brachii and supinator
- C. Flexor digitorum superficialis
- D. Extensor carpi radialis longus and brevis (Correct Answer)
Explanation: ***Extensor carpi radialis longus and brevis*** - The symptoms described, such as **lateral elbow pain** and pain with actions like hammering and squeezing, are classic for **lateral epicondylitis**, also known as **tennis elbow**. - **Extensor carpi radialis longus** and **brevis** are the primary muscles that originate from the **lateral epicondyle**, and their tendons are commonly affected in this condition. *Triceps brachii and anconeus* - The **triceps brachii** is responsible for elbow extension; injury to this muscle or the anconeus would typically cause pain in the **posterior aspect of the elbow**. - Pain specifically localized to the **lateral elbow** with gripping and wrist extension activities is not characteristic of triceps or anconeus involvement. *Biceps brachii and supinator* - The **biceps brachii** is a primary supinator and elbow flexor, while the **supinator** muscle also aids in supination; involvement of these would typically cause pain in the **anterior elbow** or with supination against resistance. - These muscles are generally not associated with pain in the **lateral epicondyle** with wrist extension and gripping activities. *Flexor digitorum superficialis* - The **flexor digitorum superficialis** is involved in flexing the fingers and wrist and originates from the **medial epicondyle** of the humerus. - Injury to this muscle would cause pain on the **medial side of the elbow** (golfer's elbow), not the lateral side, and is typically exacerbated by repetitive wrist flexion.
Question 7: A 52-year-old female complains of increasing pain in the right shoulder. She is also finding it increasingly difficult to do overhead abduction of the affected joint. She had been diagnosed as a diabetic 20 years back and is on treatment since then. What is the most likely cause of her clinical condition?
- A. Frozen shoulder (Correct Answer)
- B. Bacterial arthritis
- C. Osteoarthritis
- D. Rotator cuff tear
Explanation: ***Frozen shoulder*** - The patient's presentation with **increasing pain** and **difficulty with overhead abduction** of the shoulder, especially in the context of long-standing **diabetes**, is highly characteristic of **adhesive capsulitis** (frozen shoulder). - This condition is marked by **progressive stiffness** and **restricted range of motion** in the shoulder joint due to inflammation and fibrosis of the joint capsule. *Bacterial arthritis* - **Bacterial arthritis** typically presents with an **acutely painful**, **swollen**, and **erythematous joint**, often accompanied by systemic symptoms like **fever** and **malaise**. - The chronic, progressive nature of the patient's symptoms and the absence of acute inflammatory signs or fever make bacterial arthritis less likely. *Osteoarthritis* - While **osteoarthritis** can cause shoulder pain and stiffness, it usually presents with **pain that worsens with activity** and is relieved by rest, often with **crepitus** and a more gradual loss of range of motion. - The pronounced restriction in **overhead abduction** in this patient, particularly given the diabetic history, points away from primary osteoarthritis as the most likely cause. *Rotator cuff tear* - A **rotator cuff tear** typically presents with pain and weakness, especially during **abduction** or **external rotation**, and may have a specific mechanism of injury. - While abduction can be difficult, the classic presentation of a frozen shoulder with severe, global restriction of both active and passive range of motion is a stronger fit for the described symptoms.
Question 8: Which of the following statement(s) is/are true?
- A. Normally the radial styloid is 1/2 lower than the ulnar
- B. Dinner fork deformity is characteristic of Colles' fracture (Correct Answer)
- C. All of the options
- D. Oedema & tenderness over the anatomical snuffbox is the characteristic features of Fracture of the scaphoid
Explanation: **Dinner fork deformity is characteristic of Colles' fracture** - **Colles' fracture** involves a **dorsal displacement** and angulation of the distal radius, creating a characteristic **"dinner fork" or "bayonet" deformity** of the wrist. - This specific deformity is a classic clinical sign that aids in the diagnosis of a Colles' fracture, which is an **extra-articular fracture** of the distal radius with dorsal angulation. *Normally the radial styloid is 1/2 lower than the ulnar* - The **radial styloid** normally extends approximately **1-1.5 cm (or about 1/2 inch)** *distal* to the ulnar styloid, not lower than. - This difference in length is crucial for normal wrist kinematics, and its reversal can indicate conditions like **ulnar positive variance**. *All of the options* - This option is incorrect because the statement regarding the radial styloid being lower than the ulnar is **false**. - Since one of the options provided is factually incorrect, this choice cannot be true. *Oedema & tenderness over the anatomical snuffbox is the characteristic features of Fracture of the scaphoid* - While **oedema and tenderness in the anatomical snuffbox** are hallmark signs of a **scaphoid fracture**, this statement alone does not encompass all the truth presented in the options. - This specific physical finding is highly indicative of a scaphoid fracture, necessitating further imaging to confirm the diagnosis due to **poor vascular supply** to the scaphoid and risk of **avascular necrosis**.
Question 9: Identify the true statement regarding the clinical examination given in the image:
- A. Wrist is held in forced flexion for 60 sec eliciting pain (Correct Answer)
- B. Wrist is held in forced extension for 60 sec
- C. Wrist is held in forced flexion for 45 sec eliciting pain
- D. Wrist is held in forced extension for 45 sec
Explanation: ***Wrist is held in forced flexion for 60 sec eliciting pain*** - The image depicts **Phalen's test**, used to diagnose **carpal tunnel syndrome**. In this test, the patient's wrists are held in maximal sustained **flexion** for 30-60 seconds. - The reproduction of **tingling or pain** in the median nerve distribution (thumb, index, middle, and radial half of the ring finger) within this time frame indicates a positive test. *Wrist is held in forced extension for 60 sec* - Holding the wrist in **forced extension** for 60 seconds describes **reverse Phalen's test**, not the standard Phalen's test shown. - While reverse Phalen's test also assesses for **carpal tunnel syndrome**, it typically involves holding the wrists in **extension**. *Wrist is held in forced flexion for 45 sec eliciting pain* - While **flexion** is correct for Phalen's test, the standard duration is up to **60 seconds**, not specifically 45 seconds to determine a positive result. - Pain should be elicited within this timeframe, but the 45-second duration is not the most accurate statement regarding the full range of the test's timing. *Wrist is held in forced extension for 45 sec* - This option incorrectly states **forced extension** rather than flexion for Phalen's test, and the specific duration of 45 seconds is not universally cited as the definitive endpoint for a positive result. - **Forced extension** is part of the reverse Phalen's maneuver, not the test shown.
Question 10: With reference to frozen shoulder, consider the following statements: 1. It is associated with diabetes and heart disease. 2. It may follow minor trauma. 3. Its differential diagnosis are infection and fractures. 4. Treatment of choice is surgery. Which of the statements given above are correct?
- A. 1 and 2 only
- B. 3 and 4 only
- C. 1, 2 and 3 (Correct Answer)
- D. 2, 3 and 4
Explanation: ***1, 2 and 3*** - **Frozen shoulder** (adhesive capsulitis) has a higher incidence in individuals with **diabetes mellitus** and **cardiovascular diseases**, indicating systemic associations. - It can be triggered by minor trauma or surgery, but often it has **no identifiable cause** (idiopathic). - The differential diagnoses for shoulder pain and restricted motion include serious conditions like **infection (septic arthritis)** and **fractures**, which must be ruled out. *1 and 2 only* - This option correctly identifies the association with diabetes and heart disease, and the possibility of minor trauma. - However, it incorrectly excludes the importance of considering infection and fractures in the differential diagnosis. *3 and 4 only* - This option correctly identifies the importance of differential diagnosis (infection and fractures). - However, **surgery is generally not the first-line treatment for frozen shoulder**; it is reserved for severe cases unresponsive to conservative measures. - It also fails to acknowledge the associations with diabetes and heart disease, or the role of minor trauma. *2, 3 and 4* - This option correctly notes that frozen shoulder can follow minor trauma and that infection and fractures are important differential diagnoses. - However, it incorrectly states that **surgery is the treatment of choice**, when **conservative management is usually first-line**. - It also misses the crucial association with **diabetes and heart disease**.
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