Contributors: Dr Sachin Khetan, Dr A Abhishek, Prof A Hassall Prof N Arden
Question 1 A 25 year old male bowler sustained an inversion injury of the right ankle during a local cricket tournament. You see him in the emergency department. He is able to walk with difficulty. On examination, he has swelling around the ankle. X-ray of the ankle shows soft tissue swelling but no fracture. You suspect a ligament injury.
Which is the most common ligament involved in ankle inversion injury?
Question 2 Oliver, a 25 year old musician noticed difficulty in picking up a cup of tea with his right hand because of weakness of thumb and index finger. There was no pain or sensory symptoms. Examination showed weak flexion of terminal phalanx of right thumb, and right index and middle finger. Sensory examination of the hand was normal.
What is the most likely cause of his symptoms?
Anterior interosseous nerve syndrome
Carpel tunnel syndrome
Cubital tunnel syndrome
Pronator teres syndrome
Ulnar tunnel syndrome
Question 3 A 75 year old patient with long standing Rheumatoid arthritis of 30 years duration has pain and paresthesia in his distal right foot, radiating to the medial malleolus. His symptoms were worse at night and improved marginally on walking. On examination he had pes planus, and hind foot valgus in the right foot. Motor and sensory examination of both feet was normal. His symptoms were reproduced by tapping behind the right medial malleolus.
What is the most likely cause of his symptoms?
Question 4 A 22 year old runner was referred to Rheumatology department with medial left knee pain for 6 months. The pain is worsened running, by going up stairs and by sleeping on either side at night. On examination, there is localized tenderness on the lower medial aspect of the left knee. There is no joint line tenderness or swelling. X-ray of the left knee (PA and sky line view) is unremarkable.
What is the most likely cause of her symptoms?
Osteoarthritis of the patella-femoral joint
Pes Anserinus Bursitis
Question 5 A 45 year old porter was referred by his GP with 6 months history of right lateral elbow and forearm pain. The pain gets worse while lifting at work. He denies any trauma, or similar symptoms in other joint. There are no other co morbidities. On examination he has excruciating tenderness around the right lateral epicondyle, and the elbow pain worsens on resisted wrist extension. There is no swelling. X-ray of the right elbow is normal.
What’s the most likely cause for his symptoms?
Valgus extension overload
Question 6 A 33 year old man was assessed in rheumatology outpatients with a 4 month history of pain localised around the right lateral thigh. The pain occasionally radiates down his thigh, and is worsened if he sleeps in right lateral position. He is otherwise fit and healthy. He smokes 3 cigarettes per day & drinks 12 units of alcohol per week. Palpation of the affected area reproduced similar symptoms. Abduction of the hip against restistance reproduces pain over the trochanteric bursa. Hip movements are intact. Straight leg raising test is negative. X-ray pelvis is unremarkable.
What’s the most likely cause for his symptoms?
A 24 year old lady was seen in rheumatology outpatients with pain and dysaesthesia in her left forefoot for 6 months. The pain is sharp and burning in nature, and is associated with numbness between 2nd & 3rd toes of the left foot. Narrow high-heeled shoes aggravate her symptoms. The symptoms are intermittent in nature, and she gets 2-3 episodes in a week. She has no other medical co-morbidities. Examinations of her feet are normal. An ultrasound scan of the foot was requested. Image of the scan is given below
What is the most likely diagnosis ?
Intermetatarsal bursal fluid collection
Metatarsal head osteonecrosis
Question 8 A 55 year old man was seen in rheumatology outpatients with a 4 month history of paresthesia and numbness on the lateral aspect of upper right thigh. This is aggravated by walking and standing. He denies any back pain or weakness. Bowel & bladder function is intact. He has diet controlled diabetes. He is a non-smoker, and drinks 3 units of alcohol per week. He is overweight (BMI is 29 kg/m2). Neurological examination is unremarkable except for numbness on the anterolateral thigh.
What is the most likely cause for his symptoms?
Q1. 1.Anterior talofibular ligament
The anterior talofibular ligament passes from the anterior margin of the fibular malleolus, forward and medially, to the talus bone, in front of its lateral articular facet. It is one of the lateral ligaments of the ankle and prevents the foot from sliding forward in relation to the shin. It is the most commonly injured ligament in a sprained ankle, resulting from an inversion injury, and will allow a positive anterior drawer test of the ankle if completely torn.
Q2. 1.Anterior interosseous nerve syndrome
The anterior interosseous nerve is a motor branch of the median nerve, which arises just below the elbow. It passes distally in the anterior interosseous membrane and innervates the long flexor muscles of the thumb, index and middle finger. Injuries of the forearm with compression of the nerve is the most common cause. Fibrous bands or arcuate ligaments may entrap the median as well as the anterior interosseous nerves, in which case a patient may experience numbness as well as pain. Rheumatoid disease and gouty arthritis may be a predisposing factor in anterior interosseous nerve entrapment. Most patients experience poorly localised pain in the forearm. The characteristic impairment of the pincer movement of the thumb and index finger is most striking. In a pure lesion of the anterior interosseous nerve there may be weakness of the long flexor muscle of the thumb (Flexor pollicis longus), the deep flexor muscles of the index and middle fingers (Flexor digitorum profundus I & II), and the pronator quadratus muscle.
Q3. 5. Tarsal tunnel syndrome
Tarsal tunnel syndrome is a known complication of longstanding Rheumatoid arthritis. It causes sensory symptoms in the foot. Symptoms are reproduced by tapping behind the right medial malleolus – Tinel’s sign.
Q4. 1.Pes Anserinus Bursitis
Pes anserine bursitis (or pes anserinus bursitis) is an inflammatory condition of the medial knee. Pes anserinus is the anatomic term used to identify the insertion of the conjoined tendons into the anteromedial proximal tibia. From anterior to posterior, the pes anserinus is made up of the tendons of the sartorius, gracilis, and semitendinosus muscles. The sartorius, gracilis, and semitendinosus muscles are primary flexors of the knee. These 3 muscles also influence internal rotation of the tibia and protect the knee against rotary and valgus stress. Theoretically, bursitis results from stress to this area (eg, stress may result when an obese individual with anatomic deformity from arthritis ascends or descends stairs). Pes anserine bursitis can result from acute trauma to the medial knee, athletic overuse, or chronic mechanical and degenerative processes. An occurrence of pes anserine bursitis commonly is characterized by pain, tenderness, and local swelling.
Q5. 3. Tennis elbow
Tennis elbow is the most common overuse syndrome is related to excessive wrist extension. It is also commonly referred to as lateral epicondylitis. The tendons are relatively hypovascular proximal to the tendon insertion. This hypovascularity may predispose the tendon to hypoxic tendon degeneration and has been implicated in the etiology of tendinopathies. The area of maximal tenderness is usually an area just distal to the origin of the extensor muscles of the forearm at the lateral epicondyle. Most typically the Extensor carpi radialis bravis (ECRB) is involved, but others may include the extensor carpi radialis longus (ECRL), extensor digitorum, and extensor carpi ulnaris. The patient complains of pain over the lateral elbow that worsens with activity and improves with rest. The patient will also often describe aggravating conditions such as a backhand stroke in tennis or the overuse of a screwdriver.
Q6. 5. Trochanteric bursitis
Trochanteric bursitis is characterized by painful inflammation of the bursa that is located just superficial to the greater trochanter of the femur. Patients typically complain of lateral hip pain, although the hip joint itself is not involved, because pain may radiate down the lateral aspect of the thigh. Inflammation of the affected bursa between the femoral trochanteric process and the gluteus medius/iliotibial tract may be due to acute or repetitive (cumulative) trauma. The most classic finding in trochanteric bursitis is the elicitation of point tenderness over the greater trochanter, which reproduces the presenting symptoms.
Q7. 5. Morton’s Neuroma
Morton neuroma (interdigital neuroma), is a perineural fibrosis and nerve degeneration of the common digital nerve. It results in neuropathic pain in the distribution of the interdigital nerve secondary to repetitive irritation of the nerve. The most frequent location is between the third and fourth metatarsals (third webspace). Other, less common locations are between the second and third metatarsals (second webspace). Episodes of pain are intermittent. Patients may experience 2 attacks in a week and then none for a year. Recurrences are variable and tend to become more frequent. Between attacks, no symptoms or physical signs occur. The female-to-male ratio for Morton's neuroma is 51.
Q8. 4. Meralgia paresthetica
Meralgia paresthetica is painful mononeuropathy of the lateral femoral cutaneous nerve.Meralgia paresthetica is commonly due to focal entrapment of this nerve as it passes through the inguinal ligament. The clinical history and examination is usually sufficient for making the diagnosis. However, the diagnosis can be confirmed by nerve conduction studies. The lateral femoral cutaneous nerve (LFCN) is responsible for the sensation of the anterolateral thigh. It is a purely sensory nerve and has no motor component. The LFCN is a nerve of the lumbar plexus. It arises from the dorsal divisions of the second and third lumbar nerves. When the LFCN is entrapped, paresthesias and numbness of the upper lateral thigh area are the presenting symptoms. The paresthesias may be quite painful. Walking or standing may aggravate the symptoms; sitting tends to relieve them.