1

Rotator-Cuff Tendinopathy

4 questions · Physical Medicine

Clinical Case

A 47-year-old right-handed painter presents with three months of progressive right shoulder pain. The pain is worse while painting overhead and when lying on the affected side. There was no major trauma. Examination reveals: • Painful active shoulder abduction between 70° and 120° • Nearly full passive range of motion • Pain with resisted abduction and external rotation • Positive Hawkins-Kennedy and Neer tests • No cervical radicular symptoms • No obvious muscle atrophy

Question 1 of 4NPLEX-PM-001

What is the most likely diagnosis?

AAdhesive capsulitisBRotator-cuff tendinopathyCCervical radiculopathyDGlenohumeral osteoarthritisEPosterior shoulder dislocation

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Rotator-cuff tendinopathy

Explanation Pain with overhead activity, a painful arc, pain during resisted rotator-cuff testing, positive subacromial provocation tests, and relatively preserved passive movement support rotator-cuff tendinopathy. • A: Adhesive capsulitis restricts both active and passive motion. • C: Cervical radiculopathy usually produces radiating pain, sensory changes, weakness, or reflex abnormalities. • D: Glenohumeral osteoarthritis usually causes loss of active and passive movement with crepitus. • E: Posterior dislocation usually follows trauma, seizure, or electrocution and causes marked motion restriction. Current rotator-cuff guidance emphasizes clinical assessment and individualized active rehabilitation; routine early advanced imaging is usually unnecessary in an uncomplicated presentation.

Question 2 of 4NPLEX-PM-002

Which test most directly reproduces subacromial shoulder pain in this patient?

APhalen testBNeer testCMcMurray testDFinkelstein testEThompson test

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Neer test

Explanation The Neer test provokes symptoms by elevating the internally rotated arm, narrowing the subacromial space and stressing sensitive rotator-cuff and bursal structures. • A: Assesses median-nerve symptoms associated with carpal tunnel syndrome. • C: Assesses possible meniscal pathology. • D: Assesses de Quervain tenosynovitis. • E: Assesses Achilles-tendon integrity. Exam point: A single shoulder test does not establish the diagnosis. Interpret test findings within the complete history and examination.

Question 3 of 4NPLEX-PM-003

What is the most appropriate initial rehabilitation plan?

AComplete shoulder immobilization for six weeksBImmediate maximal overhead strengtheningCActivity modification with progressive rotator-cuff and scapular strengtheningDForceful manipulation under anesthesiaECervical traction as the primary treatment

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Activity modification with progressive rotator-cuff and scapular strengthening

Explanation The patient should temporarily reduce aggravating overhead load while beginning graded shoulder and scapular exercise. Rehabilitation may include: • Pain-limited range-of-motion exercise • Scapular control • Isometric rotator-cuff activation • Progressive resisted external rotation and abduction • Gradual work-specific loading • A: Prolonged immobilization may increase stiffness and deconditioning. • B: Maximal loading is inappropriate during an irritable phase. • D: Manipulation under anesthesia is not first-line therapy for tendinopathy. • E: There is no evidence of a cervical cause. Exercise-based rehabilitation is a central component of nonsurgical rotator-cuff management.

Question 4 of 4NPLEX-PM-004

Which new finding would most strongly indicate imaging and referral rather than continued conservative treatment?

AMild pain during resisted abductionBPain after prolonged paintingCSudden inability to actively raise the arm after a traumatic fallDMild scapular protractionEImprovement after activity modification

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Sudden inability to actively raise the arm after a traumatic fall

Explanation Acute traumatic weakness or inability to elevate the arm raises concern for a significant full-thickness rotator-cuff tear, fracture, dislocation, or neurologic injury.

Reveal Case Review & NPLEX Trap

Diagnosis: Rotator-cuff tendinopathy/subacromial shoulder pain Differential diagnosis: Full-thickness tear, adhesive capsulitis, cervical radiculopathy, glenohumeral arthritis, AC-joint disease Key investigations: Usually clinical initially; radiography, ultrasound, or MRI when trauma, severe weakness, suspected tear, or failure to improve changes management Treatment: Activity modification, graded exercise, ergonomic correction, symptom control Manual therapy: May be used as an adjunct, not as a replacement for active rehabilitation NPLEX trap: Preserved passive motion argues against adhesive capsulitis.

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2

Adhesive Capsulitis

4 questions · Physical Medicine

Clinical Case

A 58-year-old woman with type 2 diabetes reports six months of gradually progressive left shoulder pain and stiffness. She has difficulty fastening her bra and reaching overhead. There was no trauma. Examination reveals: • Restricted active and passive shoulder movement • External rotation is most restricted • No focal neurologic deficit • Normal elbow and wrist examination • Mild pain at the end of the available range

Question 1 of 4NPLEX-PM-005

What is the most likely diagnosis?

AAdhesive capsulitisBIsolated supraspinatus tearCCarpal tunnel syndromeDCervical myelopathyEBicipital tendon rupture

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Adhesive capsulitis

Explanation Adhesive capsulitis causes progressive shoulder pain and global restriction of active and passive glenohumeral motion. External rotation is commonly the most affected movement. • B: A cuff tear usually limits active movement more than passive movement. • C: Carpal tunnel syndrome causes median-nerve hand symptoms. • D: Cervical myelopathy causes upper motor-neuron findings and gait or hand dysfunction. • E: Bicipital rupture may produce bruising, weakness, and a “Popeye” deformity. The typical clinical pattern includes gradual onset in middle age with significant mobility loss.

Question 2 of 4NPLEX-PM-006

Which test best documents functional shoulder mobility?

AApley scratch testBLachman testCTalar tilt testDCozen testEStraight-leg raise

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Apley scratch test

Explanation The Apley scratch test evaluates functional combinations of shoulder abduction, adduction, internal rotation, and external rotation. • B: ACL integrity • C: Ankle ligament stability • D: Lateral elbow pain • E: Lumbosacral nerve-root irritation

Question 3 of 4NPLEX-PM-007

What is the most appropriate initial physical medicine prescription?

AAggressive high-velocity stretching beyond pain toleranceBGentle mobility exercise matched to symptom irritabilityCComplete immobilization until all pain disappearsDHeavy overhead resistance trainingEImmediate return to unrestricted activity

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Gentle mobility exercise matched to symptom irritability

Explanation Exercise intensity should be matched to the condition’s irritability. Appropriate options include: • Pendulum exercise • Assisted flexion • Gentle external-rotation stretching • Cross-body mobility • Gradual functional reaching More aggressive mobilization may be considered later as pain decreases and stiffness becomes the primary limitation. • A: Excessive loading can aggravate the painful stage. • C: Prolonged immobilization worsens stiffness. • D: Heavy loading is premature. • E: Functional activity must be progressed gradually. Joint mobilization and stretching can support pain reduction and mobility improvement when tailored to the patient’s stage.

Question 4 of 4NPLEX-PM-008

Which hydrotherapy application may be used immediately before gentle stretching when sensation and circulation are normal?

AComfortable superficial heatBProlonged direct ice over anesthetic skinCScalding water applicationDAlternating extreme temperatures despite vascular diseaseEContinuous heat over an acutely infected joint

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Comfortable superficial heat

Explanation Comfortable heat may temporarily reduce guarding and improve tolerance of gentle mobility work in a chronically stiff shoulder. The practitioner must first confirm: • Intact skin sensation • Adequate circulation • Ability to report excessive heat • Absence of acute infection or bleeding • Appropriate exposure time and temperature

Reveal Case Review & NPLEX Trap

Diagnosis: Adhesive capsulitis Risk association: Diabetes and thyroid disease may be associated Key examination: Active and passive restriction, especially external rotation Treatment: Education, pain control, stage-appropriate mobility, later strengthening Imaging: Consider when the clinical pattern is atypical or another disorder is suspected NPLEX trap: Rotator-cuff tears usually do not produce the same global passive restriction.

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3

Cervical Radiculopathy

4 questions · Physical Medicine

Clinical Case

A 45-year-old office worker reports neck pain radiating into the right lateral forearm and thumb. Examination reveals: • Reduced sensation over the thumb • Weak wrist extension • Reduced right biceps reflex • Symptoms increase with cervical compression • Symptoms improve with cervical distraction • No gait abnormality or bowel or bladder symptoms

Question 1 of 4NPLEX-PM-009

Which cervical nerve root is most likely affected?

AC4BC5CC6DC7EC8

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. C6

Explanation A C6 pattern may include: • Pain or sensory change extending toward the thumb • Weakness of wrist extension and sometimes elbow flexion • Reduced biceps or brachioradialis reflex • C5: More strongly associated with shoulder abduction and lateral upper-arm sensation. • C7: Middle finger symptoms, triceps weakness, and reduced triceps reflex. • C8: Medial forearm and small-finger symptoms with finger-flexion weakness.

Question 2 of 4NPLEX-PM-010

Which finding supports cervical nerve-root compression?

ASymptoms relieved by cervical compressionBSymptoms reproduced by cervical compression and relieved by distractionCPositive McMurray testDPositive Thompson testEPain limited to the lateral epicondyle

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Symptoms reproduced by cervical compression and relieved by distraction

Explanation Cervical compression may reproduce radicular symptoms by reducing foraminal space. Distraction may reduce symptoms by decreasing mechanical compression. The NPLEX Physical Medicine blueprint includes cervical compression and distraction testing.

Question 3 of 4NPLEX-PM-011

What is the most appropriate initial management when no serious neurologic deficit is present?

AImmediate cervical manipulation without neurologic examinationBEducation, activity modification, therapeutic exercise, and monitored conservative careCComplete bed rest for four weeksDRepeated end-range loading regardless of symptom responseEImmediate surgery in every case

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Education, activity modification, therapeutic exercise, and monitored conservative care

Explanation Conservative care may include: • Postural and workplace modification • Pain-limited cervical mobility • Scapular and deep-neck-flexor exercise • Neural mobility when appropriate • Carefully selected manual therapy • Monitoring of strength, sensation, and reflexes Any worsening motor deficit requires reassessment and possible imaging or referral.

Question 4 of 4NPLEX-PM-012

Which new finding is most concerning for cervical myelopathy?

AMild neck stiffnessBPain with prolonged computer useCHyperreflexia, hand clumsiness, and an unsteady gaitDSymptoms that decrease with restELocal trapezius tenderness

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Hyperreflexia, hand clumsiness, and an unsteady gait

Explanation Upper motor-neuron signs, loss of hand dexterity, gait dysfunction, pathologic reflexes, or bowel or bladder disturbance raise concern for spinal-cord involvement. MRI of the relevant spinal region is generally the preferred initial imaging modality for suspected myelopathy.

Reveal Case Review & NPLEX Trap

Diagnosis: C6 cervical radiculopathy Differential diagnosis: Carpal tunnel syndrome, radial neuropathy, rotator-cuff disease, cervical myelopathy Key investigations: Neurologic examination; MRI when progressive deficit, myelopathy, trauma, infection, malignancy, or persistent severe symptoms are present Treatment: Exercise, posture, graded activity, selected manual therapy Contraindication: Do not perform forceful cervical treatment when instability, fracture, myelopathy, vascular pathology, or progressive neurologic loss is suspected NPLEX trap: Radiculopathy is a nerve-root disorder; myelopathy involves the spinal cord.

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4

Cauda Equina Syndrome

4 questions · Physical Medicine

Clinical Case

A 61-year-old patient presents with severe low-back pain after several weeks of increasing sciatica. During the previous 12 hours, the patient developed: • Bilateral leg weakness • Saddle anesthesia • Urinary retention • Reduced anal tone • Difficulty walking

Question 1 of 4NPLEX-PM-013

What is the most likely diagnosis?

AUncomplicated lumbar strainBCauda equina syndromeCPiriformis syndromeDGreater trochanteric pain syndromeEMechanical sacroiliac dysfunction

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Cauda equina syndrome

Explanation The combination of urinary retention, saddle anesthesia, bilateral neurologic dysfunction, and reduced anal tone is highly concerning for cauda equina compression.

Question 2 of 4NPLEX-PM-014

What is the most appropriate next action?

APrescribe home stretching and review in one weekBBegin lumbar manipulationCArrange immediate emergency assessmentDApply continuous deep heatEBegin core-strengthening exercises

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Arrange immediate emergency assessment

Explanation Suspected cauda equina syndrome is a time-sensitive emergency. Physical treatment must not delay definitive evaluation.

Question 3 of 4NPLEX-PM-015

Which investigation is most appropriate?

ARoutine bone-density testingBUrgent lumbar MRICDiagnostic ultrasound of the lumbar musclesDElectromyography before imagingENo investigation is required

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Urgent lumbar MRI

Explanation The American College of Radiology identifies lumbar MRI as an appropriate initial imaging examination for suspected cauda equina syndrome.

Question 4 of 4NPLEX-PM-016

Which physical medicine treatment is contraindicated at this visit?

AImmediate lumbar manipulationBEmergency transferCRepeated neurologic assessmentDDocumentation of bladder and saddle symptomsECommunication with emergency specialists

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Immediate lumbar manipulation

Explanation Manipulation could delay emergency imaging and specialist management. The priority is urgent assessment for decompression and treatment of the cause.

Reveal Case Review & NPLEX Trap

Diagnosis: Cauda equina syndrome Possible causes: Large disc herniation, tumor, epidural abscess, hematoma, severe stenosis, trauma Red flags: Urinary retention, saddle anesthesia, bilateral deficits, reduced anal tone Gold-standard investigation: Urgent MRI Treatment: Emergency surgical or specialist management based on the cause NPLEX trap: Severe pain alone does not establish cauda equina syndrome; the neurologic and bladder findings are decisive.

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5

Carpal Tunnel Syndrome

4 questions · Physical Medicine

Clinical Case

A 51-year-old bookkeeper reports nocturnal numbness and tingling in the right thumb, index finger, middle finger, and radial half of the ring finger. Shaking the hand temporarily reduces the symptoms. Examination shows: • Positive Phalen test • Positive Tinel sign at the carpal tunnel • Mild thenar weakness • No neck pain • Normal ulnar distribution sensation

Question 1 of 4NPLEX-PM-017

What is the most likely diagnosis?

AC8 radiculopathyBUlnar neuropathyCCarpal tunnel syndromeDDe Quervain tenosynovitisELateral epicondylalgia

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Carpal tunnel syndrome

Explanation Carpal tunnel syndrome results from median-nerve compression at the wrist. Typical symptoms include nocturnal paresthesia affecting the thumb, index, middle, and radial ring fingers. • A: C8 radiculopathy more often affects the medial hand and may include neck symptoms. • B: Ulnar neuropathy affects the small finger and ulnar half of the ring finger. • D: De Quervain tenosynovitis causes radial wrist pain rather than median sensory symptoms. • E: Lateral epicondylalgia causes lateral elbow pain.

Question 2 of 4NPLEX-PM-018

Which nerve is compressed?

ARadial nerveBUlnar nerveCMedian nerveDAxillary nerveEMusculocutaneous nerve

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Median nerve

Explanation The median nerve passes through the carpal tunnel with the finger-flexor tendons.

Question 3 of 4NPLEX-PM-019

Which initial physical intervention is most appropriate for mild nocturnal symptoms?

ANeutral-position wrist splint at nightBWrist splint in maximal flexionCHeavy repetitive gripping exerciseDContinuous immobilization of the elbowECervical collar for six weeks

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Neutral-position wrist splint at night

Explanation A neutral-position nocturnal wrist orthosis reduces prolonged wrist flexion or extension, which can increase pressure within the carpal tunnel. Other management considerations include: • Ergonomic modification • Reduction of sustained wrist postures • Tendon or nerve-gliding exercise when appropriate • Monitoring strength and sensation • Evaluation of contributing systemic conditions The 2024 AAOS guideline addresses evidence-based diagnosis and treatment of adult carpal tunnel syndrome.

Question 4 of 4NPLEX-PM-020

Which finding most strongly supports referral for further evaluation?

ASymptoms only after one unusually long workdayBProgressive thenar atrophy and persistent motor weaknessCSymptoms relieved by changing hand positionDMild forearm tightnessENegative elbow valgus stress testing

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Progressive thenar atrophy and persistent motor weakness

Explanation Progressive motor deficit or thenar atrophy suggests more advanced median-nerve dysfunction and warrants prompt assessment. Electrodiagnostic testing may be useful when the diagnosis is uncertain, symptoms are severe, or surgery is being considered.

Reveal Case Review & NPLEX Trap

Diagnosis: Carpal tunnel syndrome Key tests: Phalen, Tinel, sensory examination, thenar strength Differential diagnosis: Cervical radiculopathy, pronator syndrome, peripheral neuropathy, ulnar neuropathy Treatment: Neutral night splint, ergonomic changes, activity modification, selected exercises Referral indications: Persistent weakness, thenar atrophy, severe sensory loss, failure of conservative care NPLEX trap: Tinel and Phalen tests support but do not independently prove the diagnosis.

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6

Lateral Epicondylalgia

4 questions · Physical Medicine

Clinical Case

A 42-year-old recreational tennis player develops pain over the lateral right elbow after increasing backhand practice. The pain is worse with gripping, lifting a kettle, and resisted wrist extension. Examination reveals: • Tenderness near the lateral epicondyle • Pain with resisted wrist extension • Positive Cozen test • Pain during passive wrist-flexor stretch with the elbow extended • Normal sensory and reflex examination

Question 1 of 4NPLEX-PM-021

What is the most likely diagnosis?

ALateral epicondylalgiaBCubital tunnel syndromeCMedial epicondylalgiaDCervical myelopathyEOlecranon fracture

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Lateral epicondylalgia

Explanation Lateral epicondylalgia is characterized by lateral elbow pain associated with gripping and loading of the wrist-extensor tendon complex.

Question 2 of 4NPLEX-PM-022

Which orthopedic test most directly assesses this condition?

ACozen testBFinkelstein testCPhalen testDYergason testEAnterior drawer test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Cozen test

Explanation The Cozen test provokes lateral elbow pain through resisted wrist extension, usually with radial deviation. • B: De Quervain tenosynovitis • C: Carpal tunnel syndrome • D: Long-head biceps tendon • E: Knee or ankle ligament stability depending on technique Lateral elbow pain and its relevant tests are included within published orthopedic physical-therapy guidance.

Question 3 of 4NPLEX-PM-023

What is the most appropriate rehabilitation approach?

AComplete upper-limb immobilization for three monthsBProgressive wrist-extensor loading and modification of aggravating activitiesCImmediate maximal gripping through severe painDHigh-velocity elbow manipulation despite suspected fractureERepeated throwing without recovery time

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Progressive wrist-extensor loading and modification of aggravating activities

Explanation A reasonable plan includes: • Temporary reduction of high-load gripping • Isometric wrist-extensor exercise during an irritable phase • Progressive isotonic and eccentric loading • Grip-strength rehabilitation • Shoulder and scapular conditioning where relevant • Racquet, technique, and workplace modification

Question 4 of 4NPLEX-PM-024

Which finding would make the original diagnosis less likely and suggest neurologic evaluation?

ALocalized lateral-epicondyle tendernessBPain during resisted wrist extensionCWidespread sensory loss with reduced reflexesDPain when gripping a racquetESymptoms after repetitive backhand strokes

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Widespread sensory loss with reduced reflexes

Explanation Lateral epicondylalgia is a local tendon-related disorder and should not produce widespread dermatomal sensory loss or reflex abnormalities. Such findings suggest cervical radiculopathy or peripheral nerve disease.

Reveal Case Review & NPLEX Trap

Diagnosis: Lateral epicondylalgia Differential diagnosis: Radial tunnel syndrome, cervical radiculopathy, radiocapitellar arthritis, fracture Key tests: Cozen, Mill, resisted middle-finger or wrist extension as clinically appropriate Treatment: Load modification, progressive strengthening, ergonomics, optional bracing Manual therapy: May provide short-term symptom relief when combined with exercise NPLEX trap: “Tennis elbow” is not limited to tennis players.

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7

Anterior Cruciate Ligament Injury

4 questions · Physical Medicine

Clinical Case

A 23-year-old soccer player plants the right foot and rapidly changes direction. The knee twists inward, and the patient hears a pop. A large effusion develops within two hours. The knee feels unstable. Examination reveals: • Increased anterior tibial translation • Soft endpoint on Lachman testing • No fracture deformity • Intact distal pulses and sensation

Question 1 of 4NPLEX-PM-025

Which structure is most likely injured?

APosterior cruciate ligamentBAnterior cruciate ligamentCLateral meniscus onlyDPatellar tendonEMedial patellofemoral ligament only

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Anterior cruciate ligament

Explanation A noncontact pivoting mechanism, audible pop, rapid effusion, instability, and positive Lachman test strongly suggest ACL injury.

Question 2 of 4NPLEX-PM-026

Which test is most useful for evaluating the suspected injury?

ALachman testBFinkelstein testCThomas testDSpeed testEThompson test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Lachman test

Explanation The Lachman test assesses anterior tibial translation relative to the femur and the quality of the endpoint. AAOS guidance supports a focused history and physical examination, including Lachman testing, when evaluating suspected ACL injury.

Question 3 of 4NPLEX-PM-027

What is the most appropriate immediate management?

AReturn to soccer when the swelling decreases slightlyBProtect the knee, control swelling, assess associated injury, and begin safe motion as appropriateCForceful manipulation of the unstable kneeDContinuous high-temperature heat during the acute effusionEMaximal resisted squatting on the same day

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Protect the knee, control swelling, assess associated injury, and begin safe motion as appropriate

Explanation Initial priorities include: • Protection from further pivoting • Swelling and pain management • Neurovascular assessment • Evaluation for associated meniscal or collateral injury • Appropriate imaging or orthopedic assessment • Restoration of extension and quadriceps activation when safe

Question 4 of 4NPLEX-PM-028

Which rehabilitation component is especially important before returning to pivoting sport?

ABed restBNeuromuscular, balance, strength, and sport-specific movement trainingCAvoidance of all weight-bearing exercise permanentlyDPassive heat without exerciseEImmediate maximal jumping despite instability

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Neuromuscular, balance, strength, and sport-specific movement training

Explanation Return-to-sport rehabilitation should address: • Full or near-full range of motion • Quadriceps and hamstring strength • Single-leg control • Balance and proprioception • Landing and cutting mechanics • Functional testing • Psychological readiness

Reveal Case Review & NPLEX Trap

Diagnosis: ACL tear Differential diagnosis: Meniscal tear, patellar dislocation, collateral ligament injury, osteochondral injury Investigation: MRI can define associated soft-tissue injuries when results affect management; radiography may be required after trauma Treatment: Individualized operative or nonoperative management based on instability, activity demands, associated injuries, and preferences NPLEX trap: A negative McMurray test does not exclude an ACL injury.

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8

Hip Osteoarthritis

4 questions · Physical Medicine

Clinical Case

A 67-year-old patient reports gradually progressive right groin pain and stiffness. Symptoms worsen with walking, stairs, and putting on shoes. Morning stiffness lasts approximately 20 minutes. Examination reveals: • Reduced hip internal rotation • Groin pain with passive internal rotation • Reduced hip flexion • Mild antalgic gait • No fever or systemic illness

Question 1 of 4NPLEX-PM-029

What is the most likely diagnosis?

AHip osteoarthritisBLumbar cauda equina syndromeCAcute septic arthritisDAchilles-tendon ruptureECarpal tunnel syndrome

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Hip osteoarthritis

Explanation Typical hip osteoarthritis findings include: • Age over 50 • Activity-related anterior hip or groin pain • Brief morning stiffness • Reduced internal rotation and flexion • Pain with weight-bearing These features are reflected in current hip osteoarthritis guidelines.

Question 2 of 4NPLEX-PM-030

Which examination finding is particularly characteristic?

AIncreased painless internal rotationBPainful and restricted internal rotationCPositive Phalen testDPositive Thompson testELoss of the triceps reflex

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Painful and restricted internal rotation

Explanation Internal rotation is frequently one of the first hip movements to become restricted or painful in osteoarthritis.

Question 3 of 4NPLEX-PM-031

What is the most appropriate conservative physical medicine plan?

AProgressive strengthening, aerobic activity, mobility exercise, and functional trainingBPermanent complete avoidance of activityCForceful manipulation during an acute fractureDBed rest until radiographic changes disappearEHigh-impact running as the only treatment

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Progressive strengthening, aerobic activity, mobility exercise, and functional training

Explanation Management may include: • Hip-abductor and extensor strengthening • Low-impact aerobic exercise • Range-of-motion work • Gait and balance training • Weight-management support when applicable • Activity pacing • Assistive-device assessment Manual therapy may provide short-term pain or mobility benefit in selected patients, but it should be combined with active treatment.

Question 4 of 4NPLEX-PM-032

Which presentation requires urgent assessment rather than routine osteoarthritis rehabilitation?

AGradual stiffness lasting 20 minutesBMild discomfort after a long walkCAcutely hot, severely painful hip with fever and inability to bear weightDReduced internal rotation over several yearsEImprovement with a walking aid

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Acutely hot, severely painful hip with fever and inability to bear weight

Explanation This presentation raises concern for septic arthritis or another acute destructive process. Manual therapy and routine exercise should be postponed until urgent medical assessment is completed.

Reveal Case Review & NPLEX Trap

Diagnosis: Hip osteoarthritis Differential diagnosis: Lumbar radiculopathy, femoral neck fracture, septic arthritis, avascular necrosis, greater trochanteric pain syndrome Investigations: Weight-bearing radiography when confirmation will affect management; laboratory tests if inflammatory or infectious disease is suspected Treatment: Education, exercise, weight management, walking aid, medication discussion, referral when symptoms remain severe NPLEX trap: Hip-joint disease frequently presents as groin pain and may also be felt at the knee.

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9

Lateral Ankle Sprain

4 questions · Physical Medicine

Clinical Case

A 19-year-old basketball player lands on another player’s foot and sustains an inversion injury. The lateral ankle becomes swollen and painful. The patient can take four steps with discomfort. Examination shows: • Tenderness over the anterior talofibular ligament • No tenderness at the posterior edge of either malleolus • No tenderness at the base of the fifth metatarsal • Mild laxity and pain with anterior drawer testing • Intact pulses and sensation

Question 1 of 4NPLEX-PM-033

Which ligament is most likely injured?

ADeltoid ligamentBAnterior talofibular ligamentCPosterior cruciate ligamentDSpring ligament onlyEAnterior cruciate ligament

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Anterior talofibular ligament

Explanation The anterior talofibular ligament is commonly injured during plantar-flexion and inversion trauma.

Question 2 of 4NPLEX-PM-034

Which orthopedic test assesses the suspected ligament?

AAnkle anterior drawer testBMcMurray testCApley scratch testDYergason testEPhalen test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Ankle anterior drawer test

Explanation The ankle anterior drawer test evaluates anterior translation of the talus and helps assess the anterior talofibular ligament.

Question 3 of 4NPLEX-PM-035

What is the most appropriate early rehabilitation approach for an uncomplicated sprain?

AProlonged rigid immobilization in every caseBProtected weight-bearing with external support and progressive exerciseCImmediate unrestricted jumpingDAggressive inversion stretchingEContinuous bed rest

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Protected weight-bearing with external support and progressive exercise

Explanation For many uncomplicated lateral ankle sprains, functional treatment includes: • External support such as a brace or taping • Progressive weight-bearing • Range-of-motion exercise • Strengthening • Balance and proprioceptive training • Gradual return to sport Current ankle-sprain guidance supports structured functional rehabilitation and exercise rather than unnecessary prolonged immobilization.

Question 4 of 4NPLEX-PM-036

Which intervention best reduces the risk of recurrent ankle sprain?

AAvoiding all activity permanentlyBBalance and proprioceptive trainingCPassive heat aloneDRepeated ankle inversionEStopping rehabilitation once swelling decreases

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Balance and proprioceptive training

Explanation Neuromuscular and balance training improves dynamic control and can reduce recurrence risk. Examples include: • Single-leg stance • Progression to unstable surfaces • Star-excursion-type tasks • Hopping and landing control • Sport-specific cutting drills

Reveal Case Review & NPLEX Trap

Diagnosis: Lateral ankle sprain, likely ATFL involvement Differential diagnosis: Ankle fracture, syndesmotic injury, peroneal-tendon injury, osteochondral lesion, fifth-metatarsal fracture Key tests: Anterior drawer, talar tilt, palpation, weight-bearing ability Treatment: Protection, compression, external support, early appropriate loading, exercise NPLEX trap: Do not assume every inversion injury is a simple sprain; apply fracture-screening criteria and assess the entire foot and ankle.

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10

Achilles-Tendon Rupture

4 questions · Physical Medicine

Clinical Case

A 46-year-old recreational badminton player suddenly feels as though someone kicked the back of the left ankle while pushing off. The patient falls and cannot continue playing. Examination reveals: • A palpable gap several centimetres above the calcaneus • Weak plantar flexion • Inability to perform a single-leg heel raise • Positive Thompson squeeze test • Intact distal circulation

Question 1 of 4NPLEX-PM-037

What is the most likely diagnosis?

APlantar fasciitisBAchilles-tendon ruptureCLateral ankle sprainDGastrocnemius delayed-onset sorenessEMorton neuroma

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Achilles-tendon rupture

Explanation The sudden “kicked in the heel” sensation, functional loss, tendon gap, and positive Thompson test are characteristic of Achilles rupture.

Question 2 of 4NPLEX-PM-038

What constitutes a positive Thompson test?

ACompression of the calf produces normal plantar flexionBCompression of the calf fails to produce normal plantar flexionCWrist flexion produces hand paresthesiaDHip flexion causes lumbar painEKnee rotation produces a meniscal click

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Compression of the calf fails to produce normal plantar flexion

Explanation With an intact Achilles tendon, squeezing the calf produces passive plantar flexion. Absence or marked reduction of this movement indicates tendon discontinuity.

Question 3 of 4NPLEX-PM-039

What is the most appropriate immediate management?

AAggressive calf stretching into dorsiflexionBImmobilize in relative plantar flexion, restrict unsafe loading, and arrange prompt orthopedic assessmentCDeep friction directly over the ruptureDImmediate return to sport with tapingEMaximal heel raises

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Immobilize in relative plantar flexion, restrict unsafe loading, and arrange prompt orthopedic assessment

Explanation Initial care protects the tendon ends by positioning the ankle in plantar flexion and arranging specialist evaluation. Both surgical and structured nonsurgical approaches may be considered depending on patient factors, timing, activity demands, and available rehabilitation.

Question 4 of 4NPLEX-PM-040

Which treatment is contraindicated during the immediate acute stage?

ANeurovascular assessmentBProtected immobilizationCPrompt referralDForceful dorsiflexion stretching across the ruptured tendonEPatient education

Reveal Answer

Answer and Clinical Rationale

Correct answer: D. Forceful dorsiflexion stretching across the ruptured tendon

Explanation Forceful dorsiflexion can separate the tendon ends and interfere with healing. Rehabilitation must follow an appropriate staged protocol.

Reveal Case Review & NPLEX Trap

Diagnosis: Acute Achilles-tendon rupture Differential diagnosis: Gastrocnemius strain, plantaris injury, Achilles tendinopathy, ankle fracture Key test: Thompson squeeze test Imaging: Often a clinical diagnosis; ultrasound or MRI may be used when the diagnosis or extent is uncertain Treatment: Plantar-flexion protection, specialist assessment, operative or functional nonsurgical protocol Rehabilitation: Gradual weight-bearing, controlled ankle motion, progressive calf strengthening, balance training, functional return NPLEX trap: Some plantar flexion may remain because other muscles can plantar-flex the ankle; this does not exclude rupture.

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11

Lumbar Disc Herniation with L5 Radiculopathy

4 questions · Physical Medicine

Clinical Case

A 39-year-old warehouse worker develops low-back pain after lifting a heavy box. Two days later, the pain begins radiating down the lateral thigh and leg to the dorsum of the right foot and great toe. Examination reveals: • Positive straight-leg raise on the right • Reduced sensation over the dorsum of the foot • Weakness of great-toe extension • Difficulty heel walking • Normal bowel and bladder function • No saddle anesthesia • No fever or history of malignancy

Question 1 of 4NPLEX-PM-041

Which nerve root is most likely affected?

AL2BL3CL4DL5ES1

Reveal Answer

Answer and Clinical Rationale

Correct answer: D. L5

Explanation L5 radiculopathy commonly produces: • Pain extending down the lateral leg • Sensory changes over the dorsum of the foot and great toe • Weakness of great-toe extension • Weakness of ankle dorsiflexion • Difficulty heel walking Why the alternatives are less likely: • L2–L3: More likely to affect the anterior thigh and hip flexion. • L4: May affect the medial leg, knee extension, and patellar reflex. • S1: Commonly affects the lateral foot, plantar flexion, and Achilles reflex.

Question 2 of 4NPLEX-PM-042

Which orthopedic test is most appropriate for reproducing lumbosacral nerve-root symptoms?

AStraight-leg raiseBPhalen testCThompson testDHawkins-Kennedy testELachman test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Straight-leg raise

Explanation The straight-leg raise increases tension on the lumbosacral nerve roots and sciatic nerve. Reproduction of radiating leg symptoms, rather than isolated posterior-thigh tightness, supports nerve-root irritation. A positive result is more clinically meaningful when it reproduces the patient’s familiar radicular symptoms.

Question 3 of 4NPLEX-PM-043

What is the most appropriate initial management?

AStrict bed rest for four weeksBForceful lumbar manipulation without neurologic reassessmentCRelative activity modification, education, symptom-guided movement, and monitored rehabilitationDImmediate maximal deadliftingEPermanent avoidance of spinal movement

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Relative activity modification, education, symptom-guided movement, and monitored rehabilitation

Explanation In the absence of emergency findings, management may include: • Avoiding aggravating lifting temporarily • Remaining active within tolerable limits • Direction-specific movement when helpful • Gradual trunk and lower-extremity strengthening • Ergonomic and lifting education • Monitoring strength, reflexes, and sensation Prolonged bed rest may worsen deconditioning and delay functional recovery.

Question 4 of 4NPLEX-PM-044

Which new symptom requires immediate emergency referral?

AMild pain after sittingBImproving leg painCUrinary retention with saddle anesthesiaDHamstring tightnessETemporary relief while walking

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Urinary retention with saddle anesthesia

Explanation Urinary dysfunction and saddle sensory loss raise concern for cauda equina syndrome. Manual therapy and routine rehabilitation must stop while emergency assessment is arranged.

Reveal Case Review & NPLEX Trap

Diagnosis: Lumbar disc herniation with L5 radiculopathy Differential diagnosis: Peroneal neuropathy, lumbar stenosis, piriformis syndrome, hip disease Key tests: Straight-leg raise, myotomal strength, dermatomes, reflexes, gait Imaging: Consider MRI for progressive weakness, emergency red flags, severe persistent symptoms, or when invasive treatment is being considered Treatment: Education, graded activity, appropriate exercise, symptom monitoring NPLEX trap: Back pain with leg radiation is not automatically a surgical emergency; neurologic red flags determine urgency.

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12

Lumbar Spinal Stenosis

4 questions · Physical Medicine

Clinical Case

A 72-year-old patient reports low-back discomfort and bilateral leg heaviness after walking approximately 200 metres. Symptoms improve after sitting or leaning forward over a shopping cart. Standing upright and walking downhill worsen the symptoms. Examination reveals: • Mildly reduced lumbar extension • Symptoms reproduced with prolonged extension • Relief in lumbar flexion • Normal peripheral pulses • No saddle anesthesia • No major motor deficit

Question 1 of 4NPLEX-PM-045

What is the most likely diagnosis?

ALumbar spinal stenosis with neurogenic claudicationBAcute Achilles ruptureCCauda equina syndromeDLateral ankle sprainESeptic arthritis

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Lumbar spinal stenosis with neurogenic claudication

Explanation Neurogenic claudication is characterized by leg pain, weakness, numbness, or heaviness provoked by standing and walking and relieved by sitting or lumbar flexion. The “shopping-cart sign” is a classic clue.

Question 2 of 4NPLEX-PM-046

Which feature best differentiates neurogenic claudication from peripheral arterial claudication?

ABoth conditions are relieved only by antibioticsBNeurogenic symptoms frequently improve with sitting or spinal flexionCPeripheral arterial disease always produces normal pulsesDNeurogenic claudication always causes feverEVascular claudication improves only when leaning forward

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Neurogenic symptoms frequently improve with sitting or spinal flexion

Explanation Neurogenic claudication is posture-dependent. Sitting or flexing the lumbar spine may enlarge the spinal canal and reduce symptoms. Vascular claudication is more closely related to muscular exertion and may improve by stopping activity regardless of spinal position. Peripheral pulses and vascular risk assessment are important.

Question 3 of 4NPLEX-PM-047

Which exercise program is most appropriate?

ARepeated loaded lumbar extension despite symptom reproductionBFlexion-tolerant aerobic conditioning and progressive trunk and lower-extremity strengtheningCComplete immobilizationDMaximal downhill walking initiallyEHigh-impact jumping as the first intervention

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Flexion-tolerant aerobic conditioning and progressive trunk and lower-extremity strengthening

Explanation A program may include: • Stationary cycling • Supported walking • Flexion-tolerant mobility • Hip and lower-extremity strengthening • Trunk endurance exercise • Balance training • Gradual walking progression Exercise selection should reflect the patient’s symptoms, function, and comorbidities.

Question 4 of 4NPLEX-PM-048

Which finding requires urgent reassessment rather than routine rehabilitation?

ASymptoms relieved by sittingBGradually reduced walking toleranceCNew urinary retention and rapidly progressive bilateral weaknessDMild stiffness after prolonged standingEImprovement while using a walker

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. New urinary retention and rapidly progressive bilateral weakness

Explanation These symptoms raise concern for severe neurologic compression, including cauda equina syndrome. Emergency imaging and specialist assessment are required.

Reveal Case Review & NPLEX Trap

Diagnosis: Lumbar spinal stenosis with neurogenic claudication Differential diagnosis: Peripheral arterial disease, hip osteoarthritis, peripheral neuropathy, disc herniation Key assessment: Walking tolerance, posture dependence, pulses, neurologic findings Treatment: Education, activity modification, flexion-tolerant conditioning, strengthening, balance work Referral: Progressive neurologic loss, bladder dysfunction, severe disability despite conservative care NPLEX trap: Leg pain with walking is not always vascular; determine whether posture changes the symptoms.

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13

Thoracic Outlet Syndrome

4 questions · Physical Medicine

Clinical Case

A 32-year-old hairstylist reports intermittent aching, paresthesia, and heaviness in the right arm, especially while working with the arm elevated. Symptoms involve the medial forearm and the fourth and fifth fingers. Examination reveals: • Rounded-shoulder posture • Symptoms reproduced during sustained overhead positioning • Positive Roos test • Tight pectoralis minor and scalene muscles • No persistent motor deficit • Normal arm colour and temperature at rest

Question 1 of 4NPLEX-PM-049

What is the most likely diagnosis?

ANeurogenic thoracic outlet syndromeBCarpal tunnel syndromeCRotator-cuff ruptureDC6 radiculopathyEDe Quervain tenosynovitis

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Neurogenic thoracic outlet syndrome

Explanation Thoracic outlet syndrome may involve compression or irritation of the brachial plexus as it passes through the thoracic outlet. Supporting findings include: • Symptoms during sustained arm elevation • Paresthesia in the medial forearm or ulnar hand • Arm heaviness • Postural and occupational contributors • Reproduction with provocative positioning

Question 2 of 4NPLEX-PM-050

Which orthopedic test requires the patient to hold the arms in an elevated “surrender” position while repeatedly opening and closing the hands?

ARoos testBMcMurray testCThomas testDThompson testECozen test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Roos test

Explanation During the Roos test, the patient maintains shoulder abduction and external rotation while opening and closing the hands. Reproduction of heaviness, fatigue, pain, or paresthesia may support thoracic outlet involvement. Provocative tests may produce false-positive results and must not be interpreted in isolation.

Question 3 of 4NPLEX-PM-051

Which rehabilitation approach is most appropriate?

APostural correction, breathing mechanics, scapular control, and gradual shoulder-girdle conditioningBRepeated prolonged overhead loadingCComplete immobilization of the armDForceful manipulation despite vascular signsEMaximal gripping exercises only

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Postural correction, breathing mechanics, scapular control, and gradual shoulder-girdle conditioning

Explanation Rehabilitation may include: • Reducing prolonged overhead positions • Scapular retraction and upward-rotation control • Pectoralis minor and scalene mobility • Thoracic mobility • Diaphragmatic breathing • Ergonomic modification • Gradual endurance training Treatment must be individualized because excessive stretching or strengthening may worsen symptoms in some patients.

Question 4 of 4NPLEX-PM-052

Which finding requires urgent vascular referral?

AMild shoulder fatigue after workBSymptoms improving with posture correctionCSudden arm swelling, cyanosis, and prominent superficial veinsDMild pectoralis tightnessESymptoms occurring only after prolonged overhead activity

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Sudden arm swelling, cyanosis, and prominent superficial veins

Explanation Sudden swelling and cyanosis raise concern for venous obstruction or upper-extremity thrombosis. Pallor, coolness, severe ischemic pain, or loss of pulse may indicate arterial compromise.

Reveal Case Review & NPLEX Trap

Diagnosis: Neurogenic thoracic outlet syndrome Differential diagnosis: Cervical radiculopathy, ulnar neuropathy, carpal tunnel syndrome, shoulder disease Orthopedic tests: Roos, Adson, reverse Adson, Wright hyperabduction Treatment: Ergonomics, postural rehabilitation, scapular endurance, breathing and mobility work Referral: Swelling, cyanosis, pallor, ischemia, thrombosis, progressive weakness NPLEX trap: Loss of the radial pulse during a provocative test does not independently confirm thoracic outlet syndrome.

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14

De Quervain Tenosynovitis

4 questions · Physical Medicine

Clinical Case

A 36-year-old parent of a six-month-old infant reports pain along the radial side of the right wrist. The pain is aggravated by lifting the infant, gripping, and moving the thumb. Examination reveals: • Tenderness over the radial styloid • Pain with resisted thumb abduction and extension • Positive Finkelstein test • No numbness or tingling • Negative Phalen test

Question 1 of 4NPLEX-PM-053

What is the most likely diagnosis?

ACarpal tunnel syndromeBDe Quervain tenosynovitisCUlnar neuropathyDScaphoid fractureELateral epicondylalgia

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. De Quervain tenosynovitis

Explanation De Quervain tenosynovitis involves the first dorsal wrist compartment, primarily affecting the: • Abductor pollicis longus • Extensor pollicis brevis Pain is typically located near the radial styloid and worsens with thumb movement, gripping, or lifting.

Question 2 of 4NPLEX-PM-054

Which test most directly supports the diagnosis?

AFinkelstein testBPhalen testCTinel test at the elbowDLachman testEFABER test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Finkelstein test

Explanation The Finkelstein test places tension on the first dorsal compartment tendons and reproduces pain near the radial styloid. The maneuver should be performed carefully because excessive force can cause pain even in an unaffected wrist.

Question 3 of 4NPLEX-PM-055

What is the most appropriate initial physical medicine prescription?

AThumb-spica support, activity modification, and gradual tendon rehabilitationBMaximal resisted thumb exercise through severe painCWrist immobilization in full flexionDCervical tractionERepeated forceful ulnar deviation

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Thumb-spica support, activity modification, and gradual tendon rehabilitation

Explanation Conservative management may include: • Thumb-spica orthosis • Modification of lifting technique • Reduction of repetitive thumb loading • Gentle pain-free mobility • Progressive strengthening after irritability decreases • Ergonomic education The patient may be taught to lift the infant using the forearms and palms rather than placing sustained stress through the thumb.

Question 4 of 4NPLEX-PM-056

Which finding suggests an alternative diagnosis requiring imaging?

APain near the radial styloid during thumb movementBPositive Finkelstein testCAnatomical-snuffbox tenderness after a fall on an outstretched handDSymptoms aggravated by lifting an infantENo sensory loss

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Anatomical-snuffbox tenderness after a fall on an outstretched hand

Explanation Snuffbox tenderness after trauma raises concern for a scaphoid fracture. A fracture may initially be radiographically occult and should not be treated as simple tendinopathy.

Reveal Case Review & NPLEX Trap

Diagnosis: De Quervain tenosynovitis Key test: Finkelstein test Differential diagnosis: Scaphoid fracture, thumb-base osteoarthritis, radial sensory neuropathy, intersection syndrome Treatment: Load modification, thumb-spica support, graded exercise Referral: Persistent disability, suspected fracture, severe swelling, neurologic symptoms NPLEX trap: De Quervain disease produces pain, not median-nerve sensory loss.

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15

Medial Epicondylalgia

4 questions · Physical Medicine

Clinical Case

A 48-year-old golfer reports gradual pain along the medial aspect of the dominant elbow. The pain is worse when gripping the club, flexing the wrist, and pronating the forearm. Examination reveals: • Tenderness just distal to the medial epicondyle • Pain with resisted wrist flexion • Pain with resisted forearm pronation • No sensory loss in the fourth or fifth fingers • Stable elbow valgus testing

Question 1 of 4NPLEX-PM-057

What is the most likely diagnosis?

AMedial epicondylalgiaBLateral epicondylalgiaCCubital tunnel syndromeDOlecranon bursitisECervical myelopathy

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Medial epicondylalgia

Explanation Medial epicondylalgia involves the common flexor-pronator tendon origin. It is associated with repetitive gripping, wrist flexion, and forearm pronation.

Question 2 of 4NPLEX-PM-058

Which examination finding best supports the diagnosis?

APain with resisted wrist flexion and pronationBNumbness of the thumb and index fingerCPositive Thompson testDPain during ankle inversionELoss of shoulder external rotation

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Pain with resisted wrist flexion and pronation

Explanation The wrist flexor and pronator muscles originate near the medial epicondyle. Loading these tissues reproduces local tendon pain.

Question 3 of 4NPLEX-PM-059

What is the most appropriate rehabilitation approach?

AProgressive flexor-pronator loading with modification of aggravating activitiesBComplete arm immobilization for six monthsCImmediate maximal golf practiceDRepetitive forceful valgus stressEDeep heat over an acutely swollen joint with fever

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Progressive flexor-pronator loading with modification of aggravating activities

Explanation Rehabilitation may include: • Temporary reduction of painful gripping • Isometric wrist-flexor exercise • Progressive concentric and eccentric loading • Grip-strength progression • Shoulder and trunk mechanics • Golf-technique assessment • Gradual return to play

Question 4 of 4NPLEX-PM-060

Which symptom suggests associated ulnar neuropathy?

ALocal medial-elbow tenderness onlyBNumbness and tingling in the small finger and ulnar half of the ring fingerCPain during resisted wrist flexionDPain after gripping a golf clubEMild forearm muscle fatigue

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Numbness and tingling in the small finger and ulnar half of the ring finger

Explanation The ulnar nerve passes posterior to the medial epicondyle. Sensory symptoms in the small finger and ulnar ring finger suggest cubital tunnel syndrome or another ulnar neuropathy.

Reveal Case Review & NPLEX Trap

Diagnosis: Medial epicondylalgia Differential diagnosis: Ulnar neuropathy, UCL injury, cervical radiculopathy, elbow arthritis Key examination: Local tenderness, resisted wrist flexion and pronation Treatment: Load management, progressive tendon strengthening, technique correction NPLEX trap: Medial-elbow pain with ulnar sensory symptoms should not be treated as isolated tendinopathy.

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16

Meniscal Tear

4 questions · Physical Medicine

Clinical Case

A 34-year-old patient twists the right knee while rising from a deep squat. The patient develops medial joint-line pain, intermittent swelling, catching, and difficulty fully extending the knee. Examination reveals: • Medial joint-line tenderness • Pain and clicking during McMurray testing • Stable Lachman test • No major valgus or varus instability • Mild effusion

Question 1 of 4NPLEX-PM-061

What is the most likely diagnosis?

AMedial meniscal tearBACL ruptureCPatellar tendon ruptureDLateral ankle sprainEHip osteoarthritis

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Medial meniscal tear

Explanation A twisting mechanism combined with joint-line pain, catching, swelling, restricted extension, and a positive McMurray test supports a meniscal tear.

Question 2 of 4NPLEX-PM-062

Which test most directly evaluates a suspected meniscal tear?

AMcMurray testBLachman testCFinkelstein testDSpeed testEThomas test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. McMurray test

Explanation The McMurray test uses knee flexion, extension, and tibial rotation to stress the menisci. Joint-line pain, clicking, or a palpable clunk may support meniscal pathology.

Question 3 of 4NPLEX-PM-063

What is the most appropriate initial management when the knee is not mechanically locked?

AActivity modification, swelling control, range-of-motion restoration, and progressive strengtheningBImmediate maximal pivoting drillsCProlonged bed restDForceful manipulation into painful extensionEContinuous deep heat during an acute large effusion

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Activity modification, swelling control, range-of-motion restoration, and progressive strengthening

Explanation A conservative program may include: • Temporary reduction of twisting and deep squatting • Swelling control • Restoration of extension and flexion • Quadriceps and hip strengthening • Balance and functional training • Gradual return to activity Not every meniscal tear requires surgery.

Question 4 of 4NPLEX-PM-064

Which finding requires prompt orthopedic assessment?

AMild discomfort after prolonged walkingBA truly locked knee that cannot fully extendCImprovement with exerciseDMild quadriceps weaknessESmall activity-related effusion

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. A truly locked knee that cannot fully extend

Explanation A displaced meniscal fragment may mechanically block knee extension. Persistent true locking requires prompt evaluation.

Reveal Case Review & NPLEX Trap

Diagnosis: Medial meniscal tear Differential diagnosis: ACL injury, collateral ligament injury, osteoarthritis, osteochondral injury Key tests: McMurray, Apley compression, joint-line palpation Imaging: MRI may be useful when diagnosis is uncertain, mechanical locking is present, or surgery is being considered Treatment: Exercise-based rehabilitation for appropriate cases; referral for locked knee or persistent major dysfunction NPLEX trap: Clicking alone is nonspecific; combine it with mechanism, pain location, swelling, and functional loss.

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17

Patellofemoral Pain Syndrome

4 questions · Physical Medicine

Clinical Case

A 21-year-old runner reports gradual anterior knee pain without trauma. Symptoms worsen while descending stairs, squatting, running downhill, and sitting through long lectures. Examination reveals: • Peripatellar tenderness • Pain during a single-leg squat • Dynamic knee valgus • Weak hip abductors • No large effusion • Stable ligament testing • No true locking

Question 1 of 4NPLEX-PM-065

What is the most likely diagnosis?

APatellofemoral pain syndromeBACL ruptureCSeptic arthritisDAchilles ruptureECauda equina syndrome

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Patellofemoral pain syndrome

Explanation Patellofemoral pain is typically characterized by poorly localized anterior or retropatellar pain aggravated by activities that load the patellofemoral joint. Common aggravating activities include: • Squatting • Stair climbing • Running • Jumping • Prolonged sitting

Question 2 of 4NPLEX-PM-066

Which functional finding is most relevant to rehabilitation?

ADynamic knee valgus during a single-leg squatBPositive Phalen testCAbsent plantar flexion after calf squeezeDSaddle anesthesiaELoss of radial pulse

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Dynamic knee valgus during a single-leg squat

Explanation Dynamic valgus may reflect impaired control of the hip, pelvis, and lower extremity. It can guide strengthening and movement-retraining strategies.

Question 3 of 4NPLEX-PM-067

Which treatment is most appropriate?

AProgressive hip and knee strengthening with load modificationBComplete immobilization until all pain disappearsCImmediate maximal hill runningDRepeated deep squats through severe painELumbar traction as the primary intervention

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Progressive hip and knee strengthening with load modification

Explanation Management may include: • Hip-abductor and external-rotator strengthening • Quadriceps strengthening • Movement retraining • Gradual running-load modification • Temporary reduction of downhill running • Foot or ankle assessment when relevant • Short-term taping or orthoses in selected patients Exercise is the central treatment rather than passive modalities alone.

Question 4 of 4NPLEX-PM-068

Which finding suggests a different and potentially urgent diagnosis?

APain while descending stairsBPain after prolonged sittingCHot swollen knee with fever and inability to bear weightDWeak hip abductorsEPain during a single-leg squat

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Hot swollen knee with fever and inability to bear weight

Explanation A hot, acutely swollen joint with fever raises concern for septic arthritis. Routine exercise and manual therapy should be postponed pending urgent medical assessment.

Reveal Case Review & NPLEX Trap

Diagnosis: Patellofemoral pain syndrome Differential diagnosis: Patellar instability, tendinopathy, meniscal injury, osteochondral lesion, referred hip pain Key assessment: Squat mechanics, hip strength, patellar symptoms, training load Treatment: Progressive hip and knee exercise, load management, movement correction Adjuncts: Patellar taping or foot orthoses may help selected patients temporarily NPLEX trap: Patellofemoral pain is not diagnosed by imaging findings alone.

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18

Greater Trochanteric Pain Syndrome

4 questions · Physical Medicine

Clinical Case

A 55-year-old woman reports gradually progressive pain over the lateral right hip. The pain worsens when lying on the affected side, climbing stairs, and standing on one leg. Examination reveals: • Tenderness over the greater trochanter • Pain with resisted hip abduction • Pelvic drop during single-leg stance • Nearly full hip-joint range of motion • No groin pain during passive internal rotation • Normal neurologic examination

Question 1 of 4NPLEX-PM-069

What is the most likely diagnosis?

AGreater trochanteric pain syndromeBHip osteoarthritisCLumbar cauda equina syndromeDFemoral neck fractureESeptic arthritis

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Greater trochanteric pain syndrome

Explanation Greater trochanteric pain syndrome commonly involves gluteus medius or minimus tendinopathy, with or without bursal irritation. Typical findings include: • Lateral hip pain • Pain while lying on the affected side • Greater-trochanter tenderness • Pain with hip-abductor loading • Reduced single-leg pelvic control

Question 2 of 4NPLEX-PM-070

Which examination most directly evaluates hip-abductor function?

ATrendelenburg testBPhalen testCMcMurray testDThompson testENeer test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Trendelenburg test

Explanation During single-leg stance, weakness or painful inhibition of the stance-side hip abductors may allow the opposite side of the pelvis to drop.

Question 3 of 4NPLEX-PM-071

What is the most appropriate rehabilitation strategy?

AProgressive gluteal strengthening while reducing compressive positionsBRepeatedly lying on the painful sideCAggressive hip adduction stretching into severe painDComplete bed restEImmediate high-impact lateral jumping

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Progressive gluteal strengthening while reducing compressive positions

Explanation Management may include: • Avoiding prolonged side-lying on the affected side • Using a pillow between the knees when side-lying • Avoiding standing with the hip “hanging” into adduction • Isometric hip-abductor exercise • Progressive gluteal strengthening • Gait and pelvic-control training • Gradual return to stairs and walking

Question 4 of 4NPLEX-PM-072

Which finding would make isolated greater trochanteric pain syndrome less likely?

ALateral tendernessBPain while lying on the affected sideCMarked groin pain with restricted passive hip internal rotationDPain during resisted abductionEPelvic drop on single-leg stance

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Marked groin pain with restricted passive hip internal rotation

Explanation Groin pain with restricted hip internal rotation is more suggestive of intra-articular hip disease, including osteoarthritis.

Reveal Case Review & NPLEX Trap

Diagnosis: Greater trochanteric pain syndrome Differential diagnosis: Hip osteoarthritis, lumbar radiculopathy, femoral stress fracture, meralgia paresthetica Key tests: Palpation, resisted abduction, Trendelenburg, single-leg stance Treatment: Load modification and progressive gluteal rehabilitation NPLEX trap: “Trochanteric bursitis” may actually represent gluteal tendon pathology rather than isolated bursal inflammation.

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19

Sacroiliac Joint Pain

4 questions · Physical Medicine

Clinical Case

A 41-year-old patient develops unilateral pain near the right posterior superior iliac spine after stepping awkwardly off a curb. The pain is worse when transitioning from sitting to standing and while climbing stairs. Examination reveals: • Pain localized below the belt line • No dermatomal sensory loss • Normal lower-extremity reflexes • Positive Gaenslen test • Positive pelvic compression and distraction tests • Negative straight-leg raise

Question 1 of 4NPLEX-PM-073

What is the most likely pain source?

ASacroiliac joint regionBMedian nerveCAchilles tendonDRotator cuffECervical spinal cord

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Sacroiliac joint region

Explanation Unilateral pain near the posterior superior iliac spine with reproduction during multiple sacroiliac provocation tests supports sacroiliac-region pain. No single test is sufficiently diagnostic. A cluster of concordant provocation tests is more useful.

Question 2 of 4NPLEX-PM-074

Which test is commonly used to provoke sacroiliac-region pain?

AGaenslen testBPhalen testCHawkins-Kennedy testDLachman testEThompson test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Gaenslen test

Explanation Gaenslen testing applies torsional stress across the pelvis and sacroiliac joints. A positive test reproduces the patient’s familiar pain.

Question 3 of 4NPLEX-PM-075

What is the most appropriate initial treatment?

AEducation, temporary load modification, lumbopelvic stabilization, and graded functional exerciseBPermanent bed restCForceful manipulation despite suspected fractureDImmediate maximal liftingECervical immobilization

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Education, temporary load modification, lumbopelvic stabilization, and graded functional exercise

Explanation A rehabilitation plan may include: • Activity modification • Hip and trunk strengthening • Lumbopelvic stabilization • Movement retraining • Gradual return to lifting and stairs • Selected manual therapy when no contraindications are present Manual therapy may provide short-term relief but should generally be combined with active rehabilitation.

Question 4 of 4NPLEX-PM-076

Which presentation requires investigation for inflammatory sacroiliitis?

APain after an awkward step that improves over several daysBChronic morning stiffness, alternating buttock pain, and improvement with exerciseCLocal tenderness after carrying groceriesDSymptoms only when climbing one staircaseEPain relieved by temporary activity modification

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Chronic morning stiffness, alternating buttock pain, and improvement with exercise

Explanation Features suggesting inflammatory axial disease include: • Gradual onset at a younger age • Prolonged morning stiffness • Improvement with exercise • Night pain • Alternating buttock pain • Associated psoriasis, inflammatory bowel disease, or uveitis

Reveal Case Review & NPLEX Trap

Diagnosis: Mechanical sacroiliac-region pain Differential diagnosis: Lumbar radiculopathy, hip disease, fracture, inflammatory sacroiliitis, pelvic pathology Tests: Gaenslen, pelvic compression, distraction, thigh thrust, FABER as clinically appropriate Treatment: Education, stabilization, progressive exercise, selected manual care NPLEX trap: Apparent pelvic asymmetry alone does not establish sacroiliac dysfunction.

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20

Plantar Fasciitis

4 questions · Physical Medicine

Clinical Case

A 49-year-old restaurant worker reports pain at the plantar-medial aspect of the right heel. The pain is most severe with the first few steps in the morning and after standing following a period of rest. It improves briefly after walking but returns after a long shift. Examination reveals: • Tenderness at the medial calcaneal tubercle • Pain with passive extension of the great toe • Limited ankle dorsiflexion • Tight calf muscles • Normal sensation and pulses • No swelling or bruising from acute trauma

Question 1 of 4NPLEX-PM-077

What is the most likely diagnosis?

APlantar fasciitisBAchilles-tendon ruptureCL5 radiculopathyDSeptic ankle arthritisEMorton neuroma

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Plantar fasciitis

Explanation Plantar fasciitis typically causes: • Plantar-medial heel pain • Severe pain with the first steps after rest • Tenderness near the medial calcaneal tubercle • Pain after prolonged standing or walking • Tightness of the calf and limited dorsiflexion in some patients

Question 2 of 4NPLEX-PM-078

Which maneuver may reproduce plantar-fascia pain?

APassive extension of the great toeBPhalen testCCervical distractionDLachman testEThompson calf squeeze

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Passive extension of the great toe

Explanation Great-toe extension tensions the plantar fascia through the windlass mechanism. Reproduction of heel pain supports plantar-fascia involvement.

Question 3 of 4NPLEX-PM-079

What is the most appropriate initial treatment plan?

APlantar-fascia and calf stretching, load modification, supportive footwear, and progressive strengtheningBComplete non-weight-bearing for six monthsCImmediate barefoot distance runningDRepeated jumping on the painful heelEForceful manipulation over a suspected stress fracture

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Plantar-fascia and calf stretching, load modification, supportive footwear, and progressive strengthening

Explanation Management may include: • Plantar-fascia-specific stretching • Gastrocnemius and soleus stretching • Supportive footwear • Temporary reduction of high-impact loading • Foot and calf strengthening • Taping • Short-term orthotic support • Night splint in selected patients with persistent morning pain • Gradual return to walking or running

Question 4 of 4NPLEX-PM-080

Which finding should prompt investigation for a calcaneal stress fracture rather than routine plantar-fascia treatment?

APain with the first morning stepsBMedial heel tenderness onlyCProgressive pain after a rapid increase in running with a positive calcaneal squeeze testDImprovement after calf stretchingEPain after prolonged standing at work

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Progressive pain after a rapid increase in running with a positive calcaneal squeeze test

Explanation A calcaneal stress fracture may cause progressively worsening pain with loading, diffuse heel tenderness, and pain when the calcaneus is compressed from both sides. High-impact rehabilitation should be postponed until fracture is excluded.

Reveal Case Review & NPLEX Trap

Diagnosis: Plantar fasciitis Differential diagnosis: Calcaneal stress fracture, fat-pad syndrome, nerve entrapment, inflammatory enthesitis, Achilles disorder Key assessment: First-step pain, medial calcaneal tenderness, great-toe extension, calf flexibility Treatment: Stretching, load modification, footwear support, progressive strengthening NPLEX trap: A heel spur on radiography does not necessarily identify the source of pain.

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21

Whiplash-Associated Disorder

4 questions · Physical Medicine

Clinical Case

A 34-year-old woman is evaluated two days after a rear-end motor-vehicle collision. She was wearing a seat belt and did not lose consciousness. She reports neck pain, stiffness, and occipital headache. Examination reveals: • Mildly reduced cervical range of motion • Bilateral upper-trapezius tenderness • Normal upper-extremity strength and sensation • Symmetric reflexes • No midline cervical spinous-process tenderness • No gait disturbance • No bowel or bladder symptoms

Question 1 of 4NPLEX-PM-081

What is the most likely diagnosis?

ACervical spinal-cord compressionBUncomplicated whiplash-associated disorderCCervical fractureDCervical myelopathyEVertebral osteomyelitis

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Uncomplicated whiplash-associated disorder

Explanation The patient has neck pain and musculoskeletal tenderness after an acceleration-deceleration injury without neurologic deficit, fracture findings, or other serious red flags. Common symptoms include: • Neck pain and stiffness • Headache • Shoulder-girdle discomfort • Reduced cervical movement • Muscle tenderness A cervical fracture or spinal-cord injury must be excluded when the mechanism, history, or examination is concerning.

Question 2 of 4NPLEX-PM-082

Which finding would most strongly indicate imaging and urgent medical assessment?

AMild trapezius tendernessBNeck stiffness that improves with movementCMidline cervical tenderness with upper-extremity weaknessDMild headache after the collisionEDiscomfort during prolonged computer use

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Midline cervical tenderness with upper-extremity weakness

Explanation Midline cervical tenderness and neurologic dysfunction raise concern for fracture, instability, nerve-root injury, or spinal-cord involvement. Other concerning findings include: • Altered consciousness • High-risk trauma • Progressive weakness or sensory loss • Hyperreflexia or gait dysfunction • Severe unremitting pain • Loss of bowel or bladder control

Question 3 of 4NPLEX-PM-083

What is the most appropriate initial physical medicine approach?

AProlonged rigid cervical-collar immobilizationBEducation, reassurance, gentle movement, and gradual return to normal activityCImmediate maximal cervical strengtheningDForceful manipulation at the first visitEStrict bed rest until all pain disappears

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Education, reassurance, gentle movement, and gradual return to normal activity

Explanation For an uncomplicated whiplash injury, treatment generally emphasizes: • Reassurance • Avoidance of unnecessary immobilization • Pain-limited cervical movement • Gradual restoration of normal activity • Postural and scapular exercise • Monitoring for delayed neurologic symptoms A soft collar may occasionally be used briefly for symptom control, but prolonged immobilization can increase stiffness, fear, and deconditioning.

Question 4 of 4NPLEX-PM-084

Which situation is a contraindication to cervical manipulation?

AMild muscular tenderness after serious pathology has been excludedBReduced movement caused by muscle guardingCSuspected cervical instability or fractureDMild postural dysfunctionEImproving pain with normal neurologic findings

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Suspected cervical instability or fracture

Explanation Manipulation must not be performed when fracture, instability, spinal-cord compression, vascular pathology, severe osteoporosis, infection, or malignancy is suspected.

Reveal Case Review & NPLEX Trap

Diagnosis: Uncomplicated whiplash-associated disorder Differential diagnosis: Cervical fracture, radiculopathy, concussion, myelopathy, vascular injury Assessment: Mechanism, midline tenderness, neurologic examination, gait, cognition, red flags Treatment: Education, gentle mobility, graded activity, progressive exercise Manual therapy: Consider only after contraindications have been excluded NPLEX trap: Pain after a collision does not automatically justify immediate manipulation.

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22

Anterior Shoulder Instability

4 questions · Physical Medicine

Clinical Case

A 22-year-old volleyball player previously dislocated the right shoulder while diving for a ball. Since the injury, the patient experiences apprehension when the arm is placed in abduction and external rotation. Examination reveals: • Full resting shoulder motion • Apprehension with the shoulder abducted to 90° and externally rotated • Mild weakness of the rotator cuff • No current deformity • Normal radial pulse • Normal sensation over the lateral shoulder

Question 1 of 4NPLEX-PM-085

What is the most likely diagnosis?

ARecurrent anterior shoulder instabilityBAdhesive capsulitisCCarpal tunnel syndromeDCervical myelopathyELong-head biceps rupture

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Recurrent anterior shoulder instability

Explanation Anterior shoulder instability commonly occurs when the arm is forced into abduction and external rotation. Patients may report fear or apprehension rather than pain when the shoulder is placed in the vulnerable position.

Question 2 of 4NPLEX-PM-086

Which test is most appropriate for this condition?

AAnterior apprehension testBPhalen testCLachman testDThompson testEMcMurray test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Anterior apprehension test

Explanation The anterior apprehension test places the shoulder in abduction and external rotation. A positive test produces apprehension that the shoulder will dislocate. Pain alone is less specific and may represent rotator-cuff, labral, or impingement-related pathology.

Question 3 of 4NPLEX-PM-087

Which rehabilitation program is most appropriate?

AProgressive rotator-cuff, scapular-stabilizer, and proprioceptive trainingBRepeated forced external rotationCComplete immobilization for six monthsDMaximal overhead throwing immediatelyEPassive heat as the only treatment

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Progressive rotator-cuff, scapular-stabilizer, and proprioceptive training

Explanation Rehabilitation should improve dynamic stabilization of the glenohumeral joint through: • Rotator-cuff strengthening • Scapular control • Closed-chain stabilization • Proprioceptive exercise • Gradual overhead loading • Sport-specific progression The vulnerable position of combined abduction and external rotation is initially restricted and later reintroduced gradually.

Question 4 of 4NPLEX-PM-088

Which structure should be specifically assessed after an anterior shoulder dislocation?

AAxillary nerveBMedian nerve at the wrist onlyCAchilles tendonDPosterior cruciate ligamentEFemoral nerve only

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Axillary nerve

Explanation The axillary nerve may be injured during anterior shoulder dislocation. Assessment includes: • Sensation over the lateral shoulder • Deltoid muscle activation • Shoulder abduction strength • Distal pulses and capillary refill

Reveal Case Review & NPLEX Trap

Diagnosis: Recurrent anterior shoulder instability Possible associated injuries: Bankart lesion, Hill-Sachs lesion, rotator-cuff injury, axillary-nerve injury Key test: Anterior apprehension test Treatment: Dynamic stabilization, proprioception, graded return to overhead activity Referral: Recurrent dislocations, major bone loss, persistent instability, neurologic deficit NPLEX trap: Do not force the shoulder farther into the apprehension position.

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23

Long-Head Biceps Tendinopathy

4 questions · Physical Medicine

Clinical Case

A 44-year-old construction worker reports gradual anterior shoulder pain aggravated by lifting materials overhead and carrying objects with the palm facing upward. Examination reveals: • Tenderness in the bicipital groove • Pain with resisted shoulder flexion • Pain with resisted forearm supination • Positive Speed and Yergason tests • Full passive shoulder motion • No visible arm deformity

Question 1 of 4NPLEX-PM-089

What is the most likely diagnosis?

ALong-head biceps tendinopathyBAdhesive capsulitisCCervical myelopathyDPosterior shoulder dislocationECarpal tunnel syndrome

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Long-head biceps tendinopathy

Explanation Anterior shoulder pain localized to the bicipital groove and reproduced with resisted shoulder flexion or supination supports long-head biceps tendon pathology. Biceps tendinopathy frequently coexists with: • Rotator-cuff disease • Subacromial pain • Labral pathology • Glenohumeral instability

Question 2 of 4NPLEX-PM-090

Which test stresses the long-head biceps tendon through resisted shoulder flexion?

ASpeed testBMcMurray testCFinkelstein testDTalar tilt testEThomas test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Speed test

Explanation During the Speed test, the patient resists shoulder flexion with the elbow extended and forearm supinated. Reproduction of anterior shoulder pain may support biceps tendon involvement. The test should be interpreted with other findings because it is not independently diagnostic.

Question 3 of 4NPLEX-PM-091

What is the most appropriate initial treatment?

ATemporary load modification and progressive shoulder and biceps strengtheningBComplete upper-extremity immobilizationCImmediate maximal resisted supinationDForceful manipulation over the painful tendonERepeated painful overhead lifting

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Temporary load modification and progressive shoulder and biceps strengthening

Explanation Treatment may include: • Reduction of aggravating overhead loading • Isometric biceps activation • Progressive resisted elbow flexion and supination • Rotator-cuff strengthening • Scapular stabilization • Correction of occupational mechanics • Gradual return to lifting

Question 4 of 4NPLEX-PM-092

Which finding suggests rupture of the long-head biceps tendon?

AMild pain during resisted flexionBSudden bruising with a distal “Popeye” muscle deformityCPositive Phalen testDPain over the lateral epicondyleEReduced Achilles reflex

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Sudden bruising with a distal “Popeye” muscle deformity

Explanation Proximal long-head biceps rupture may produce: • Sudden pain or tearing sensation • Bruising • A bulging distal biceps muscle • Weakness of supination • Reduction of previously severe tendon pain

Reveal Case Review & NPLEX Trap

Diagnosis: Long-head biceps tendinopathy Key tests: Speed and Yergason tests Differential diagnosis: Rotator-cuff disease, SLAP lesion, glenohumeral arthritis, cervical radiculopathy Treatment: Load modification, graded strengthening, scapular and cuff rehabilitation Referral: Acute traumatic rupture, marked weakness, persistent severe dysfunction NPLEX trap: A positive Speed test does not exclude associated rotator-cuff or labral disease.

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24

Cubital Tunnel Syndrome

4 questions · Physical Medicine

Clinical Case

A 53-year-old delivery driver reports intermittent numbness and tingling in the left small finger and ulnar half of the ring finger. Symptoms worsen while driving with the elbow flexed and while sleeping. Examination reveals: • Positive Tinel sign over the cubital tunnel • Symptoms reproduced by prolonged elbow flexion • Mild weakness of finger abduction • Normal thumb, index, and middle-finger sensation • No major neck pain

Question 1 of 4NPLEX-PM-093

What is the most likely diagnosis?

ACubital tunnel syndromeBCarpal tunnel syndromeCC6 radiculopathyDDe Quervain tenosynovitisELateral epicondylalgia

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Cubital tunnel syndrome

Explanation Cubital tunnel syndrome involves compression or irritation of the ulnar nerve at the elbow. Typical symptoms include: • Paresthesia in the small finger • Paresthesia in the ulnar half of the ring finger • Symptoms with prolonged elbow flexion • Reduced grip or finger-abduction strength • Possible intrinsic hand-muscle wasting in advanced cases

Question 2 of 4NPLEX-PM-094

Which nerve is involved?

AMedian nerveBRadial nerveCUlnar nerveDAxillary nerveEFemoral nerve

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Ulnar nerve

Explanation The ulnar nerve travels through the cubital tunnel posterior to the medial epicondyle. Sustained elbow flexion increases pressure and stretch on the nerve.

Question 3 of 4NPLEX-PM-095

What is the most appropriate initial intervention?

AAvoid prolonged elbow flexion and direct pressure, particularly during sleepBSleep with the elbow tightly flexedCPerform maximal gripping through numbnessDApply prolonged pressure over the cubital tunnelEImmobilize the wrist in maximal flexion

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Avoid prolonged elbow flexion and direct pressure, particularly during sleep

Explanation Initial management may include: • Avoiding leaning on the elbow • Modifying driving and desk posture • Using a nighttime elbow-extension support • Gentle nerve mobility when appropriate • Monitoring intrinsic hand strength • Addressing occupational repetition

Question 4 of 4NPLEX-PM-096

Which finding requires prompt referral?

AMild intermittent paresthesiaBSymptoms improving after changing elbow positionCProgressive intrinsic hand-muscle atrophy and clawingDMild tenderness over the medial elbowESymptoms occurring only after prolonged driving

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Progressive intrinsic hand-muscle atrophy and clawing

Explanation Muscle wasting, persistent weakness, clawing, or severe sensory loss indicates significant ulnar-nerve dysfunction and warrants prompt evaluation.

Reveal Case Review & NPLEX Trap

Diagnosis: Cubital tunnel syndrome Differential diagnosis: C8–T1 radiculopathy, thoracic outlet syndrome, ulnar compression at the wrist Key tests: Tinel at the elbow, sustained elbow-flexion testing, intrinsic hand strength Treatment: Position modification, night support, ergonomics, selected neural mobility NPLEX trap: Ulnar neuropathy affects the small finger; carpal tunnel syndrome generally does not.

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25

Acute Hamstring Strain

4 questions · Physical Medicine

Clinical Case

A 27-year-old sprinter develops sudden posterior-thigh pain while accelerating. The athlete stops immediately and has difficulty running but can walk with a mild limp. Examination reveals: • Local tenderness in the middle posterior thigh • Pain with resisted knee flexion • Pain with passive hip flexion and knee extension • No major bruising • No palpable defect • Normal neurologic examination

Question 1 of 4NPLEX-PM-097

What is the most likely diagnosis?

AHamstring strainBAchilles-tendon ruptureCLumbar spinal stenosisDHip septic arthritisELateral ankle sprain

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Hamstring strain

Explanation A sudden posterior-thigh injury during sprinting, with pain during hamstring contraction and stretch, is characteristic of a hamstring strain. A mild limp without a palpable defect or major bruising suggests a low- or moderate-grade injury rather than complete rupture.

Question 2 of 4NPLEX-PM-098

Which action most strongly activates the injured muscle group?

AResisted knee flexionBResisted wrist extensionCPassive thumb extensionDResisted shoulder abductionECervical distraction

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Resisted knee flexion

Explanation The hamstrings primarily perform: • Knee flexion • Hip extension • Control of terminal knee extension during running Pain during resisted knee flexion supports injury to the hamstring muscle-tendon unit.

Question 3 of 4NPLEX-PM-099

What is the most appropriate early rehabilitation strategy?

AProtect the injury and begin pain-limited isometric activation followed by progressive loadingBPerform maximal sprinting the following dayCApply aggressive stretching during the first painful hoursDImmobilize the entire leg for three monthsEPerform repeated explosive jumping immediately

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Protect the injury and begin pain-limited isometric activation followed by progressive loading

Explanation Rehabilitation generally progresses through: 1. Protection from high-speed running 2. Pain-limited range of motion 3. Isometric hamstring activation 4. Progressive concentric and eccentric strengthening 5. Running mechanics 6. Acceleration and sprint progression 7. Sport-specific drills Aggressive early stretching can increase pain and tissue disruption.

Question 4 of 4NPLEX-PM-100

Which finding raises concern for a proximal hamstring avulsion?

AMild tenderness in the middle thighBSevere buttock pain, extensive bruising, and weakness after forced hip flexionCImproving pain with walkingDMild discomfort during isometric contractionENo palpable defect

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Severe buttock pain, extensive bruising, and weakness after forced hip flexion

Explanation Proximal hamstring avulsion may occur when the hip is forcefully flexed while the knee is extended. Findings may include: • Severe pain near the ischial tuberosity • Extensive bruising • Palpable defect • Significant weakness • Difficulty sitting or walking

Reveal Case Review & NPLEX Trap

Diagnosis: Acute hamstring strain Differential diagnosis: Lumbar radiculopathy, proximal tendon avulsion, adductor strain, posterior-thigh contusion Treatment: Progressive loading, especially later eccentric strengthening Return to sport: Pain-free function, restored strength, full-speed running tolerance, no apprehension NPLEX trap: Pain relief alone is not sufficient for return to sprinting.

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26

Medial Collateral Ligament Sprain

4 questions · Physical Medicine

Clinical Case

A 20-year-old football player is struck on the lateral side of the right knee. The knee collapses inward. The patient reports medial knee pain but no audible pop. Examination reveals: • Tenderness along the medial collateral ligament • Pain with valgus stress at 30° of knee flexion • Mild increased medial opening with a firm endpoint • Negative Lachman test • No major effusion • Intact neurovascular status

Question 1 of 4NPLEX-PM-101

Which structure is most likely injured?

AMedial collateral ligamentBLateral collateral ligamentCPosterior cruciate ligamentDPatellar tendonEAchilles tendon

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Medial collateral ligament

Explanation A force applied to the lateral knee creates valgus stress and may injure the medial collateral ligament. Localized medial tenderness and pain or laxity with valgus testing support the diagnosis.

Question 2 of 4NPLEX-PM-102

Why is valgus stress commonly tested at approximately 30° of knee flexion?

ATo better isolate the medial collateral ligamentBTo test the Achilles tendonCTo evaluate the lateral meniscus exclusivelyDTo assess the patellofemoral jointETo test the hip abductors

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. To better isolate the medial collateral ligament

Explanation At approximately 30° of flexion, other stabilizing structures are relatively relaxed, allowing better assessment of the MCL. Valgus laxity in full extension may indicate a more extensive injury involving additional capsular or cruciate structures.

Question 3 of 4NPLEX-PM-103

What is the most appropriate management for an uncomplicated mild-to-moderate MCL sprain?

AProtected weight-bearing, possible hinged bracing, early motion, and progressive strengtheningBPermanent immobilizationCImmediate unrestricted contact sportDForceful valgus stretchingEContinuous high-temperature heat during acute swelling

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Protected weight-bearing, possible hinged bracing, early motion, and progressive strengthening

Explanation Rehabilitation may include: • Protection from valgus stress • Compression and symptom control • Early restoration of range of motion • Quadriceps and hamstring activation • Progressive weight-bearing • Balance and agility training • Gradual return to sport Many isolated MCL injuries heal successfully without surgery.

Question 4 of 4NPLEX-PM-104

Which finding suggests a more extensive knee injury?

ALocal MCL tenderness onlyBMild pain with valgus stress at 30°CMarked valgus laxity in full extensionDNo effusionENormal Lachman testing

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Marked valgus laxity in full extension

Explanation Laxity in full extension suggests injury beyond the superficial MCL, potentially involving: • Joint capsule • Cruciate ligaments • Posteromedial structures • Multiple ligament complexes

Reveal Case Review & NPLEX Trap

Diagnosis: MCL sprain Mechanism: Valgus force to the knee Key test: Valgus stress at 30° and full extension Treatment: Protection, early motion, progressive strengthening, functional rehabilitation Referral: Gross instability, multiligament injury, neurovascular findings, suspected fracture NPLEX trap: Valgus laxity in full extension is more concerning than isolated laxity at 30°.

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27

Syndesmotic “High Ankle” Sprain

4 questions · Physical Medicine

Clinical Case

A 25-year-old hockey player’s foot is forced into external rotation while the leg remains planted. The patient reports pain above the ankle joint and has greater difficulty walking than expected from the amount of swelling. Examination reveals: • Tenderness over the distal tibiofibular syndesmosis • Pain with external rotation of the foot • Pain when the tibia and fibula are compressed higher in the leg • Minimal tenderness over the anterior talofibular ligament • No gross deformity

Question 1 of 4NPLEX-PM-105

What is the most likely diagnosis?

ASyndesmotic ankle sprainBSimple anterior talofibular ligament sprainCAchilles-tendon ruptureDPlantar fasciitisEMorton neuroma

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Syndesmotic ankle sprain

Explanation A high ankle sprain involves the distal tibiofibular syndesmosis. It often results from external rotation of the foot relative to the leg. Pain is usually located above the ankle joint and recovery may be longer than for a typical lateral ankle sprain.

Question 2 of 4NPLEX-PM-106

Which finding supports syndesmotic injury?

APain during external rotation stressBPositive Phalen testCPositive Speed testDPain with resisted wrist extensionELoss of passive shoulder rotation

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Pain during external rotation stress

Explanation External rotation stress separates the distal tibia and fibula and places tension on the syndesmotic ligaments. The squeeze test may also reproduce distal syndesmotic pain when the tibia and fibula are compressed higher in the leg.

Question 3 of 4NPLEX-PM-107

What is the most appropriate initial management?

AProtect the ankle, limit painful loading, and evaluate the stability of the syndesmosisBImmediate unrestricted skatingCAggressive external-rotation stretchingDMaximal hopping drillsETreat as plantar fasciitis

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Protect the ankle, limit painful loading, and evaluate the stability of the syndesmosis

Explanation Management may include: • Protected weight-bearing • Immobilization or bracing when necessary • Imaging when instability or fracture is suspected • Gradual range-of-motion restoration • Strength and balance rehabilitation • Progressive return to skating or running An unstable syndesmotic injury may require orthopedic management.

Question 4 of 4NPLEX-PM-108

Which finding most strongly indicates imaging and orthopedic assessment?

AMild pain that improves dailyBInability to bear weight with widening of the ankle mortiseCMinimal swellingDMild calf tightnessENormal neurovascular findings

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Inability to bear weight with widening of the ankle mortise

Explanation Widening of the ankle mortise suggests syndesmotic instability. Unstable high ankle sprains can lead to chronic pain and degenerative joint changes if inadequately treated.

Reveal Case Review & NPLEX Trap

Diagnosis: Syndesmotic ankle sprain Mechanism: External rotation, often with dorsiflexion Key tests: External-rotation stress and squeeze testing Treatment: Protection, stability assessment, gradual rehabilitation Referral: Mortise widening, fracture, gross instability, inability to progress NPLEX trap: A high ankle sprain may have relatively little swelling but substantial functional disability.

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28

Morton Neuroma

4 questions · Physical Medicine

Clinical Case

A 46-year-old woman reports burning forefoot pain and numbness extending into the third and fourth toes. Symptoms are worse when wearing narrow high-heeled shoes and improve after removing the shoes and massaging the foot. Examination reveals: • Tenderness in the third intermetatarsal space • Reproduction of symptoms with forefoot compression • A palpable click during metatarsal squeeze testing • Normal ankle strength • No heel tenderness

Question 1 of 4NPLEX-PM-109

What is the most likely diagnosis?

AMorton neuromaBPlantar fasciitisCAchilles ruptureDL5 radiculopathyETarsal fracture

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Morton neuroma

Explanation Morton neuroma is a painful interdigital nerve disorder, most commonly affecting the third intermetatarsal space. Symptoms may include: • Burning forefoot pain • Toe numbness or tingling • Sensation of a pebble in the shoe • Worsening in narrow footwear • Relief after shoe removal

Question 2 of 4NPLEX-PM-110

Which orthopedic maneuver supports the diagnosis?

AMorton metatarsal squeeze testBLachman testCHawkins-Kennedy testDThompson testECervical compression test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Morton metatarsal squeeze test

Explanation Compression of the metatarsal heads may reproduce pain or produce a palpable click when the involved nerve is compressed between the metatarsals.

Question 3 of 4NPLEX-PM-111

What is the most appropriate initial management?

AWide toe-box footwear and a properly positioned metatarsal padBNarrower high-heeled footwearCImmediate barefoot sprintingDFull-leg immobilizationEMaximal forefoot compression exercise

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Wide toe-box footwear and a properly positioned metatarsal pad

Explanation Conservative management may include: • Wider footwear • Lower heels • Metatarsal pad placed proximal to the painful metatarsal heads • Reduction of repetitive forefoot loading • Foot intrinsic strengthening • Calf and ankle mobility work when relevant

Question 4 of 4NPLEX-PM-112

Which finding suggests a metatarsal stress fracture rather than Morton neuroma?

ABurning pain between the toesBSymptoms relieved after removing tight shoesCFocal bony tenderness with pain during hopping after a sudden increase in runningDPalpable intermetatarsal clickENumbness extending into adjacent toes

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Focal bony tenderness with pain during hopping after a sudden increase in running

Explanation Stress fracture is more likely with: • Focal metatarsal bone tenderness • Progressive load-related pain • Recent increase in training • Pain during hopping • Possible swelling

Reveal Case Review & NPLEX Trap

Diagnosis: Morton neuroma Differential diagnosis: Metatarsal stress fracture, metatarsalgia, MTP synovitis, peripheral neuropathy Key test: Metatarsal squeeze Treatment: Footwear change, metatarsal support, load modification Referral: Persistent disabling pain, progressive neurologic symptoms, suspected fracture NPLEX trap: Place a metatarsal pad behind—not directly underneath—the painful metatarsal heads.

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29

Adolescent Idiopathic Scoliosis

4 questions · Physical Medicine

Clinical Case

A 14-year-old girl is noted to have uneven shoulders during a routine examination. She has no significant pain, weakness, numbness, or bowel or bladder symptoms. Examination reveals: • Right thoracic prominence during forward bending • Mild asymmetry of the waist • Normal strength, sensation, and reflexes • No cutaneous spinal abnormalities • Normal gait

Question 1 of 4NPLEX-PM-113

What is the most likely diagnosis?

AAdolescent idiopathic scoliosisBCauda equina syndromeCAcute lumbar disc herniationDCervical myelopathyESeptic sacroiliitis

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Adolescent idiopathic scoliosis

Explanation Adolescent idiopathic scoliosis is a structural lateral curvature of the spine with vertebral rotation that develops without an identifiable underlying cause. It is often detected through: • Shoulder asymmetry • Uneven waist • Rib prominence • Trunk shift • Forward-bend examination

Question 2 of 4NPLEX-PM-114

Which screening examination is most appropriate?

AAdam forward-bend testBPhalen testCMcMurray testDThompson testEFinkelstein test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Adam forward-bend test

Explanation During the Adam forward-bend test, the examiner observes for rib or lumbar prominence caused by vertebral rotation. A scoliometer may be used to quantify trunk rotation and determine whether radiographic evaluation is indicated.

Question 3 of 4NPLEX-PM-115

How is the spinal curve measured radiographically?

ACobb angleBQ angleCCarrying angleDFemoral-neck angleETalar angle only

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Cobb angle

Explanation The Cobb angle is measured on a standing spinal radiograph using the most tilted vertebrae above and below the curve. Management depends on: • Curve magnitude • Skeletal maturity • Curve progression • Symptoms • Underlying cause

Question 4 of 4NPLEX-PM-116

Which finding is atypical and requires further investigation?

AMild painless right thoracic curveBNormal neurologic examinationCSignificant night pain with neurologic abnormalitiesDMild shoulder asymmetryEGradual discovery during adolescence

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Significant night pain with neurologic abnormalities

Explanation Pain, neurologic deficits, rapid progression, very young age, or an unusual curve pattern may suggest an underlying disorder such as: • Spinal-cord lesion • Tumor • Infection • Congenital abnormality • Neuromuscular disease

Reveal Case Review & NPLEX Trap

Diagnosis: Adolescent idiopathic scoliosis Key test: Adam forward-bend test Confirmation: Standing spinal radiography and Cobb-angle measurement when indicated Management: Observation, exercise support, bracing, or surgical referral depending on severity and progression Exercise: Supports strength and function but does not replace bracing or specialist care when indicated NPLEX trap: Postural asymmetry does not automatically establish structural scoliosis.

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30

Physical-Modality and Hydrotherapy Safety

4 questions · Physical Medicine

Clinical Case

A 68-year-old man with knee osteoarthritis requests heat, TENS, and therapeutic ultrasound. His history includes: • Type 2 diabetes • Reduced temperature and light-touch sensation below both knees • Peripheral arterial disease • Implanted cardiac pacemaker • No acute knee trauma • No fever or joint redness

Question 1 of 4NPLEX-PM-117

What should be done before applying a thermal or electrical modality?

AAssess sensation, circulation, skin condition, medical devices, and treatment contraindicationsBApply maximal intensity immediatelyCAllow the patient to sleep during unattended treatmentDApply treatment without documenting medical historyEAssume all modalities are safe for osteoarthritis

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Assess sensation, circulation, skin condition, medical devices, and treatment contraindications

Explanation Before applying a physical modality, the practitioner should evaluate: • Sensation • Circulation • Skin integrity • Cognitive and communication ability • Implanted electronic devices • Active infection • Thrombosis • Malignancy • Acute bleeding • Treatment goals

Question 2 of 4NPLEX-PM-118

Which treatment creates the greatest burn risk for this patient?

AUnattended high-temperature heating pad over an area with reduced sensationBSupervised strengthening exerciseCGentle active knee range of motionDLow-load quadriceps exerciseESupported walking within tolerance

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Unattended high-temperature heating pad over an area with reduced sensation

Explanation Impaired sensation prevents the patient from reliably detecting excessive heat. Peripheral arterial disease may further reduce the tissue’s ability to tolerate thermal stress. Heat should be avoided or applied only with substantial caution, close monitoring, conservative temperature, and an appropriate protective barrier.

Question 3 of 4NPLEX-PM-119

Which statement about TENS is most appropriate?

APlace the electrodes across the chest over the pacemakerBApply TENS without considering the implanted deviceCAvoid electrical stimulation near the pacemaker unless appropriate medical-device guidance has confirmed safetyDIncrease intensity until the skin burnsETENS permanently cures knee osteoarthritis

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Avoid electrical stimulation near the pacemaker unless appropriate medical-device guidance has confirmed safety

Explanation Electrical stimulation may interfere with some implanted electronic devices. Treatment location, device type, manufacturer guidance, and specialist recommendations must be considered. TENS is a symptom-management adjunct; it does not reverse structural osteoarthritis.

Question 4 of 4NPLEX-PM-120

What should form the foundation of this patient’s long-term knee management?

AProgressive therapeutic exercise and functional rehabilitationBPassive modalities aloneCComplete avoidance of walkingDDaily high-temperature hydrotherapy despite impaired sensationEContinuous knee immobilization

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Progressive therapeutic exercise and functional rehabilitation

Explanation The foundation of physical management should include: • Quadriceps and hip strengthening • Comfortable range-of-motion exercise • Low-impact aerobic activity • Balance and gait training • Weight-management support when relevant • Appropriate footwear or assistive device • Activity pacing Modalities may provide temporary symptom relief, but they should not replace active rehabilitation.

Reveal Case Review & NPLEX Trap

Condition: Knee osteoarthritis with major modality precautions Heat precautions: Impaired sensation, vascular disease, inability to report discomfort Electrical precautions: Pacemaker and other implanted electronic devices Ultrasound precautions: Avoid over active malignancy, thrombosis, acute infection, eyes, reproductive organs, and other contraindicated tissues Hydrotherapy: Use safe temperatures and direct supervision; avoid extremes when circulation or sensation is impaired NPLEX trap: The presence of pain is not enough to justify a modality. Safety screening comes first.

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31

Full-Thickness Rotator-Cuff Tear

4 questions · Physical Medicine

Clinical Case

A 63-year-old man falls onto his outstretched right hand. He develops immediate shoulder pain and is unable to lift the arm above shoulder level. Examination reveals: • Markedly reduced active abduction • Nearly preserved passive shoulder motion • Significant weakness during resisted abduction • Positive drop-arm test • No shoulder deformity • Normal distal pulses • Normal sensation over the lateral shoulder

Question 1 of 4NPLEX-PM-121

What is the most likely diagnosis?

AAdhesive capsulitisBFull-thickness rotator-cuff tearCCervical myelopathyDAcromioclavicular arthritisECarpal tunnel syndrome

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Full-thickness rotator-cuff tear

Explanation A traumatic onset, major loss of active elevation, preserved passive motion, objective weakness, and a positive drop-arm test strongly suggest a substantial rotator-cuff tear. Rotator-cuff tears commonly cause pain when lifting or lowering the arm, weakness during elevation or rotation, night pain, and sometimes crepitus. • A: Adhesive capsulitis restricts both active and passive movement. • C: Cervical myelopathy produces spinal-cord signs, such as hyperreflexia and gait disturbance. • D: AC arthritis usually causes localized superior shoulder pain, especially during cross-body movement. • E: Carpal tunnel syndrome affects the median nerve at the wrist.

Question 2 of 4NPLEX-PM-122

Which orthopedic test is most appropriate for assessing a major supraspinatus or rotator-cuff tear?

ADrop-arm testBPhalen testCPosterior drawer testDThompson testEGaenslen test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Drop-arm test

Explanation The examiner passively abducts the shoulder and asks the patient to lower the arm slowly. Sudden dropping of the arm or inability to control the descent suggests significant rotator-cuff dysfunction. Pain alone is less specific than true weakness or loss of controlled lowering.

Question 3 of 4NPLEX-PM-123

What is the most appropriate next step?

ABegin maximal overhead strengthening immediatelyBArrange appropriate shoulder imaging and orthopedic assessmentCImmobilize the shoulder permanentlyDPerform forceful shoulder manipulationETreat only with a heating compress

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Arrange appropriate shoulder imaging and orthopedic assessment

Explanation Acute traumatic weakness in an older adult requires assessment for a full-thickness tear, occult fracture, dislocation, or neurologic injury. Ultrasound or MRI can evaluate tendon integrity when the result will affect treatment. Physical therapy can improve patient-reported outcomes in some symptomatic full-thickness tears, but acute traumatic tears with major weakness warrant timely specialist evaluation.

Question 4 of 4NPLEX-PM-124

Which exercise is most appropriate while awaiting definitive assessment, assuming no fracture or dislocation?

AMaximal resisted shoulder abductionBRepeated heavy overhead pressesCGentle pain-limited pendulum movement and protected range of motionDForceful end-range stretchingEBallistic throwing exercises

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Gentle pain-limited pendulum movement and protected range of motion

Explanation Gentle protected movement may help limit unnecessary stiffness while avoiding excessive stress on the injured tendon. Strengthening should be prescribed only after the diagnosis, tear severity, pain level, and treatment plan are established.

Reveal Case Review & NPLEX Trap

Diagnosis: Traumatic full-thickness rotator-cuff tear Key examination: Active versus passive motion, drop-arm test, resisted abduction and external rotation Differential diagnosis: Fracture, dislocation, axillary neuropathy, cervical radiculopathy, adhesive capsulitis Investigations: Radiography after trauma; ultrasound or MRI for tendon evaluation Treatment: Protection, pain control, appropriate imaging, specialist assessment, structured rehabilitation NPLEX trap: Preserved passive motion with severe active weakness suggests tendon or neurologic dysfunction rather than adhesive capsulitis.

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32

Acromioclavicular Joint Sprain

4 questions · Physical Medicine

Clinical Case

A 28-year-old cyclist falls directly onto the superior aspect of the left shoulder. The patient develops localized pain and swelling over the top of the shoulder. Examination reveals: • Tenderness over the acromioclavicular joint • Pain during cross-body adduction • Mild visible prominence of the distal clavicle • Full elbow and wrist function • Normal axillary-nerve sensation • Intact distal circulation

Question 1 of 4NPLEX-PM-125

Which structure is most likely injured?

AAcromioclavicular jointBGlenohumeral joint onlyCMedian nerveDLong-head biceps tendonECervical spinal cord

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Acromioclavicular joint

Explanation A shoulder separation involves the AC joint, where the distal clavicle meets the acromion. It commonly follows a direct fall onto the shoulder. The injury is distinct from a glenohumeral dislocation.

Question 2 of 4NPLEX-PM-126

Which movement is most likely to reproduce AC-joint pain?

ACross-body shoulder adductionBWrist flexionCAnkle plantar flexionDKnee extensionECervical distraction

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Cross-body shoulder adduction

Explanation Cross-body adduction compresses the acromioclavicular joint and commonly reproduces localized superior shoulder pain. The location of pain is important. Deep anterior or lateral shoulder pain may suggest other shoulder pathology.

Question 3 of 4NPLEX-PM-127

What is the most appropriate initial management of a stable, low-grade AC sprain?

ABrief sling use for comfort, symptom control, early protected motion, and progressive rehabilitationBPermanent shoulder immobilizationCImmediate heavy overhead liftingDForceful clavicular manipulationEAggressive stretching through severe pain

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Brief sling use for comfort, symptom control, early protected motion, and progressive rehabilitation

Explanation Management usually includes: • Short-term protection • Ice or another appropriate symptom-control method • Brief sling use if needed • Early elbow, wrist, and hand movement • Gradual shoulder range of motion • Scapular and shoulder strengthening • Progressive return to work or sport Most lower-grade AC-joint injuries are treated nonsurgically.

Question 4 of 4NPLEX-PM-128

Which finding requires evaluation for a more serious injury?

ALocal tenderness over the AC jointBMild pain during cross-body movementCAbsent distal pulse with a cool, pale armDMild swelling after the fallEPain while sleeping on the affected side

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Absent distal pulse with a cool, pale arm

Explanation A cool, pale extremity or absent pulse suggests vascular compromise. Immediate emergency assessment is required. Other serious findings include: • Severe deformity • Open injury • Neurologic loss • Suspected clavicular fracture • Skin tenting • Chest pain or respiratory symptoms

Reveal Case Review & NPLEX Trap

Diagnosis: Acromioclavicular joint sprain Mechanism: Direct impact onto the shoulder Key examination: AC tenderness, cross-body adduction, deformity, neurovascular status Treatment: Protection, early movement, scapular and shoulder rehabilitation Referral: Severe displacement, skin compromise, neurovascular dysfunction, associated fracture NPLEX trap: A shoulder separation affects the AC joint, not the main glenohumeral ball-and-socket joint.

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33

Posterior Cruciate Ligament Injury

4 questions · Physical Medicine

Clinical Case

A 36-year-old driver is involved in a motor-vehicle collision. The front of the flexed right knee strikes the dashboard. Examination reveals: • Posterior knee pain • Mild effusion • Increased posterior translation of the tibia • Positive posterior drawer test • Negative Lachman test • Intact distal pulses and sensation

Question 1 of 4NPLEX-PM-129

Which ligament is most likely injured?

AAnterior cruciate ligamentBPosterior cruciate ligamentCMedial collateral ligamentDLateral collateral ligamentEPatellar ligament

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Posterior cruciate ligament

Explanation A direct force against the anterior tibia while the knee is flexed is a classic mechanism for posterior cruciate ligament injury. Dashboard trauma and falling onto a flexed knee are commonly described mechanisms.

Question 2 of 4NPLEX-PM-130

Which test best assesses the suspected ligament?

APosterior drawer testBLachman testCMcMurray testDFinkelstein testEThompson test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Posterior drawer test

Explanation The posterior drawer test assesses posterior displacement of the tibia relative to the femur. The examiner should also observe for a posterior sag of the tibia before performing the test.

Question 3 of 4NPLEX-PM-131

Which early rehabilitation approach is most appropriate for an isolated stable PCL injury?

AQuadriceps activation, protected weight-bearing, and avoidance of excessive posterior tibial translationBImmediate maximal hamstring loadingCRepeated forceful posterior drawer movementsDUnrestricted pivoting on the first dayEComplete immobilization for six months

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Quadriceps activation, protected weight-bearing, and avoidance of excessive posterior tibial translation

Explanation Initial rehabilitation commonly emphasizes: • Swelling control • Restoration of appropriate range of motion • Quadriceps activation • Protected weight-bearing • Gradual closed-chain strengthening • Avoidance of early exercises that create excessive posterior tibial shear Hamstring contraction can increase posterior translation of the tibia and may need to be progressed cautiously during early rehabilitation.

Question 4 of 4NPLEX-PM-132

Which finding would suggest a multiligament knee injury requiring urgent assessment?

AMild isolated posterior laxityBMild activity-related discomfortCGross instability with a diminished foot pulseDMild quadriceps weaknessESmall effusion

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Gross instability with a diminished foot pulse

Explanation High-energy multiligament knee injuries can damage the popliteal artery and peripheral nerves. Neurovascular findings require immediate emergency evaluation.

Reveal Case Review & NPLEX Trap

Diagnosis: Posterior cruciate ligament injury Mechanism: Dashboard trauma or fall onto a flexed knee Key tests: Posterior drawer and posterior sag assessment Differential diagnosis: Tibial plateau fracture, meniscal injury, posterolateral-corner injury Treatment: Protection, quadriceps-focused rehabilitation, progressive functional loading Referral: Neurovascular deficit, major instability, combined ligament injury, fracture NPLEX trap: Anterior tibial translation indicates ACL injury; posterior translation indicates PCL injury.

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34

Lateral Collateral Ligament Injury

4 questions · Physical Medicine

Clinical Case

A 30-year-old rugby player is struck on the medial aspect of the left knee, forcing the knee outward. Examination reveals: • Lateral joint-line and fibular-head tenderness • Pain and laxity with varus stress at 30° • Mild instability • Negative valgus stress testing • Normal ankle dorsiflexion and eversion • Intact sensation over the dorsum of the foot

Question 1 of 4NPLEX-PM-133

Which ligament is most likely injured?

AMedial collateral ligamentBLateral collateral ligamentCAnterior cruciate ligamentDPosterior cruciate ligamentEPatellar ligament

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Lateral collateral ligament

Explanation A blow to the medial knee produces varus stress and can injure the lateral collateral ligament. The LCL is located on the outer side of the knee and connects the femur to the fibula.

Question 2 of 4NPLEX-PM-134

Which orthopedic test is most appropriate?

AVarus stress testBValgus stress testCPhalen testDFABER testEHawkins-Kennedy test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Varus stress test

Explanation Varus stress evaluates the lateral stabilizing structures of the knee. Testing at approximately 30° helps assess the LCL more specifically. Laxity in full extension suggests a more extensive capsular, cruciate, or posterolateral-corner injury.

Question 3 of 4NPLEX-PM-135

Which nerve should be carefully evaluated in a substantial lateral knee injury?

ACommon peroneal nerveBMedian nerveCAxillary nerveDMusculocutaneous nerveEUlnar nerve

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Common peroneal nerve

Explanation The common peroneal nerve passes around the fibular neck and may be injured with trauma involving the lateral knee. Assessment includes: • Ankle dorsiflexion • Great-toe extension • Foot eversion • Sensation over the dorsum of the foot • Gait assessment for foot drop

Question 4 of 4NPLEX-PM-136

What is the most appropriate treatment for a mild isolated LCL sprain?

AProtection from varus stress, progressive motion, strengthening, and balance rehabilitationBImmediate unrestricted contact sportCRepeated forceful varus stretchingDComplete permanent immobilizationEDeep massage over an unstable acute injury

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Protection from varus stress, progressive motion, strengthening, and balance rehabilitation

Explanation A mild isolated injury may be treated with: • Protection or bracing • Swelling control • Progressive range of motion • Quadriceps and hamstring strengthening • Hip strengthening • Balance and neuromuscular training • Gradual return to cutting and contact activity LCL injuries are less commonly isolated than MCL injuries and should be assessed for associated posterolateral and cruciate damage.

Reveal Case Review & NPLEX Trap

Diagnosis: Lateral collateral ligament sprain Mechanism: Varus force applied to the knee Key test: Varus stress at 30° and full extension Neurologic concern: Common peroneal nerve Treatment: Protection, motion, strengthening, neuromuscular rehabilitation NPLEX trap: Severe lateral instability may indicate a posterolateral-corner or multiligament injury rather than an isolated LCL sprain.

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35

Midportion Achilles Tendinopathy

4 questions · Physical Medicine

Clinical Case

A 43-year-old recreational runner reports gradual pain and stiffness approximately 4 cm above the right heel. Symptoms are worse during the first few minutes of running and the morning after training. Examination reveals: • Localized thickening of the Achilles tendon • Tenderness 3–5 cm proximal to the calcaneal insertion • Pain during repeated heel raises • Preserved plantar-flexion strength • Negative Thompson test • No sudden traumatic event

Question 1 of 4NPLEX-PM-137

What is the most likely diagnosis?

AMidportion Achilles tendinopathyBComplete Achilles ruptureCPlantar fasciitisDLateral ankle sprainEPosterior tibial tendon rupture

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Midportion Achilles tendinopathy

Explanation Gradual load-related tendon pain, morning stiffness, tendon thickening, and preserved continuity support Achilles tendinopathy rather than acute rupture. Achilles tendinopathy commonly develops when the tendon becomes irritated after repetitive loading.

Question 2 of 4NPLEX-PM-138

Which finding most strongly argues against a complete Achilles rupture?

APain during runningBMorning stiffnessCNormal plantar flexion during the Thompson testDLocal tendon thickeningESymptoms lasting several weeks

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Normal plantar flexion during the Thompson test

Explanation An intact plantar-flexion response during calf compression suggests tendon continuity. A complete rupture typically produces absent or markedly reduced plantar flexion during the Thompson test. Clinical findings must still be interpreted together, because partial tears may be more difficult to identify.

Question 3 of 4NPLEX-PM-139

What is the most appropriate rehabilitation plan?

AProgressive calf-loading exercise with modification of running loadBComplete rest until all tendon structure appears normalCImmediate maximal sprintingDForceful stretching through severe painEPassive heat as the only intervention

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Progressive calf-loading exercise with modification of running load

Explanation Treatment commonly includes: • Temporary reduction of provocative running volume • Isometric calf exercise for initial load tolerance • Progressive heel-raise strengthening • Slow heavy or eccentric loading as tolerated • Foot, ankle, hip, and kinetic-chain assessment • Gradual return to running • Monitoring of next-day symptoms Foot and ankle conditioning programs emphasize progressive strengthening of the plantar flexors and other supporting muscles.

Question 4 of 4NPLEX-PM-140

Which new finding requires prompt assessment for Achilles rupture?

AMild morning stiffnessBPain during the first kilometre of runningCSudden pop with inability to perform a heel raiseDTendon thickeningEMild pain after increasing mileage

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Sudden pop with inability to perform a heel raise

Explanation A sudden pop, immediate functional loss, palpable tendon gap, and abnormal Thompson test suggest an acute rupture.

Reveal Case Review & NPLEX Trap

Diagnosis: Midportion Achilles tendinopathy Differential diagnosis: Partial tear, complete rupture, retrocalcaneal bursitis, posterior ankle impingement Key assessment: Pain location, tendon thickening, heel raises, Thompson test Treatment: Load modification and progressive tendon loading NPLEX trap: Tendinopathy is not treated with indefinite rest; the tendon usually requires carefully progressed loading.

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36

Progressive Collapsing Foot Deformity

4 questions · Physical Medicine

Clinical Case

A 59-year-old woman reports progressive pain and swelling behind the medial ankle. Over the past year, the arch of the right foot has become flatter. Examination reveals: • Tenderness along the posterior tibial tendon • Hindfoot valgus • Forefoot abduction • “Too-many-toes” appearance from behind • Difficulty performing a single-leg heel raise • Arch partially corrects during non-weight-bearing examination

Question 1 of 4NPLEX-PM-141

What is the most likely diagnosis?

AProgressive collapsing foot deformity due to posterior tibial tendon dysfunctionBMorton neuromaCAchilles-tendon ruptureDPlantar fasciitisEAcute lateral ankle sprain

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Progressive collapsing foot deformity due to posterior tibial tendon dysfunction

Explanation Progressive arch collapse, medial ankle pain, hindfoot valgus, forefoot abduction, and difficulty with a single-leg heel raise support posterior tibial tendon dysfunction. This condition was formerly called adult-acquired flatfoot and is now commonly described as progressive collapsing foot deformity.

Question 2 of 4NPLEX-PM-142

What is a primary function of the posterior tibial tendon?

ASupporting the medial arch and assisting foot inversionBExtending the great toeCEverting the ankle onlyDFlexing the kneeEExtending the hip

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Supporting the medial arch and assisting foot inversion

Explanation The posterior tibial tendon runs behind the medial malleolus and contributes to: • Supporting the medial arch • Inverting the foot • Controlling pronation during gait • Assisting heel rise Loss of tendon function can allow progressive flattening and abduction of the foot.

Question 3 of 4NPLEX-PM-143

What is the most appropriate conservative management while the deformity remains flexible?

AArch-supporting orthosis, appropriate footwear, and progressive posterior tibial and calf rehabilitationBNarrow high-heeled shoesCRepeated unsupported long-distance walking through severe painDForceful flattening of the archEComplete permanent non-weight-bearing

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Arch-supporting orthosis, appropriate footwear, and progressive posterior tibial and calf rehabilitation

Explanation Conservative treatment may include: • Supportive footwear • An ankle or foot orthosis • Temporary reduction of painful loading • Calf flexibility work • Posterior tibial strengthening • Foot-intrinsic strengthening • Balance and gait rehabilitation • Weight-management support where applicable

Question 4 of 4NPLEX-PM-144

Which finding suggests progression requiring specialist assessment?

AMild flexible arch loweringBSymptoms improving with footwear modificationCIncreasing rigid deformity with lateral ankle pain and inability to heel raiseDMild calf tightnessENormal walking tolerance

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Increasing rigid deformity with lateral ankle pain and inability to heel raise

Explanation Progressive rigidity, worsening deformity, lateral impingement pain, severe weakness, or failure of conservative care warrants orthopedic or foot-and-ankle assessment.

Reveal Case Review & NPLEX Trap

Diagnosis: Progressive collapsing foot deformity/posterior tibial tendon dysfunction Key findings: Medial ankle pain, arch collapse, hindfoot valgus, too-many-toes sign, failed heel raise Treatment: Orthotic support, footwear, progressive strengthening and gait rehabilitation Referral: Rigid deformity, rapid progression, severe functional loss, failure of conservative care NPLEX trap: A flexible flatfoot and a rigid progressive collapsing deformity are not managed identically.

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37

Adolescent Lumbar Spondylolysis

4 questions · Physical Medicine

Clinical Case

A 16-year-old competitive gymnast reports gradually progressive low-back pain. The pain is worse during backbends, tumbling, and repeated lumbar extension. It improves with rest. Examination reveals: • Localized lower-lumbar tenderness • Pain with lumbar extension • Tight hamstrings • Normal lower-extremity strength and sensation • Normal reflexes • No bowel or bladder symptoms • No fever or constitutional symptoms

Question 1 of 4NPLEX-PM-145

What is the most likely diagnosis?

ALumbar spondylolysisBCauda equina syndromeCVertebral osteomyelitisDAcute cervical radiculopathyEHip septic arthritis

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Lumbar spondylolysis

Explanation Spondylolysis is a stress injury or defect of the pars interarticularis. It is associated with sports involving repetitive lumbar extension and rotation, including gymnastics, football, diving, and weightlifting.

Question 2 of 4NPLEX-PM-146

Which activity should initially be modified?

ARepetitive painful lumbar hyperextensionBGentle pain-free walkingCComfortable neutral-spine movementDUpper-extremity activity that does not provoke symptomsEBreathing exercise

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Repetitive painful lumbar hyperextension

Explanation Repeated painful extension can continue to load the pars region. Initial management should reduce the provocative activity while maintaining general conditioning within safe limits.

Question 3 of 4NPLEX-PM-147

What is the most appropriate initial rehabilitation plan?

ATemporary removal from painful extension activity followed by trunk, hip, and movement-control rehabilitationBImmediate return to full gymnasticsCForceful lumbar manipulation over the suspected stress fractureDComplete bed rest for six monthsERepeated loaded back extensions through pain

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Temporary removal from painful extension activity followed by trunk, hip, and movement-control rehabilitation

Explanation Management may include: • Temporary activity modification • Pain-free aerobic conditioning • Trunk endurance and stabilization • Hip and lower-extremity strengthening • Hamstring and hip-flexor mobility • Gradual reintroduction of extension • Sport-specific progression Manipulation directly over a suspected stress fracture is inappropriate until structural injury and stability have been evaluated.

Question 4 of 4NPLEX-PM-148

Which finding requires broader investigation rather than routine sports rehabilitation?

APain only during repeated extensionBSymptoms improving with restCNight pain, fever, weight loss, or neurologic abnormalitiesDTight hamstringsELocal muscle fatigue after practice

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Night pain, fever, weight loss, or neurologic abnormalities

Explanation Constitutional symptoms, persistent night pain, neurologic deficits, bowel or bladder changes, or rapidly progressive symptoms suggest infection, tumor, spinal-cord disease, or another serious condition.

Reveal Case Review & NPLEX Trap

Diagnosis: Lumbar spondylolysis Underlying lesion: Stress injury of the pars interarticularis Risk activities: Repetitive lumbar extension and rotation Investigations: Radiography or advanced imaging when clinically indicated Treatment: Activity modification, trunk and hip rehabilitation, graded return to sport NPLEX trap: Do not perform forceful manipulation over a suspected pars stress fracture.

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38

Osteoporotic Vertebral Compression Fracture

4 questions · Physical Medicine

Clinical Case

A 76-year-old woman with known osteoporosis develops sudden mid-thoracic pain after lifting a light grocery bag. She has no major trauma. Examination reveals: • Focal thoracic vertebral tenderness • Increased thoracic kyphosis • Pain with standing and spinal movement • Normal lower-extremity strength • Normal sensation and reflexes • No fever • No bowel or bladder symptoms

Question 1 of 4NPLEX-PM-149

What is the most likely diagnosis?

AOsteoporotic vertebral compression fractureBUncomplicated trapezius strainCThoracic outlet syndromeDCarpal tunnel syndromeEAchilles tendinopathy

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Osteoporotic vertebral compression fracture

Explanation Osteoporotic vertebrae may fracture during apparently minor activities such as lifting, reaching, twisting, coughing, or sneezing. Compression fractures commonly cause sudden focal spinal pain and may contribute to height loss or kyphosis.

Question 2 of 4NPLEX-PM-150

What is the most appropriate initial investigation?

AThoracic spine imagingBPhalen testingCKnee MRIDAnkle ultrasoundENo investigation because trauma was minor

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Thoracic spine imaging

Explanation A new focal pain episode in a patient with osteoporosis warrants imaging to evaluate for vertebral fracture and determine whether the fracture appears stable or has concerning features. Further imaging may be required when malignancy, infection, neurologic compression, or fracture acuity is uncertain. The ACR provides specific imaging pathways for vertebral compression fractures.

Question 3 of 4NPLEX-PM-151

Which treatment is contraindicated before the fracture is appropriately assessed?

AHigh-velocity manipulation over the painful thoracic segmentBCareful neurologic examinationCFall-risk assessmentDOsteoporosis evaluationEEducation about safe movement

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. High-velocity manipulation over the painful thoracic segment

Explanation Forceful manipulation over a suspected osteoporotic fracture may worsen pain, displacement, or tissue injury. Treatment should focus on appropriate medical assessment, protection, pain management, and safe functional recovery.

Question 4 of 4NPLEX-PM-152

Which long-term intervention is most important after the acute fracture is stabilized?

ABone-health management, fall prevention, and appropriately prescribed strengtheningBPermanent bed restCRepeated loaded spinal flexionDHeavy unsupported liftingEPassive heat as the sole treatment

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Bone-health management, fall prevention, and appropriately prescribed strengthening

Explanation Long-term management should address: • Osteoporosis assessment and treatment • Nutrition and medication factors • Fall-risk reduction • Balance exercise • Lower-extremity strengthening • Postural endurance • Safe weight-bearing activity • Avoidance of excessive loaded spinal flexion or twisting in severe osteoporosis Exercise selection must consider fracture history and fall risk.

Reveal Case Review & NPLEX Trap

Diagnosis: Osteoporotic vertebral compression fracture Key findings: Sudden focal pain, vertebral tenderness, osteoporosis risk, kyphosis Investigation: Appropriate spinal imaging Treatment: Medical assessment, pain control, safe mobilization, osteoporosis treatment, rehabilitation Contraindication: Forceful manipulation over a suspected or confirmed fracture NPLEX trap: Minimal trauma does not exclude fracture in a patient with severely weakened bone.

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39

Cervical Myofascial Pain

4 questions · Physical Medicine

Clinical Case

A 38-year-old graphic designer reports gradual aching across the neck and upper shoulders after several weeks of prolonged computer work. The pain occasionally refers toward the temple. Examination reveals: • Forward-head posture • Rounded shoulders • Taut, tender bands in the upper trapezius • Familiar referred pain reproduced with pressure • Mildly reduced cervical rotation • Normal strength, sensation, and reflexes • No fever, trauma, or systemic symptoms

Question 1 of 4NPLEX-PM-153

What is the most likely diagnosis?

ACervical myofascial painBCervical myelopathyCVertebral fractureDCervical epidural abscessEThoracic outlet thrombosis

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Cervical myofascial pain

Explanation Myofascial pain commonly presents as regional muscle pain and stiffness associated with tender or hyperirritable points in taut muscle bands. Pressure may reproduce local or referred pain. The normal neurologic examination and absence of systemic red flags make spinal-cord, infectious, and fracture diagnoses less likely.

Question 2 of 4NPLEX-PM-154

What is the most appropriate treatment plan?

AErgonomic modification, movement breaks, mobility work, and progressive postural strengtheningBPermanent cervical immobilizationCPassive treatment without addressing prolonged computer postureDForceful manipulation despite unassessed red flagsEComplete avoidance of exercise

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Ergonomic modification, movement breaks, mobility work, and progressive postural strengthening

Explanation Management may include: • Workstation modification • Regular movement breaks • Cervical and thoracic mobility • Scapular endurance exercise • Deep-neck-flexor training • Sleep and stress assessment • Gradual aerobic exercise • Short-term soft-tissue treatment The goal is to restore function and reduce the mechanical and behavioural factors maintaining symptoms.

Question 3 of 4NPLEX-PM-155

How should massage or myofascial therapy be used?

AAs a possible adjunct to active rehabilitationBAs proof that no medical assessment is neededCAs the only permanent treatmentDDirectly over an acute fractureEOver an area of active infection

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. As a possible adjunct to active rehabilitation

Explanation Soft-tissue treatment may temporarily reduce pain or muscle guarding. It should generally support an active plan involving movement, strengthening, ergonomics, and self-management. Manual therapy is inappropriate over: • Acute fracture • Active infection • Unexplained mass • Acute thrombosis • Significant bleeding • Severe tissue injury • Areas where pressure may cause harm

Question 4 of 4NPLEX-PM-156

Which new finding would require investigation before continuing manual therapy?

AMild postural fatigueBLocal tenderness after computer workCProgressive arm weakness with hyperreflexia and gait disturbanceDSymptoms improving after exerciseEMildly restricted cervical rotation

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Progressive arm weakness with hyperreflexia and gait disturbance

Explanation Progressive weakness, hyperreflexia, hand clumsiness, gait dysfunction, or bowel or bladder symptoms suggest cervical myelopathy or another central neurologic disorder.

Reveal Case Review & NPLEX Trap

Diagnosis: Cervical myofascial pain Key findings: Taut tender bands, referred pain, postural and occupational aggravation Treatment: Ergonomics, mobility, strengthening, movement breaks, selected manual therapy Referral: Neurologic loss, systemic symptoms, trauma, severe night pain, vascular symptoms NPLEX trap: Trigger-point tenderness does not eliminate the need to screen for serious cervical pathology.

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40

Suspected Deep-Vein Thrombosis

4 questions · Physical Medicine

Clinical Case

A 64-year-old man presents requesting massage and heat for a painful swollen left calf. He returned from a 10-hour flight two days ago. Examination reveals: • Unilateral calf swelling • Warmth and tenderness • Left calf circumference 4 cm greater than the right • Mild pitting edema • No history of direct trauma • Heart rate 104/min • Oxygen saturation 97% • No chest pain at present

Question 1 of 4NPLEX-PM-157

What is the most concerning diagnosis?

ADeep-vein thrombosisBDelayed-onset muscle sorenessCPlantar fasciitisDAchilles tendinopathyELateral ankle sprain

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Deep-vein thrombosis

Explanation Unilateral swelling, warmth, tenderness, edema, recent prolonged immobility, and unexplained tachycardia raise concern for lower-extremity venous thrombosis. A physical examination cannot reliably confirm or exclude DVT. Formal clinical assessment and diagnostic testing are required.

Question 2 of 4NPLEX-PM-158

What is the most appropriate next action?

AArrange urgent medical evaluationBPerform deep calf massageCApply continuous high-temperature heatDBegin vigorous calf exerciseEApply therapeutic ultrasound over the painful vein

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Arrange urgent medical evaluation

Explanation Suspected DVT requires urgent medical assessment. Treatment may involve diagnostic ultrasound, laboratory testing, anticoagulation, and evaluation for pulmonary embolism. Physical treatment must not delay definitive evaluation.

Question 3 of 4NPLEX-PM-159

Which treatment is contraindicated before DVT has been excluded?

ADeep massage and vigorous mechanical treatment of the calfBChecking vital signsCAsking about chest painDArranging urgent referralEDocumenting the swelling

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Deep massage and vigorous mechanical treatment of the calf

Explanation Deep massage, vigorous exercise, heat, and certain therapeutic modalities should not be applied over a suspected acute thrombosis. The concern is worsening symptoms, delaying diagnosis, and potentially contributing to embolic complications. The NPLEX Physical Medicine blueprint specifically expects candidates to evaluate the safety and contraindications of manual therapy, hydrotherapy, electrical modalities, ultrasound, compression, and other physical treatments.

Question 4 of 4NPLEX-PM-160

Which new symptom would indicate possible pulmonary embolism and require emergency activation?

ASudden shortness of breath with pleuritic chest painBMild calf tendernessCChronic heel painDShoulder stiffnessEPain during wrist extension

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Sudden shortness of breath with pleuritic chest pain

Explanation Sudden dyspnea, pleuritic chest pain, hemoptysis, syncope, unexplained hypoxemia, or hemodynamic instability may indicate pulmonary embolism and require emergency care.

Reveal Case Review & NPLEX Trap

Suspected diagnosis: Deep-vein thrombosis Risk factor: Prolonged travel and immobility Key findings: Unilateral swelling, warmth, tenderness, edema Immediate action: Urgent medical evaluation Contraindicated treatment: Deep massage, vigorous exercise, heat, compression, or therapeutic modalities before clearance NPLEX trap: A painful calf is not automatically a muscular strain. Always assess thrombotic risk and asymmetrical swelling.

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41

Mechanical Cervical Facet and Postural Pain

4 questions · Physical Medicine

Clinical Case

A 40-year-old accountant reports gradual right-sided neck pain after several weeks of prolonged computer work. The pain remains localized to the lower cervical and upper trapezius region. Examination reveals: • Forward-head posture • Reduced right cervical rotation • Local pain with extension and right rotation • Mild cervical paraspinal tenderness • Normal upper-extremity strength and sensation • Symmetric reflexes • Negative signs of spinal-cord dysfunction • No trauma, fever, or constitutional symptoms

Question 1 of 4NPLEX-PM-161

What is the most likely diagnosis?

AMechanical cervical painBCervical myelopathyCCervical epidural abscessDAcute cervical fractureEThoracic outlet thrombosis

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Mechanical cervical pain

Explanation The localized neck pain, postural aggravation, restricted movement, paraspinal tenderness, and normal neurologic examination support uncomplicated mechanical cervical pain. • B: Myelopathy produces spinal-cord findings such as hyperreflexia, gait dysfunction, or hand clumsiness. • C: Infection may produce fever, severe unremitting pain, and systemic illness. • D: There is no traumatic mechanism or focal fracture finding. • E: Venous thoracic outlet disease produces arm swelling and vascular changes.

Question 2 of 4NPLEX-PM-162

Which finding would suggest cervical radiculopathy rather than localized mechanical pain?

ALocal paraspinal tendernessBPain after prolonged computer useCDermatomal arm paresthesia with myotomal weaknessDMild restriction of cervical rotationEImprovement after changing posture

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Dermatomal arm paresthesia with myotomal weakness

Explanation Radiculopathy involves a cervical nerve root and may produce: • Radiating arm pain • Dermatomal sensory loss • Myotomal weakness • Reduced corresponding reflex • Symptoms reproduced by cervical compression Localized muscular or joint pain generally does not produce neurologic deficits.

Question 3 of 4NPLEX-PM-163

What is the most appropriate initial rehabilitation plan?

AErgonomic modification, mobility work, and progressive cervical and scapular strengtheningBPermanent cervical immobilizationCImmediate high-velocity manipulation without screeningDComplete avoidance of neck movementEPassive treatment without exercise

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Ergonomic modification, mobility work, and progressive cervical and scapular strengthening

Explanation A reasonable program includes: • Workstation adjustment • Frequent movement breaks • Pain-limited cervical mobility • Thoracic mobility • Deep-neck-flexor exercise • Scapular retraction and endurance training • Gradual aerobic activity • Education about maintaining normal activity Manual therapy may be used as an adjunct after contraindications have been excluded.

Question 4 of 4NPLEX-PM-164

When may cervical traction be considered?

AWhen carefully selected symptoms improve with distraction and no contraindications are presentBIn suspected fracture or instabilityCIn severe cervical myelopathyDIn acute spinal infectionEIn known upper-cervical ligament rupture

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. When carefully selected symptoms improve with distraction and no contraindications are present

Explanation Cervical traction may be considered for selected patients with nerve-root irritation or compressive symptoms that improve with distraction. Traction should be avoided or used only after specialist assessment when there is: • Fracture • Instability • Severe osteoporosis • Spinal-cord compression • Malignancy • Infection • Acute inflammatory disease • Significant vascular pathology

Reveal Case Review & NPLEX Trap

Diagnosis: Mechanical cervical pain Key examination: Posture, active movement, neurologic screening, compression and distraction when indicated Treatment: Ergonomics, mobility, strengthening, education, selected manual therapy NPLEX trap: A normal neurologic examination supports mechanical pain but does not eliminate the need to screen for fracture, infection, malignancy, and vascular disease.

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42

Cervical Arterial Dysfunction Red Flag

4 questions · Physical Medicine

Clinical Case

A 61-year-old patient presents with sudden severe upper-neck and occipital pain that began after forcefully rotating the neck. The patient also reports dizziness, double vision, difficulty speaking, and unsteady walking. Examination reveals: • New gait ataxia • Slurred speech • Nystagmus • Nausea • No history of similar mechanical neck pain • Blood pressure of 176/102 mmHg

Question 1 of 4NPLEX-PM-165

What is the most concerning diagnosis?

ACervical arterial dissection or posterior-circulation ischemiaBUncomplicated trapezius strainCAdhesive capsulitisDCarpal tunnel syndromeELateral epicondylalgia

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Cervical arterial dissection or posterior-circulation ischemia

Explanation Sudden unusual neck or occipital pain accompanied by neurologic symptoms raises concern for cervical arterial pathology. Concerning posterior-circulation symptoms include: • Diplopia • Dysarthria • Dysphagia • Ataxia • Nystagmus • Vertigo • Nausea or vomiting • Facial or limb sensory changes • Sudden severe headache

Question 2 of 4NPLEX-PM-166

What is the most appropriate next action?

AActivate emergency medical evaluationBPerform high-velocity cervical manipulationCBegin resisted neck exerciseDApply cervical tractionESchedule routine follow-up in one month

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Activate emergency medical evaluation

Explanation Possible cervical arterial dissection or stroke is a medical emergency. Manual treatment must not delay emergency imaging and neurologic assessment.

Question 3 of 4NPLEX-PM-167

Which treatment is contraindicated?

ACervical manipulationBEmergency transferCNeurologic documentationDVital-sign monitoringECommunication with emergency services

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Cervical manipulation

Explanation Forceful cervical movement may worsen a vascular injury or delay definitive care. Manipulation, traction, massage, and exercise are inappropriate until serious vascular pathology has been excluded.

Question 4 of 4NPLEX-PM-168

Which statement about positional vertebral-artery testing is most accurate?

AA negative positional test cannot reliably exclude vascular pathologyBA negative test guarantees that manipulation is safeCThe test replaces a neurologic historyDDizziness during testing always confirms benign positional vertigoEBlood-pressure assessment is unnecessary

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. A negative positional test cannot reliably exclude vascular pathology

Explanation Clinical safety depends on the complete history and examination. A provocative positional test alone cannot reliably establish or exclude cervical arterial disease.

Reveal Case Review & NPLEX Trap

Suspected diagnosis: Cervical arterial dissection or posterior-circulation ischemia Red flags: Sudden unusual neck pain, diplopia, dysarthria, ataxia, nystagmus Immediate action: Emergency assessment Contraindicated treatments: Manipulation, traction, vigorous massage, exercise NPLEX trap: Do not dismiss dizziness and neck pain as a musculoskeletal problem when focal neurologic symptoms are present.

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43

Lateral Meniscal Tear and Apley Testing

4 questions · Physical Medicine

Clinical Case

A 37-year-old recreational skier twists the left knee while the foot remains fixed. The patient develops lateral joint-line pain, intermittent swelling, and catching. Examination reveals: • Lateral joint-line tenderness • Pain with deep knee flexion • Pain and clicking during McMurray testing • Pain during Apley compression • Less pain during Apley distraction • Stable Lachman and posterior drawer tests

Question 1 of 4NPLEX-PM-169

What is the most likely diagnosis?

ALateral meniscal tearBACL ruptureCPCL ruptureDPatellar tendon ruptureEHip osteoarthritis

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Lateral meniscal tear

Explanation The twisting mechanism, lateral joint-line pain, catching, swelling, and positive meniscal provocation tests support a lateral meniscal tear.

Question 2 of 4NPLEX-PM-170

What does pain during Apley compression suggest?

AMeniscal pathologyBCarpal tunnel syndromeCAchilles ruptureDRotator-cuff tearEThoracic outlet syndrome

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Meniscal pathology

Explanation During Apley compression, the tibia is compressed toward the femur while being rotated. This stresses the menisci. Reproduction of joint-line pain may support meniscal injury when combined with other clinical findings.

Question 3 of 4NPLEX-PM-171

What does greater pain during Apley distraction than compression suggest?

ACollateral ligament or capsular injuryBIsolated meniscal compressionCAchilles-tendon ruptureDCervical radiculopathyEPatellofemoral pain

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Collateral ligament or capsular injury

Explanation Apley distraction places greater tension on the collateral ligaments and capsule while reducing meniscal compression. Interpretation: • Compression more painful: Meniscal pathology is more likely. • Distraction more painful: Ligamentous or capsular pathology is more likely.

Question 4 of 4NPLEX-PM-172

Which finding requires prompt orthopedic assessment?

AMild joint-line discomfort after activityBSmall intermittent effusionCA mechanically locked knee that cannot extendDMild quadriceps weaknessEImprovement with rehabilitation

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. A mechanically locked knee that cannot extend

Explanation A displaced meniscal fragment may mechanically prevent extension. True locking requires prompt evaluation.

Reveal Case Review & NPLEX Trap

Diagnosis: Lateral meniscal tear Key tests: McMurray and Apley compression Differential diagnosis: LCL injury, osteochondral injury, ACL injury, proximal tibiofibular dysfunction Treatment: Swelling control, motion restoration, strengthening, balance and functional rehabilitation NPLEX trap: Apley compression and distraction have different purposes; do not interpret them as identical tests.

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44

Patellar Dislocation and Recurrent Instability

4 questions · Physical Medicine

Clinical Case

A 19-year-old dancer reports that the kneecap moved laterally during a twisting movement. It returned to position before arrival. The patient now has medial patellar tenderness and fears that the kneecap will dislocate again. Examination reveals: • Mild knee effusion • Tenderness along the medial patellofemoral region • Positive patellar apprehension test • Increased lateral patellar mobility • Intact extensor mechanism • Normal distal neurovascular examination

Question 1 of 4NPLEX-PM-173

What is the most likely diagnosis?

ALateral patellar dislocation with residual instabilityBACL tearCPCL tearDAchilles ruptureEMedial meniscal tear only

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Lateral patellar dislocation with residual instability

Explanation Lateral patellar displacement is the most common direction of patellar dislocation. After spontaneous reduction, patients may have: • Medial retinacular tenderness • Effusion • Apprehension during lateral patellar movement • Recurrent instability • Difficulty trusting the knee

Question 2 of 4NPLEX-PM-174

Which test is most appropriate?

APatellar apprehension testBPhalen testCThompson testDSpeed testEFinkelstein test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Patellar apprehension test

Explanation The examiner gently translates the patella laterally. A positive test produces fear, guarding, or apprehension that the patella will dislocate. The test should be performed cautiously after an acute injury.

Question 3 of 4NPLEX-PM-175

Which rehabilitation plan is most appropriate after serious associated injury has been excluded?

AProgressive quadriceps, hip, balance, and movement-control trainingBImmediate unrestricted jumping and twistingCPermanent knee immobilizationDRepeated forceful lateral patellar translationEPassive heat as the only treatment

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Progressive quadriceps, hip, balance, and movement-control training

Explanation Rehabilitation may include: • Swelling control • Restoration of knee motion • Quadriceps activation • Hip-abductor and external-rotator strengthening • Balance and neuromuscular exercise • Landing and lower-extremity alignment training • Temporary bracing or taping when appropriate • Gradual return to dance or sport

Question 4 of 4NPLEX-PM-176

Which finding warrants imaging and orthopedic assessment?

AMild apprehensionBSmall resolving effusionCLarge hemarthrosis with inability to bear weight after dislocationDMild quadriceps weaknessEImprovement with bracing

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Large hemarthrosis with inability to bear weight after dislocation

Explanation A large effusion or hemarthrosis may indicate: • Osteochondral fracture • Loose body • Major medial patellofemoral ligament injury • Associated ligament injury • Patellar or femoral fracture

Reveal Case Review & NPLEX Trap

Diagnosis: Lateral patellar dislocation and instability Key test: Patellar apprehension test Associated injuries: Osteochondral fracture, MPFL injury, loose body Treatment: Protection, early appropriate motion, quadriceps and hip rehabilitation NPLEX trap: Confirm that the extensor mechanism remains intact; inability to perform a straight-leg raise may suggest tendon rupture or fracture.

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45

Iliotibial-Band Pain Syndrome

4 questions · Physical Medicine

Clinical Case

A 31-year-old long-distance runner reports gradual lateral knee pain that begins after approximately 5 km. There was no twisting injury or swelling. Examination reveals: • Tenderness near the lateral femoral epicondyle • Pain during repeated knee flexion and extension • Tightness during Ober testing • Weak hip abductors • Negative McMurray and ligament tests • Normal neurologic examination

Question 1 of 4NPLEX-PM-177

What is the most likely diagnosis?

AIliotibial-band pain syndromeBLateral meniscal tearCLCL ruptureDLumbar radiculopathyESeptic arthritis

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Iliotibial-band pain syndrome

Explanation Iliotibial-band pain syndrome is an overuse disorder associated with repetitive knee flexion and extension. It commonly causes lateral knee pain in runners and cyclists. Supporting features include: • Predictable pain after a certain running distance • Lateral femoral epicondyle tenderness • No significant effusion or instability • Training-load or biomechanical contributors

Question 2 of 4NPLEX-PM-178

Which orthopedic test assesses iliotibial-band or tensor-fascia-lata tightness?

AOber testBPhalen testCLachman testDThompson testENeer test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Ober test

Explanation The Ober test assesses the ability of the hip and thigh to adduct while the patient lies on the side. Restricted descent may suggest tightness of the iliotibial-band and tensor-fascia-lata complex.

Question 3 of 4NPLEX-PM-179

What is the most appropriate rehabilitation strategy?

AReduce provocative running load and improve hip strength and running mechanicsBContinue the same mileage through severe painCPermanently immobilize the kneeDPerform repeated painful downhill runningEApply passive modalities without changing training load

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Reduce provocative running load and improve hip strength and running mechanics

Explanation Management may include: • Temporary reduction of running distance • Avoidance of excessive downhill running • Hip-abductor and external-rotator strengthening • Single-leg control training • Running-cadence or form modification when appropriate • Gradual return to previous mileage • Soft-tissue treatment as an adjunct

Question 4 of 4NPLEX-PM-180

Which finding would suggest a lateral meniscal tear instead?

APredictable pain after several kilometresBWeak hip abductorsCJoint-line pain with locking and a positive McMurray testDPain only during downhill runningENo effusion

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Joint-line pain with locking and a positive McMurray test

Explanation Mechanical locking, joint-line tenderness, swelling, and a positive meniscal test are more consistent with a meniscal injury.

Reveal Case Review & NPLEX Trap

Diagnosis: Iliotibial-band pain syndrome Differential diagnosis: Lateral meniscal tear, LCL injury, stress fracture, referred lumbar pain Key assessment: Training history, Ober test, hip strength, single-leg control Treatment: Load management, hip strengthening, running-mechanics rehabilitation NPLEX trap: Do not treat a training-load problem with passive modalities alone.

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46

Hip-Flexor Contracture

4 questions · Physical Medicine

Clinical Case

A 49-year-old office worker reports anterior hip tightness and low-back fatigue after prolonged sitting. There is no acute trauma. Examination reveals: • Increased anterior pelvic tilt • Limited hip extension during walking • Tightness across the anterior hip • Positive Thomas test • Normal hip-joint internal rotation • Normal strength, sensation, and reflexes

Question 1 of 4NPLEX-PM-181

What is the most likely impairment?

AHip-flexor contractureBAchilles ruptureCCarpal tunnel syndromeDACL injuryECervical radiculopathy

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Hip-flexor contracture

Explanation Prolonged sitting may contribute to adaptive shortening or increased resting tension of the hip-flexor muscles. Possible findings include: • Limited hip extension • Increased anterior pelvic tilt • Lumbar extension compensation • Anterior hip tightness • Positive Thomas testing

Question 2 of 4NPLEX-PM-182

Which test is most appropriate?

AThomas testBThompson testCPhalen testDMcMurray testEDrop-arm test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Thomas test

Explanation During the Thomas test, one hip is flexed toward the chest while the opposite leg remains relaxed. Elevation of the opposite thigh suggests limited hip extension or hip-flexor tightness. If the knee extends during the test, rectus-femoris tightness may also be contributing.

Question 3 of 4NPLEX-PM-183

What is the most appropriate rehabilitation plan?

AHip-flexor mobility, gluteal strengthening, posture correction, and movement breaksBComplete bed restCRepeated prolonged sittingDMaximal lumbar extension exercise onlyEForceful stretching through sharp groin pain

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Hip-flexor mobility, gluteal strengthening, posture correction, and movement breaks

Explanation Treatment may include: • Frequent breaks from sitting • Gentle hip-flexor stretching • Gluteal strengthening • Trunk stabilization • Gait and posture retraining • Gradual hip-extension exercise • Workstation modification Sharp joint pain or neurologic symptoms require reassessment before stretching is progressed.

Question 4 of 4NPLEX-PM-184

Which finding suggests intra-articular hip disease rather than isolated muscle tightness?

AAnterior pelvic tiltBPositive Thomas testCMarked groin pain with restricted passive internal rotationDTightness after prolonged sittingEImprovement after movement breaks

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Marked groin pain with restricted passive internal rotation

Explanation Painful restriction of passive hip internal rotation raises concern for osteoarthritis, femoroacetabular disease, or another intra-articular disorder.

Reveal Case Review & NPLEX Trap

Diagnosis: Hip-flexor contracture and postural dysfunction Key test: Thomas test Treatment: Mobility, gluteal and trunk strengthening, ergonomic correction NPLEX trap: Do not assume that all anterior hip pain represents muscle tightness; assess passive hip-joint movement.

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47

Piriformis-Region Sciatic Nerve Irritation

4 questions · Physical Medicine

Clinical Case

A 43-year-old cyclist reports deep buttock pain that occasionally radiates into the posterior thigh. Symptoms worsen after prolonged sitting and cycling. Examination reveals: • Tenderness over the deep gluteal region • Pain reproduced by combined hip flexion, adduction, and internal rotation • Pain with resisted hip external rotation • Negative straight-leg raise • Normal reflexes • Normal dermatomal sensation • Normal ankle and great-toe strength

Question 1 of 4NPLEX-PM-185

What is the most likely diagnosis?

APiriformis-region sciatic nerve irritationBL5 radiculopathyCCauda equina syndromeDHip septic arthritisEAchilles tendinopathy

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Piriformis-region sciatic nerve irritation

Explanation Deep gluteal pain worsened by sitting, localized tenderness, and reproduction during piriformis loading or stretching may suggest piriformis-region sciatic nerve irritation. This is a clinical diagnosis of exclusion. Lumbar nerve-root disease, hip pathology, and sacroiliac disorders must be considered.

Question 2 of 4NPLEX-PM-186

Which finding would more strongly support lumbar radiculopathy?

ALocal buttock tendernessBPain after prolonged sittingCDermatomal sensory loss with myotomal weakness and reflex changeDPain during resisted hip external rotationENegative straight-leg raise

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Dermatomal sensory loss with myotomal weakness and reflex change

Explanation Neurologic deficits in a nerve-root pattern support lumbar radiculopathy rather than a localized deep-gluteal disorder.

Question 3 of 4NPLEX-PM-187

What is the most appropriate initial treatment?

AActivity modification, hip mobility, progressive gluteal strengthening, and sitting-position changesBPermanent avoidance of walkingCForceful deep pressure despite acute severe neurologic symptomsDImmediate maximal cyclingELumbar surgery in every case

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Activity modification, hip mobility, progressive gluteal strengthening, and sitting-position changes

Explanation A rehabilitation program may include: • Reducing prolonged sitting • Adjusting bicycle fit • Gentle piriformis and hip mobility • Gluteal strengthening • Lumbopelvic control • Neural mobility when appropriate • Gradual return to cycling Aggressive compression over an irritable sciatic nerve may worsen symptoms.

Question 4 of 4NPLEX-PM-188

Which finding requires urgent evaluation?

APain after a long bicycle rideBLocalized buttock tendernessCNew urinary retention, saddle anesthesia, and bilateral leg weaknessDImprovement after changing saddle positionEMild discomfort during hip stretching

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. New urinary retention, saddle anesthesia, and bilateral leg weakness

Explanation These symptoms suggest cauda equina syndrome rather than piriformis-related pain.

Reveal Case Review & NPLEX Trap

Diagnosis: Piriformis-region or deep-gluteal sciatic nerve irritation Differential diagnosis: Lumbar radiculopathy, sacroiliac pain, hip disease, hamstring injury Treatment: Activity modification, hip and lumbopelvic rehabilitation, ergonomic correction NPLEX trap: “Piriformis syndrome” should not be diagnosed without a neurologic and lumbar examination.

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48

Knee Osteoarthritis and Aquatic Rehabilitation

4 questions · Physical Medicine

Clinical Case

A 70-year-old woman with obesity and bilateral knee osteoarthritis reports pain during prolonged walking and stair climbing. She has difficulty exercising on land because of pain. Examination reveals: • Bony enlargement of both knees • Mild crepitus • Reduced flexion • Quadriceps weakness • No fever • No acute redness • No major instability • Intact skin and normal temperature sensation

Question 1 of 4NPLEX-PM-189

Which exercise environment may allow conditioning with reduced joint loading?

AWarm-water aquatic exerciseBHigh-impact pavement runningCContinuous bed restDMaximal stair climbingERepeated jumping

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Warm-water aquatic exercise

Explanation Water buoyancy reduces weight-bearing load while allowing: • Walking practice • Range-of-motion exercise • Aerobic conditioning • Balance work • Lower-extremity strengthening Aquatic therapy may be particularly useful when land-based exercise is poorly tolerated.

Question 2 of 4NPLEX-PM-190

Which property of water reduces loading on the knees?

ABuoyancyBGravity enhancementCElectrical conductivity onlyDUltraviolet radiationETissue compression from heat alone

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Buoyancy

Explanation Buoyancy supports part of the patient’s body weight, reducing compressive load through painful joints. Water resistance can simultaneously provide graded strengthening.

Question 3 of 4NPLEX-PM-191

Which condition is a contraindication to group pool therapy until medically managed?

AStable chronic osteoarthritisBMild quadriceps weaknessCUncontrolled fecal incontinence or an open infected woundDDifficulty with stair climbingEPain that improves in warm water

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Uncontrolled fecal incontinence or an open infected wound

Explanation Pool therapy may be inappropriate with: • Open infected wounds • Uncontrolled bowel incontinence • Certain contagious skin conditions • Unstable cardiac or respiratory disease • Uncontrolled seizures • Severe inability to enter or leave the pool safely • Acute systemic illness

Question 4 of 4NPLEX-PM-192

What should follow aquatic conditioning as tolerance improves?

AProgressive land-based strengthening and functional exerciseBPermanent reliance on passive water treatmentCComplete avoidance of weight-bearingDKnee immobilizationEDiscontinuation of all exercise

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Progressive land-based strengthening and functional exercise

Explanation Aquatic therapy can help initiate movement, but long-term rehabilitation should prepare the patient for activities performed on land. Progression may include: • Sit-to-stand practice • Quadriceps and hip strengthening • Walking • Stair training • Balance exercise • Activity pacing • Weight-management support

Reveal Case Review & NPLEX Trap

Diagnosis: Symptomatic knee osteoarthritis Hydrotherapy option: Warm-water aquatic exercise Treatment foundation: Progressive exercise and functional rehabilitation Contraindications: Infection, unsafe cardiopulmonary status, uncontrolled incontinence, inability to participate safely NPLEX trap: Warm water may improve comfort, but passive soaking alone does not restore strength.

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49

Medial Tibial Stress Syndrome

4 questions · Physical Medicine

Clinical Case

A 24-year-old new military recruit reports gradual pain along the inner lower leg after rapidly increasing running and marching. The pain initially occurs only during training. Examination reveals: • Diffuse tenderness over approximately 8 cm of the posteromedial tibial border • No focal point tenderness • No swelling • Pain with repeated running • Tight calf muscles • Foot pronation during stance • Normal neurologic and vascular examination

Question 1 of 4NPLEX-PM-193

What is the most likely diagnosis?

AMedial tibial stress syndromeBTibial stress fractureCDeep-vein thrombosisDAcute compartment syndromeEAchilles rupture

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Medial tibial stress syndrome

Explanation Medial tibial stress syndrome commonly presents with diffuse exertional pain and tenderness along a broad area of the posteromedial tibial border. Contributing factors may include: • Rapid training increase • Hard running surfaces • Poor recovery • Calf weakness or tightness • Foot mechanics • Inadequate footwear

Question 2 of 4NPLEX-PM-194

Which finding is more concerning for a tibial stress fracture?

ADiffuse tenderness over 8 cmBPain only during the final portion of a runCFocal bony tenderness over a small area with pain during hoppingDSymptoms improving after reducing mileageETight calf muscles

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Focal bony tenderness over a small area with pain during hopping

Explanation Stress fracture is more likely when there is: • Focal point tenderness • Pain during walking or at rest • Pain during hopping • Progressive symptoms • Swelling • High-risk training or nutritional history

Question 3 of 4NPLEX-PM-195

What is the most appropriate initial treatment?

AReduce impact load and begin a graded return with calf, foot, and hip rehabilitationBContinue full running mileageCApply repeated impact to condition the tibiaDPerform maximal jumping drillsEPermanently avoid weight-bearing

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Reduce impact load and begin a graded return with calf, foot, and hip rehabilitation

Explanation Management may include: • Temporary reduction of running • Low-impact aerobic conditioning • Calf strengthening • Foot-intrinsic exercise • Hip strengthening • Training-surface and footwear review • Correction of rapid workload progression • Gradual return to impact activity

Question 4 of 4NPLEX-PM-196

Which symptom suggests acute compartment syndrome rather than a simple overuse injury?

ADiffuse tenderness after runningBMild calf tightnessCSevere escalating pain with a tense compartment and pain during passive toe movementDPain improving after restESymptoms developing gradually over weeks

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Severe escalating pain with a tense compartment and pain during passive toe movement

Explanation Acute compartment syndrome is a limb-threatening emergency. Important findings include: • Pain out of proportion • Pain with passive muscle stretch • Tense swelling • Progressive sensory changes • Weakness • Late pulse changes

Reveal Case Review & NPLEX Trap

Diagnosis: Medial tibial stress syndrome Differential diagnosis: Tibial stress fracture, chronic exertional compartment syndrome, DVT, nerve entrapment Treatment: Load management and progressive kinetic-chain rehabilitation NPLEX trap: Diffuse tibial tenderness suggests medial tibial stress syndrome; focal tenderness raises greater concern for stress fracture.

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50

Complex Regional Pain Syndrome

4 questions · Physical Medicine

Clinical Case

A 52-year-old woman presents eight weeks after a distal-radius fracture. The fracture is healing appropriately, but the patient reports severe burning hand pain that is disproportionate to the original injury. Examination reveals: • Marked sensitivity to light touch • Swelling of the hand • Shiny skin • Temperature and colour asymmetry • Reduced wrist and finger movement • Weakness caused by pain • No evidence of recurrent fracture or infection

Question 1 of 4NPLEX-PM-197

What is the most likely diagnosis?

AComplex regional pain syndromeBCarpal tunnel syndrome onlyCDe Quervain tenosynovitisDCervical radiculopathyEUlnar neuropathy

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Complex regional pain syndrome

Explanation Complex regional pain syndrome may develop after trauma, fracture, surgery, or immobilization. Characteristic features include: • Pain disproportionate to the original injury • Allodynia or hyperalgesia • Temperature or colour asymmetry • Sweating changes • Edema • Reduced movement • Motor dysfunction • Trophic skin, hair, or nail changes

Question 2 of 4NPLEX-PM-198

Which finding represents allodynia?

ASevere pain produced by light touch that is not normally painfulBWeakness after maximal exerciseCPain during fracture manipulationDNumbness limited to the median nerveETenderness only over a tendon

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Severe pain produced by light touch that is not normally painful

Explanation Allodynia occurs when a normally non-painful stimulus, such as light touch or clothing contact, produces pain. Hyperalgesia is an exaggerated response to a stimulus that is normally painful.

Question 3 of 4NPLEX-PM-199

What is the most appropriate rehabilitation approach?

AEarly interdisciplinary care with desensitization, graded movement, functional use, and pain educationBForceful manipulation through severe painCPermanent immobilizationDComplete avoidance of touching the limbERepeated maximal resistance exercise immediately

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Early interdisciplinary care with desensitization, graded movement, functional use, and pain education

Explanation Rehabilitation may include: • Gentle desensitization • Edema management • Active range of motion • Graded motor imagery • Mirror therapy • Progressive functional use • Pain education • Psychological support • Medication management through an appropriate clinician • Occupational or hand therapy The program should encourage function without repeatedly provoking severe symptom flares.

Question 4 of 4NPLEX-PM-200

Which treatment approach is most likely to worsen the condition?

ARepeated aggressive pain-provoking treatment that reinforces guarding and fearBGraded exposureCGentle functional movementDDesensitizationEInterdisciplinary pain management

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Repeated aggressive pain-provoking treatment that reinforces guarding and fear

Explanation Excessively painful treatment may increase: • Guarding • Fear of movement • Autonomic symptoms • Swelling • Functional avoidance • Central pain sensitization Treatment should be progressive, consistent, and function-oriented.

Reveal Case Review & NPLEX Trap

Diagnosis: Complex regional pain syndrome Key features: Disproportionate pain, allodynia, autonomic change, edema, reduced movement, trophic changes Differential diagnosis: Infection, recurrent fracture, nerve entrapment, vascular obstruction Treatment: Early interdisciplinary rehabilitation, desensitization, graded movement, pain management NPLEX trap: Severe pain does not justify prolonged immobilization; early carefully graded functional restoration is essential.

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51

Adolescent Spinal Asymmetry

6 questions · Physical Medicine · Orthopedic source case 1

Clinical Case

A 14-year-old girl presents after her parent notices uneven shoulders. She has no pain, neurological symptoms, trauma, or systemic illness. Examination reveals right shoulder elevation and mild waist asymmetry.

Question 1 of 6NPLEX-PM-201

Which test is most appropriate?

AAdam forward-bend testBCervical compression testCKemp testDMilgram test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Adam forward-bend test

Explanation The Adam forward-bend test screens for scoliosis and rotational spinal asymmetry.

Question 2 of 6NPLEX-PM-202

Which finding constitutes a positive test?

ADisappearance of the curveBPersistent rib prominenceCReproduction of leg painDReduction of the radial pulse

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Persistent rib prominence

Explanation A persistent rib hump or lumbar prominence during forward flexion suggests vertebral rotation associated with structural scoliosis.

Question 3 of 6NPLEX-PM-203

The asymmetry disappears during forward flexion. What is the best interpretation?

AStructural scoliosisBFunctional scoliosisCLumbar radiculopathyDThoracic outlet syndrome

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Functional scoliosis

Explanation A flexible curve that corrects with positioning is more consistent with functional or postural scoliosis.

Question 4 of 6NPLEX-PM-204

Which imaging study is most appropriate when clinically significant scoliosis is suspected?

ASupine lumbar CTBStanding spinal radiographsCPelvic ultrasonographyDElectromyography

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Standing spinal radiographs

Explanation Standing posteroanterior and lateral radiographs allow assessment of the full curve under weight-bearing conditions.

Question 5 of 6NPLEX-PM-205

Which measurement quantifies the spinal curvature?

ACobb angleBQ angleCCarrying angleDBöhler angle

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Cobb angle

Explanation The Cobb angle is measured on spinal radiographs to quantify scoliosis.

Question 6 of 6NPLEX-PM-206

Which finding warrants expedited specialist assessment?

AStable mild asymmetryBFlexible postural curveCRapid progression with weaknessDPainless hamstring tightness

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Rapid progression with weakness

Explanation Rapid curve progression, neurological deficits, severe pain, systemic symptoms, or an atypical curve may indicate serious underlying pathology.

Reveal Case Review & NPLEX Trap

Orthopedic Test Source Case: 1 Test or topic: ADOLESCENT SPINAL ASYMMETRY NPLEX Examination Trap The Adam test screens for rotational asymmetry but does not measure the Cobb angle.

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52

Bechterew Test

6 questions · Physical Medicine · Orthopedic source case 11

Clinical Case

A 43-year-old warehouse worker reports low-back pain radiating into the left posterior thigh and calf. Symptoms worsen with sitting, coughing, and forward bending.

Question 1 of 6NPLEX-PM-207

Which seated test is most appropriate?

ABechterew testBHoover testCMilgram testDSoto-Hall test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Bechterew test

Explanation The Bechterew test is a seated neural-tension test for lumbosacral nerve-root or sciatic-nerve irritation.

Question 2 of 6NPLEX-PM-208

How is the test performed?

AExtend each knee while seatedBRaise both legs while supineCRotate the neck during inspirationDCompress the cervical spine

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Extend each knee while seated

Explanation Seated knee extension increases tension on the sciatic nerve and lumbosacral nerve roots.

Question 3 of 6NPLEX-PM-209

What constitutes a positive result?

ALocal knee pressureBFamiliar radiating leg painCPainless hamstring tightnessDMild quadriceps effort

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Familiar radiating leg pain

Explanation Reproduction of the patient’s familiar radicular pain is the clinically meaningful finding.

Question 4 of 6NPLEX-PM-210

The patient leans backward while extending the knee. Why?

ATo increase lumbar compressionBTo reduce neural tensionCTo stabilize the sacroiliac jointDTo contract the hamstrings

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. To reduce neural tension

Explanation Leaning backward may reduce neural tension and allow further knee extension.

Question 5 of 6NPLEX-PM-211

Which test could corroborate the finding?

AAdson testBRoos testCStraight-leg raise testDVertebral artery test

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Straight-leg raise test

Explanation Supine straight-leg raising assesses similar lumbosacral neural structures.

Question 6 of 6NPLEX-PM-212

Which finding requires emergency referral?

APain during sittingBReduced flexibilityCNew urinary retentionDPositive Bechterew test

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. New urinary retention

Explanation Urinary retention, saddle anesthesia, or progressive bilateral weakness suggests cauda equina syndrome.

Reveal Case Review & NPLEX Trap

Orthopedic Test Source Case: 11 Test or topic: BECHTEREW TEST NPLEX Examination Trap Painless hamstring tightness is not a positive neural-tension test.

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53

Lindner Test

6 questions · Physical Medicine · Orthopedic source case 12

Clinical Case

A 41-year-old patient reports neck and spinal pain with intermittent extremity paresthesia. Symptoms worsen when the neck is flexed.

Question 1 of 6NPLEX-PM-213

Which test combines cervical flexion with straight-leg elevation?

ABraggard testBLindner testCMilgram testDWright test

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Lindner test

Explanation The Lindner test increases tension through the spinal dura and associated nerve roots.

Question 2 of 6NPLEX-PM-214

Which finding constitutes a positive result?

AFamiliar spinal or radicular painBLocal calf tightnessCReduced radial pulseDShoulder apprehension

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Familiar spinal or radicular pain

Explanation Reproduction of familiar radiating symptoms suggests neural or dural irritation.

Question 3 of 6NPLEX-PM-215

Which tissues are principally stressed?

ASpinal dura and nerve rootsBRotator cuff and labrumCSacroiliac ligamentsDAchilles tendon and fascia

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Spinal dura and nerve roots

Explanation Cervical flexion and leg elevation increase tension throughout the spinal neural system.

Question 4 of 6NPLEX-PM-216

Which condition contraindicates the maneuver?

AMild chronic stiffnessBSuspected spinal fractureCStable muscular tendernessDPainless limited flexibility

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Suspected spinal fracture

Explanation Provocative testing is unsafe when fracture or spinal instability is suspected.

Question 5 of 6NPLEX-PM-217

A positive Lindner test identifies the exact lesion and spinal level.

ATrueBFalse

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. False

Explanation It may demonstrate neural tension but cannot independently localize or identify the lesion.

Question 6 of 6NPLEX-PM-218

Progressive weakness with bilateral hyperreflexia requires:

ARoutine massageBHome stretchingCPrompt imaging and referralDRepeated tension testing

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Prompt imaging and referral

Explanation These findings raise concern for spinal-cord compression.

Reveal Case Review & NPLEX Trap

Orthopedic Test Source Case: 12 Test or topic: LINDNER TEST NPLEX Examination Trap Neural-tension tests support clinical reasoning but do not establish the precise diagnosis.

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54

Milgram Test

6 questions · Physical Medicine · Orthopedic source case 13

Clinical Case

A 50-year-old patient reports persistent lumbar pain with intermittent leg radiation. While supine, the patient is asked to elevate both straight legs approximately 15 cm and hold them.

Question 1 of 6NPLEX-PM-219

Which test is being performed?

AHoover testBKemp testCMilgram testDMinor test

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Milgram test

Explanation The Milgram test involves holding both straight legs above the table.

Question 2 of 6NPLEX-PM-220

What constitutes a positive result?

AFamiliar lumbar or radicular painBMild abdominal fatigueCPainless hamstring tensionDTemporary hip-flexor effort

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Familiar lumbar or radicular pain

Explanation Reproduction of significant lumbar or radicular pain is the relevant positive result.

Question 3 of 6NPLEX-PM-221

What does the maneuver principally stress?

ALumbosacral region and intrathecal contentsBThoracic outletCRotator cuffDCarpal tunnel

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Lumbosacral region and intrathecal contents

Explanation Bilateral leg elevation loads the lumbar spine and increases abdominal and intrathecal pressure.

Question 4 of 6NPLEX-PM-222

Which patient should not undergo this test?

AStable mechanical painBSuspected acute lumbar fractureCMild chronic stiffnessDReduced abdominal conditioning

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Suspected acute lumbar fracture

Explanation Provocative loading is inappropriate when fracture or instability is possible.

Question 5 of 6NPLEX-PM-223

Which finding is least specific?

AFamiliar radicular painBSevere lumbar painCIsolated abdominal fatigueDReproduction of leg symptoms

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Isolated abdominal fatigue

Explanation Muscular fatigue can result from deconditioning and does not constitute a positive test.

Question 6 of 6NPLEX-PM-224

Which additional feature warrants urgent investigation?

AMild fatigueBFever with night painCPain after sittingDReduced flexibility

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Fever with night pain

Explanation Fever and persistent night pain raise concern for infection, malignancy, or another serious disorder.

Reveal Case Review & NPLEX Trap

Orthopedic Test Source Case: 13 Test or topic: MILGRAM TEST NPLEX Examination Trap Inability to hold the legs because of weakness or deconditioning is not necessarily a positive Milgram test.

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55

Minor Sign

6 questions · Physical Medicine · Orthopedic source case 14

Clinical Case

A 57-year-old patient with acute low-back pain rises from a chair by pushing on both thighs. The trunk remains rigid, and lumbar flexion is avoided.

Question 1 of 6NPLEX-PM-225

Which sign is being observed?

AMinor signBRoos signCSoto-Hall signDWright sign

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Minor sign

Explanation Minor sign describes guarded movement used to avoid painful spinal motion.

Question 2 of 6NPLEX-PM-226

What does the sign indicate?

APainful or guarded spinal movementBThoracic vascular compressionCRotator-cuff ruptureDMedian-nerve compression

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Painful or guarded spinal movement

Explanation It demonstrates functional adaptation to pain but not a specific lesion.

Question 3 of 6NPLEX-PM-227

Which interpretation is most accurate?

AIt confirms disc herniationBIt proves malingeringCIt is a nonspecific observationDIt excludes neurological disease

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. It is a nonspecific observation

Explanation Many painful spinal conditions can produce guarded movement.

Question 4 of 6NPLEX-PM-228

Which finding supports nerve-root involvement?

ADermatomal sensory lossBParaspinal tendernessCPain while standingDReduced lumbar flexion

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Dermatomal sensory loss

Explanation Anatomically consistent sensory loss, weakness, and reflex changes support radiculopathy.

Question 5 of 6NPLEX-PM-229

Which feature requires urgent investigation?

APain after liftingBDifficulty risingCPrevious cancer with night painDImprovement with walking

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Previous cancer with night pain

Explanation Malignancy history and new persistent night pain raise concern for metastatic disease.

Question 6 of 6NPLEX-PM-230

Which documentation is most appropriate?

A“Patient is malingering.”B“Patient used both arms to rise while keeping the trunk rigid.”C“Patient has a disc herniation.”D“Patient requires surgery.”

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. “Patient used both arms to rise while keeping the trunk rigid.”

Explanation Document the observed movement objectively without assigning an unsupported diagnosis or motive.

Reveal Case Review & NPLEX Trap

Orthopedic Test Source Case: 14 Test or topic: MINOR SIGN NPLEX Examination Trap Minor sign is not a malingering test.

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56

Shoulder Depression and Soto-Hall Tests

6 questions · Physical Medicine · Orthopedic source case 15

Clinical Case

A 45-year-old patient reports neck pain radiating into the lateral forearm after a traction injury.

Question 1 of 6NPLEX-PM-231

Depression of the symptomatic shoulder while laterally flexing the head away describes:

ACervical distraction testBShoulder depression testCSoto-Hall testDVertebral artery test

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Shoulder depression test

Explanation This maneuver increases tension on the cervical nerve roots and brachial plexus.

Question 2 of 6NPLEX-PM-232

What constitutes a positive result?

AFamiliar radiating arm painBMild trapezius stretchingCPainless shoulder depressionDPulse reduction without symptoms

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Familiar radiating arm pain

Explanation Reproduction of familiar neurological symptoms is more meaningful than muscular stretching.

Question 3 of 6NPLEX-PM-233

Which structures are principally stressed?

ACervical roots and brachial plexusBLumbar facets and sciatic nerveCRotator cuff and biceps tendonDSacroiliac ligaments

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Cervical roots and brachial plexus

Explanation Shoulder depression with contralateral neck flexion increases cervical neural tension.

Question 4 of 6NPLEX-PM-234

Flexing the neck of a supine patient while stabilizing the sternum describes:

AAdson testBLindner testCSoto-Hall testDWright test

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Soto-Hall test

Explanation Soto-Hall testing provokes pain from cervical spinal lesions.

Question 5 of 6NPLEX-PM-235

Which result after trauma is most concerning?

AMild stretchingBSevere focal cervical painCPainless flexionDThoracic tightness

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Severe focal cervical pain

Explanation Severe focal pain after trauma raises concern for fracture or ligamentous injury.

Question 6 of 6NPLEX-PM-236

What should be done when fracture is suspected?

AContinue testingBManipulate the neckCImmobilize and arrange urgent imagingDBegin resistance exercises

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Immobilize and arrange urgent imaging

Explanation Suspected fracture or instability requires protection and urgent evaluation.

Reveal Case Review & NPLEX Trap

Orthopedic Test Source Case: 15 Test or topic: SHOULDER DEPRESSION AND SOTO-HALL TESTS NPLEX Examination Trap Do not perform provocative cervical tests before excluding serious traumatic injury.

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57

Subacromial Shoulder Pain

6 questions · Physical Medicine · Orthopedic source case 16

Clinical Case

A 46-year-old painter reports progressive anterolateral shoulder pain during overhead activity. Passive motion is nearly full.

Question 1 of 6NPLEX-PM-237

Which test passively elevates the internally rotated arm while stabilizing the scapula?

ADrop-arm testBNeer testCSpeed testDYergason test

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Neer test

Explanation The Neer test compresses structures within the subacromial region.

Question 2 of 6NPLEX-PM-238

Which other test evaluates the same general syndrome?

AHawkins–Kennedy testBLippman testCPhalen testDRoos test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Hawkins–Kennedy test

Explanation Hawkins–Kennedy testing provokes subacromial structures through forced internal rotation.

Question 3 of 6NPLEX-PM-239

What constitutes a positive result?

AFamiliar anterolateral shoulder painBPainless crepitusCLittle-finger paresthesiaDPosterior elbow discomfort

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Familiar anterolateral shoulder pain

Explanation Reproduction of the typical shoulder pain supports a subacromial pain presentation.

Question 4 of 6NPLEX-PM-240

Marked restriction of active and passive external rotation suggests:

AAdhesive capsulitisBBiceps instabilityCCervical radiculopathyDThoracic outlet syndrome

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Adhesive capsulitis

Explanation Adhesive capsulitis restricts both active and passive glenohumeral motion.

Question 5 of 6NPLEX-PM-241

Inability to lower the abducted arm smoothly suggests:

ASignificant rotator-cuff dysfunctionBCarpal tunnel syndromeCElbow instabilityDCervical arterial disease

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Significant rotator-cuff dysfunction

Explanation An abnormal drop-arm test suggests substantial rotator-cuff weakness or tearing.

Question 6 of 6NPLEX-PM-242

What is appropriate when no trauma, major weakness, or red flags are present?

AActivity modification and rehabilitationBComplete immobilizationCImmediate surgeryDRepeated painful loading

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Activity modification and rehabilitation

Explanation Initial care generally includes activity modification and progressive mobility and strengthening.

Reveal Case Review & NPLEX Trap

Orthopedic Test Source Case: 16 Test or topic: SUBACROMIAL SHOULDER PAIN NPLEX Examination Trap Neer and Hawkins–Kennedy tests do not independently identify the exact injured tendon.

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58

Rotator-Cuff Tear

6 questions · Physical Medicine · Orthopedic source case 17

Clinical Case

A 64-year-old patient falls onto the shoulder. The patient can initiate abduction but cannot maintain or smoothly lower the arm. Passive motion is preserved.

Question 1 of 6NPLEX-PM-243

Which test is most appropriate?

AApley scratch testBDrop-arm testCSpeed testDYergason test

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Drop-arm test

Explanation The drop-arm test assesses the ability to maintain and control shoulder abduction.

Question 2 of 6NPLEX-PM-244

What constitutes a positive result?

AThe arm drops suddenlyBThe hand reaches the scapulaCElbow-flexion pain occursDThe radial pulse decreases

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. The arm drops suddenly

Explanation Sudden dropping or uncontrolled lowering suggests major rotator-cuff dysfunction.

Question 3 of 6NPLEX-PM-245

Which tendon is most commonly implicated?

ASupraspinatusBTricepsCPectoralis majorDCoracobrachialis

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Supraspinatus

Explanation The supraspinatus is important in shoulder abduction and is commonly involved in cuff tears.

Question 4 of 6NPLEX-PM-246

Preserved passive motion with markedly impaired active motion favors:

ARotator-cuff dysfunctionBAdhesive capsulitisCFixed joint contractureDThoracic outlet syndrome

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Rotator-cuff dysfunction

Explanation This discrepancy suggests weakness, pain inhibition, or tendon failure rather than fixed capsular restriction.

Question 5 of 6NPLEX-PM-247

Which study can assess tendon integrity?

AMusculoskeletal ultrasonographyBAbdominal radiographyCBone-density testingDCardiac ultrasonography

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Musculoskeletal ultrasonography

Explanation Musculoskeletal ultrasonography or MRI may evaluate rotator-cuff integrity.

Question 6 of 6NPLEX-PM-248

What is appropriate after an acute traumatic tear with major weakness?

AReview in one yearBPrompt imaging and referralCForceful resisted abductionDUnsupervised immobilization

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Prompt imaging and referral

Explanation Acute traumatic weakness warrants timely imaging and orthopedic assessment.

Reveal Case Review & NPLEX Trap

Orthopedic Test Source Case: 17 Test or topic: ROTATOR-CUFF TEAR NPLEX Examination Trap Pain inhibition may resemble weakness; compare active and passive movement carefully.

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59

Anterior Glenohumeral Instability

6 questions · Physical Medicine · Orthopedic source case 18

Clinical Case

A 23-year-old volleyball player previously sustained an anterior shoulder dislocation. The shoulder now feels as though it will dislocate during abduction and external rotation.

Question 1 of 6NPLEX-PM-249

Which test is most appropriate?

AAnterior apprehension testBApley scratch testCHawkins–Kennedy testDSpeed test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Anterior apprehension test

Explanation This test places the shoulder in a position that stresses anterior glenohumeral stability.

Question 2 of 6NPLEX-PM-250

What constitutes a positive result?

AApprehension of imminent dislocationBMild muscular stretchingCElbow discomfortDReduced wrist motion

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Apprehension of imminent dislocation

Explanation True apprehension is more characteristic of instability than pain alone.

Question 3 of 6NPLEX-PM-251

Which structure is commonly injured during anterior dislocation?

AAnterior-inferior labrumBPosterior cruciate ligamentCAchilles tendonDTriangular fibrocartilage

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Anterior-inferior labrum

Explanation A Bankart lesion involves the anterior-inferior glenoid labrum.

Question 4 of 6NPLEX-PM-252

Which nerve is particularly vulnerable?

AAxillary nerveBFemoral nerveCTibial nerveDObturator nerve

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Axillary nerve

Explanation Assess deltoid strength and sensation over the lateral shoulder.

Question 5 of 6NPLEX-PM-253

What must be documented before and after reduction?

ADistal neurovascular findingsBLumbar range of motionCKnee ligament stabilityDAdam test result

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Distal neurovascular findings

Explanation Pulses, perfusion, sensation, and motor function must be assessed.

Question 6 of 6NPLEX-PM-254

A newly deformed shoulder after trauma requires:

ARepeated apprehension testingBPrompt assessment and imagingCForceful home reductionDResistance exercise

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Prompt assessment and imaging

Explanation Suspected acute dislocation or fracture requires urgent evaluation.

Reveal Case Review & NPLEX Trap

Orthopedic Test Source Case: 18 Test or topic: ANTERIOR GLENOHUMERAL INSTABILITY NPLEX Examination Trap Apprehension—not pain alone—is the defining positive finding.

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60

Long-Head Biceps Pathology

6 questions · Physical Medicine · Orthopedic source case 19

Clinical Case

A 38-year-old weightlifter reports anterior shoulder pain during overhead activity and resisted elbow flexion. The bicipital groove is tender.

Question 1 of 6NPLEX-PM-255

Which test loads the biceps during resisted shoulder flexion?

ADrop-arm testBNeer testCSpeed testDWright test

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Speed test

Explanation Speed testing loads the long-head biceps tendon with resisted shoulder flexion.

Question 2 of 6NPLEX-PM-256

What constitutes a positive Speed test?

ABicipital-groove painBLittle-finger paresthesiaCPosterior apprehensionDSudden arm dropping

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Bicipital-groove pain

Explanation Familiar anterior pain localized over the bicipital groove supports biceps-related pathology.

Question 3 of 6NPLEX-PM-257

Which additional disorder may produce a positive result?

ASuperior labral pathologyBAchilles ruptureCCarpal tunnel syndromeDLumbar radiculopathy

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Superior labral pathology

Explanation The long-head biceps attaches to the superior labrum.

Question 4 of 6NPLEX-PM-258

Which test loads the biceps during resisted supination?

AHawkins–Kennedy testBYergason testCApley scratch testDDrop-arm test

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Yergason test

Explanation Yergason testing uses resisted supination and external rotation.

Question 5 of 6NPLEX-PM-259

A palpable snap from the bicipital groove suggests:

ABiceps tendon instabilityBPosterior dislocationCAcromioclavicular separationDCervical radiculopathy

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Biceps tendon instability

Explanation Snapping may indicate subluxation of the long-head biceps tendon.

Question 6 of 6NPLEX-PM-260

Which finding warrants prompt assessment?

AMild postexercise painBSudden bruising and “Popeye” deformityCTenderness improving with restDFull painless strength

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Sudden bruising and “Popeye” deformity

Explanation Sudden bruising, weakness, and deformity suggest biceps tendon rupture.

Reveal Case Review & NPLEX Trap

Orthopedic Test Source Case: 19 Test or topic: LONG-HEAD BICEPS PATHOLOGY NPLEX Examination Trap Speed and Yergason findings must be correlated with tenderness, strength, and mechanism.

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61

Apley Scratch Test

6 questions · Physical Medicine · Orthopedic source case 20

Clinical Case

A 59-year-old patient reports difficulty dressing and reaching behind the back. There is no history of trauma.

Question 1 of 6NPLEX-PM-261

Which test screens combined shoulder mobility?

AApley scratch testBDrop-arm testCLippman testDSpeed test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Apley scratch test

Explanation The Apley scratch test provides a functional screen of combined shoulder movement.

Question 2 of 6NPLEX-PM-262

Reaching over the head toward the opposite scapula assesses:

AAbduction and external rotationBAdduction and internal rotationCExtension and pronationDFlexion and supination

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Abduction and external rotation

Explanation The superior component requires abduction and external rotation.

Question 3 of 6NPLEX-PM-263

Reaching behind the back toward the opposite scapula assesses:

AAbduction and external rotationBAdduction and internal rotationCElbow extension onlyDForearm supination only

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Adduction and internal rotation

Explanation The inferior component requires extension, adduction, and internal rotation.

Question 4 of 6NPLEX-PM-264

Markedly restricted active and passive external rotation suggests:

AAdhesive capsulitisBBiceps instabilityCThoracic outlet syndromeDCervical radiculopathy

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Adhesive capsulitis

Explanation Adhesive capsulitis causes restriction of both active and passive motion.

Question 5 of 6NPLEX-PM-265

Reduced active motion with relatively preserved passive motion suggests:

ARotator-cuff dysfunctionBFixed capsular contractureCStructural scoliosisDSacroiliac dysfunction

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Rotator-cuff dysfunction

Explanation This pattern suggests weakness, tendon dysfunction, or pain inhibition.

Question 6 of 6NPLEX-PM-266

Which statement is most accurate?

AThe test identifies the exact torn tendonBThe test screens functional shoulder mobilityCThe test confirms cervical radiculopathyDThe test replaces the shoulder examination

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. The test screens functional shoulder mobility

Explanation It identifies functional restriction but does not establish a specific tissue diagnosis.

Reveal Case Review & NPLEX Trap

Orthopedic Test Source Case: 20 Test or topic: APLEY SCRATCH TEST NPLEX Examination Trap The Apley scratch test is a mobility screen, not a definitive diagnostic test.

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62

Posterior Shoulder Instability

6 questions · Physical Medicine · Orthopedic source case 21

Clinical Case

A 25-year-old football player reports posterior shoulder pain and a sensation of instability after falling onto an adducted, internally rotated arm.

Question 1 of 6NPLEX-PM-267

Which test is most appropriate?

AAnterior apprehension testBPosterior apprehension testCSpeed testDYergason test

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Posterior apprehension test

Explanation The posterior apprehension test assesses posterior glenohumeral instability.

Question 2 of 6NPLEX-PM-268

Which position principally stresses posterior stability?

AAbduction and external rotationBFlexion, adduction, and internal rotationCExtension and supinationDAbduction and elbow flexion

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Flexion, adduction, and internal rotation

Explanation Posteriorly directed force through a flexed, adducted, internally rotated arm stresses the posterior capsule.

Question 3 of 6NPLEX-PM-269

What constitutes a positive result?

AApprehension of posterior displacementBMild deltoid stretchingCAnterior elbow painDReduced radial pulse

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Apprehension of posterior displacement

Explanation Apprehension or a sense of impending posterior displacement is more significant than pain alone.

Question 4 of 6NPLEX-PM-270

Which mechanism is associated with posterior dislocation?

AForced abduction and external rotationBSeizure or electrical injuryCRepetitive wrist extensionDDirect patellar trauma

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Seizure or electrical injury

Explanation Powerful internal rotator contraction during a seizure or electrical injury can cause posterior shoulder dislocation.

Question 5 of 6NPLEX-PM-271

Which radiographic view may help identify posterior dislocation?

AAxillary viewBSunrise viewCTunnel viewDMortise view

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Axillary view

Explanation An axillary or scapular-Y view helps demonstrate glenohumeral alignment.

Question 6 of 6NPLEX-PM-272

What is appropriate when acute dislocation is suspected?

ARepeated apprehension testingBPrompt imaging and urgent managementCResistance exerciseDForceful home reduction

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Prompt imaging and urgent management

Explanation Suspected dislocation requires neurovascular assessment, imaging, and appropriate reduction by a qualified clinician.

Reveal Case Review & NPLEX Trap

Orthopedic Test Source Case: 21 Test or topic: POSTERIOR SHOULDER INSTABILITY NPLEX Examination Trap Posterior dislocation may be missed on a routine anteroposterior radiograph.

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63

Biceps Tendon Instability

6 questions · Physical Medicine · Orthopedic source case 22

Clinical Case

A 40-year-old patient reports anterior shoulder pain and clicking during forearm rotation. Examination reveals tenderness over the bicipital groove.

Question 1 of 6NPLEX-PM-273

Which test is most appropriate?

ALippman testBNeer testCPhalen testDRoos test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Lippman test

Explanation The Lippman test assesses tenderness or instability involving the long-head biceps tendon.

Question 2 of 6NPLEX-PM-274

Where is the long-head biceps tendon palpated?

ABicipital grooveBCubital tunnelCCarpal tunnelDSubacromial bursa only

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Bicipital groove

Explanation The tendon travels within the intertubercular, or bicipital, groove.

Question 3 of 6NPLEX-PM-275

Which finding constitutes a positive test?

ATenderness or abnormal tendon movementBPosterior shoulder apprehensionCLittle-finger paresthesiaDLoss of wrist extension

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Tenderness or abnormal tendon movement

Explanation Pain, tenderness, or abnormal displacement of the tendon supports biceps tendon pathology.

Question 4 of 6NPLEX-PM-276

Which test also evaluates the long-head biceps during resisted supination?

ADrop-arm testBHawkins–Kennedy testCYergason testDApley scratch test

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Yergason test

Explanation Yergason testing uses resisted supination and external rotation to load the biceps tendon.

Question 5 of 6NPLEX-PM-277

Which associated structure may be involved?

ASuperior glenoid labrumBMedial meniscusCAchilles tendonDUlnar collateral ligament

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Superior glenoid labrum

Explanation The long-head biceps originates from the superior labrum and supraglenoid region.

Question 6 of 6NPLEX-PM-278

Sudden bruising with a “Popeye” deformity suggests:

ABiceps tendon ruptureBAdhesive capsulitisCThoracic outlet syndromeDCervical radiculopathy

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Biceps tendon rupture

Explanation Distal bunching of the muscle with bruising and weakness suggests proximal long-head biceps rupture.

Reveal Case Review & NPLEX Trap

Orthopedic Test Source Case: 22 Test or topic: BICEPS TENDON INSTABILITY NPLEX Examination Trap Anterior shoulder pain is not automatically biceps tendinopathy; correlate the test with localized tenderness and function.

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64

Acute Painful Shoulder after A Fall

6 questions · Physical Medicine · Orthopedic source case 23

Clinical Case

A 71-year-old patient falls onto the lateral shoulder. Examination shows swelling, focal bony tenderness, and an inability to actively abduct the arm.

Question 1 of 6NPLEX-PM-279

What should be done before provocative shoulder testing?

AExclude fracture or dislocationBPerform resisted abductionCPerform repeated Neer testingDApply forceful manipulation

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Exclude fracture or dislocation

Explanation Acute trauma, bony tenderness, deformity, or marked functional loss requires assessment for fracture or dislocation.

Question 2 of 6NPLEX-PM-280

Which study is initially appropriate?

APlain shoulder radiographsBBone-density scanCElectromyographyDAbdominal ultrasonography

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Plain shoulder radiographs

Explanation Radiographs are the usual initial study for suspected acute fracture or dislocation.

Question 3 of 6NPLEX-PM-281

Which injury is common after a fall in an older adult?

AProximal humeral fractureBScaphoid dislocation onlyCAchilles ruptureDMeniscal tear

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Proximal humeral fracture

Explanation Older adults are at increased risk of proximal humeral fracture following a fall.

Question 4 of 6NPLEX-PM-282

Which test should be deferred until fracture is excluded?

ADrop-arm testBDistal pulse assessmentCSensory examinationDInspection

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Drop-arm test

Explanation Provocative or resisted testing can worsen pain or displacement when fracture is possible.

Question 5 of 6NPLEX-PM-283

Which nerve should be assessed around the lateral shoulder?

AAxillary nerveBTibial nerveCFemoral nerveDObturator nerve

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Axillary nerve

Explanation Assess deltoid function and sensation over the lateral shoulder.

Question 6 of 6NPLEX-PM-284

Which finding requires urgent vascular assessment?

AMild bruisingBAbsent distal pulseCLocal tendernessDReduced active motion

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Absent distal pulse

Explanation An absent pulse or impaired perfusion may indicate arterial injury.

Reveal Case Review & NPLEX Trap

Orthopedic Test Source Case: 23 Test or topic: ACUTE PAINFUL SHOULDER AFTER A FALL NPLEX Examination Trap Safety and fracture exclusion take priority over completing special tests.

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65

Shoulder Pain from the Cervical Spine

6 questions · Physical Medicine · Orthopedic source case 24

Clinical Case

A 52-year-old patient reports shoulder pain extending into the forearm. Shoulder range of motion is painless, but neck extension and rotation reproduce the symptoms.

Question 1 of 6NPLEX-PM-285

Which diagnosis is most likely?

ACervical radiculopathyBAdhesive capsulitisCBiceps ruptureDGlenohumeral instability

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Cervical radiculopathy

Explanation Pain extending below the shoulder with symptoms reproduced by neck movement supports cervical nerve-root irritation.

Question 2 of 6NPLEX-PM-286

Which test may reproduce the symptoms?

ACervical compression testBDrop-arm testCSpeed testDYergason test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Cervical compression test

Explanation Cervical compression may reproduce dermatomal arm pain by narrowing the neural foramen.

Question 3 of 6NPLEX-PM-287

Which finding favors cervical radiculopathy?

ADermatomal sensory changeBBicipital-groove tendernessCPainful shoulder arc onlyDGlenohumeral apprehension

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Dermatomal sensory change

Explanation Dermatomal sensory loss, myotomal weakness, and reflex alteration support nerve-root disease.

Question 4 of 6NPLEX-PM-288

Which test may relieve radicular pain?

ACervical distraction testBHawkins–Kennedy testCNeer testDApley scratch test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Cervical distraction test

Explanation Distraction may reduce foraminal pressure and relieve nerve-root symptoms.

Question 5 of 6NPLEX-PM-289

Which finding suggests shoulder rather than cervical pathology?

APain with resisted shoulder abductionBReduced biceps reflexCDermatomal paresthesiaDSymptoms reproduced by neck rotation

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Pain with resisted shoulder abduction

Explanation Local shoulder pain and weakness during targeted shoulder testing favor intrinsic shoulder pathology.

Question 6 of 6NPLEX-PM-290

Bilateral hyperreflexia and gait dysfunction require:

ARoutine rehabilitationBPrompt cervical imaging and referralCShoulder immobilizationDBiceps testing only

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Prompt cervical imaging and referral

Explanation These findings suggest possible cervical myelopathy.

Reveal Case Review & NPLEX Trap

Orthopedic Test Source Case: 24 Test or topic: SHOULDER PAIN FROM THE CERVICAL SPINE NPLEX Examination Trap Not all pain felt in the shoulder originates from the shoulder.

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66

Shoulder Test Interpretation

6 questions · Physical Medicine · Orthopedic source case 25

Clinical Case

A 49-year-old construction worker has lateral shoulder pain during overhead activity. Hawkins–Kennedy and Neer tests reproduce pain, but strength is normal and the drop-arm test is negative.

Question 1 of 6NPLEX-PM-291

What is the most likely clinical syndrome?

ASubacromial pain syndromeBComplete rotator-cuff tearCPosterior dislocationDCervical myelopathy

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Subacromial pain syndrome

Explanation Overhead pain with positive impingement maneuvers and preserved strength supports subacromial pain syndrome.

Question 2 of 6NPLEX-PM-292

A negative drop-arm test makes which condition less likely?

ALarge rotator-cuff tearBBiceps tendinopathyCMild bursitisDAcromioclavicular pain

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Large rotator-cuff tear

Explanation A large cuff tear is more likely to produce marked weakness or inability to control arm lowering.

Question 3 of 6NPLEX-PM-293

Which statement is most accurate?

AOne positive test confirms the diagnosisBA cluster of findings is more informativeCImaging is always required immediatelyDPain location has no value

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. A cluster of findings is more informative

Explanation Shoulder tests have limited accuracy individually and should be interpreted with history, strength, motion, and other findings.

Question 4 of 6NPLEX-PM-294

Which finding suggests adhesive capsulitis instead?

AMarkedly restricted passive external rotationBFull passive movementCNormal strengthDPainful overhead activity only

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Markedly restricted passive external rotation

Explanation Loss of passive external rotation is characteristic of adhesive capsulitis.

Question 5 of 6NPLEX-PM-295

Which initial intervention is appropriate?

ARelative activity modification and exerciseBComplete immobilizationCEmergency surgeryDRepeated painful loading

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Relative activity modification and exercise

Explanation Progressive mobility and strengthening with temporary activity modification are usually appropriate without red flags.

Question 6 of 6NPLEX-PM-296

Which development warrants imaging or referral?

AGradual improvementBProgressive objective weaknessCMild temporary sorenessDPain only after heavy work

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Progressive objective weakness

Explanation Progressive weakness raises concern for significant tendon or neurological pathology.

Reveal Case Review & NPLEX Trap

Orthopedic Test Source Case: 25 Test or topic: SHOULDER TEST INTERPRETATION NPLEX Examination Trap A positive impingement test does not reveal the precise pain-generating tissue.

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67

Lateral Epicondylopathy

6 questions · Physical Medicine · Orthopedic source case 26

Clinical Case

A 42-year-old carpenter reports lateral elbow pain aggravated by gripping and using a screwdriver. There is tenderness over the lateral epicondyle.

Question 1 of 6NPLEX-PM-297

Which test is most appropriate?

ACozen testBFinkelstein testCPhalen testDTinel test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Cozen test

Explanation Cozen testing loads the common wrist-extensor tendon origin.

Question 2 of 6NPLEX-PM-298

How is Cozen testing performed?

AResisted wrist extension with radial deviationBPassive wrist flexion with ulnar deviationCResisted thumb abductionDPassive elbow extension only

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Resisted wrist extension with radial deviation

Explanation The patient extends and radially deviates the wrist against resistance while the elbow is stabilized.

Question 3 of 6NPLEX-PM-299

What constitutes a positive result?

AFamiliar lateral epicondylar painBMedial wrist paresthesiaCPosterior shoulder apprehensionDReduced radial pulse

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Familiar lateral epicondylar pain

Explanation Reproduction of pain at the lateral epicondyle supports lateral epicondylopathy.

Question 4 of 6NPLEX-PM-300

Which test passively stretches the involved extensor tendons?

AMill testBPhalen testCSpeed testDYergason test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Mill test

Explanation Mill testing passively pronates the forearm, flexes the wrist, and extends the elbow.

Question 5 of 6NPLEX-PM-301

Which nerve disorder may resemble lateral epicondylopathy?

ARadial tunnel syndromeBCarpal tunnel syndrome onlyCFemoral neuropathyDTibial neuropathy

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Radial tunnel syndrome

Explanation Radial tunnel syndrome may cause proximal dorsal forearm pain and should remain in the differential.

Question 6 of 6NPLEX-PM-302

Which initial treatment is appropriate?

AActivity modification and graded loadingBComplete immobilization for monthsCImmediate surgeryDRepeated painful gripping

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Activity modification and graded loading

Explanation Initial care includes load modification and progressive strengthening of the wrist extensors.

Reveal Case Review & NPLEX Trap

Orthopedic Test Source Case: 26 Test or topic: LATERAL EPICONDYLOPATHY NPLEX Examination Trap Maximal tenderness distal to the lateral epicondyle may suggest radial tunnel syndrome rather than tendon-origin pain.

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68

Medial Epicondylopathy

6 questions · Physical Medicine · Orthopedic source case 27

Clinical Case

A 45-year-old golfer reports medial elbow pain aggravated by gripping and resisted wrist flexion. There is no hand numbness.

Question 1 of 6NPLEX-PM-303

Which test is most appropriate?

AReverse Cozen testBFinkelstein testCPhalen testDTinel test at the wrist

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Reverse Cozen test

Explanation Reverse Cozen testing loads the wrist-flexor and pronator tendon origin.

Question 2 of 6NPLEX-PM-304

What constitutes a positive result?

AFamiliar medial epicondylar painBLateral shoulder painCThumb paresthesiaDPosterior elbow instability

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Familiar medial epicondylar pain

Explanation Pain localized to the common flexor-pronator origin supports medial epicondylopathy.

Question 3 of 6NPLEX-PM-305

Which maneuver passively stretches the involved tissues?

AReverse Mill testBApley scratch testCHawkins–Kennedy testDRoos test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Reverse Mill test

Explanation Reverse Mill testing stretches the wrist-flexor and pronator structures.

Question 4 of 6NPLEX-PM-306

Which nerve passes behind the medial epicondyle?

AUlnar nerveBMedian nerveCRadial nerveDAxillary nerve

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Ulnar nerve

Explanation The ulnar nerve passes through the cubital tunnel near the medial epicondyle.

Question 5 of 6NPLEX-PM-307

Which finding suggests ulnar neuropathy instead?

AParesthesia in the fourth and fifth digitsBPain with resisted wrist flexionCMedial epicondylar tendernessDPain during gripping

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Paresthesia in the fourth and fifth digits

Explanation Ulnar neuropathy commonly affects sensation in the little finger and ulnar half of the ring finger.

Question 6 of 6NPLEX-PM-308

Progressive intrinsic-hand weakness requires:

ARoutine observation onlyBNeurological evaluation and referralCRepeated painful testingDWrist immobilization only

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Neurological evaluation and referral

Explanation Progressive weakness may indicate clinically significant ulnar-nerve compression.

Reveal Case Review & NPLEX Trap

Orthopedic Test Source Case: 27 Test or topic: MEDIAL EPICONDYLOPATHY NPLEX Examination Trap Medial elbow pain may arise from tendon, ligament, joint, or ulnar-nerve pathology.

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69

De Quervain Tenosynovitis

6 questions · Physical Medicine · Orthopedic source case 28

Clinical Case

A 34-year-old parent develops radial-sided wrist pain after repeatedly lifting an infant. Pain is localized near the radial styloid.

Question 1 of 6NPLEX-PM-309

Which test is most appropriate?

ACozen testBFinkelstein testCPhalen testDTinel test

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Finkelstein test

Explanation Finkelstein testing stresses the first dorsal extensor compartment.

Question 2 of 6NPLEX-PM-310

How is the test performed?

AThumb enclosed in the fist with ulnar deviationBWrist extended against resistanceCPalms pressed togetherDElbow flexed with forearm supination

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Thumb enclosed in the fist with ulnar deviation

Explanation Ulnar deviation with the thumb enclosed stresses the abductor pollicis longus and extensor pollicis brevis tendons.

Question 3 of 6NPLEX-PM-311

What constitutes a positive result?

ASharp pain at the radial styloidBNumbness in the little fingerCPain at the lateral epicondyleDThenar weakness only

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Sharp pain at the radial styloid

Explanation Reproduction of familiar pain over the first dorsal compartment supports de Quervain tenosynovitis.

Question 4 of 6NPLEX-PM-312

Which tendons are involved?

AAPL and EPBBFCR and FCUCECRL and ECRBDFDP and FDS

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. APL and EPB

Explanation Abductor pollicis longus and extensor pollicis brevis pass through the first dorsal compartment.

Question 5 of 6NPLEX-PM-313

Which condition should remain in the differential after trauma?

AScaphoid fractureBMeniscal tearCAchilles ruptureDCervical myelopathy

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Scaphoid fracture

Explanation Radial wrist pain after trauma requires assessment for scaphoid injury.

Question 6 of 6NPLEX-PM-314

Which initial management is appropriate?

AActivity modification and thumb-spica supportBForceful repetitive testingCImmediate tendon surgeryDComplete shoulder immobilization

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Activity modification and thumb-spica support

Explanation Initial care commonly includes reducing aggravating activity and supporting the thumb and wrist.

Reveal Case Review & NPLEX Trap

Orthopedic Test Source Case: 28 Test or topic: DE QUERVAIN TENOSYNOVITIS NPLEX Examination Trap Excessive force during Finkelstein testing can cause pain even in an unaffected wrist.

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70

Carpal Tunnel Syndrome

6 questions · Physical Medicine · Orthopedic source case 29

Clinical Case

A 51-year-old patient reports nocturnal numbness affecting the thumb, index, and middle fingers. Shaking the hand temporarily relieves the symptoms.

Question 1 of 6NPLEX-PM-315

Which test is most appropriate?

AFinkelstein testBPhalen testCReverse Cozen testDValgus stress test

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Phalen test

Explanation Phalen testing increases pressure within the carpal tunnel by sustained wrist flexion.

Question 2 of 6NPLEX-PM-316

What constitutes a positive Phalen test?

AMedian-distribution paresthesiaBLittle-finger numbnessCLateral elbow painDRadial-styloid pain

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Median-distribution paresthesia

Explanation Reproduction of numbness or tingling in the median-nerve distribution supports carpal tunnel syndrome.

Question 3 of 6NPLEX-PM-317

Which additional test may reproduce the symptoms?

ATinel test at the wristBMill testCSpeed testDRoos test only

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Tinel test at the wrist

Explanation Tapping over the median nerve at the carpal tunnel may reproduce distal paresthesia.

Question 4 of 6NPLEX-PM-318

Which finger is generally spared?

AThumbBIndex fingerCMiddle fingerDLittle finger

Reveal Answer

Answer and Clinical Rationale

Correct answer: D. Little finger

Explanation The little finger is supplied primarily by the ulnar nerve.

Question 5 of 6NPLEX-PM-319

Which finding indicates advanced neuropathy?

AThenar atrophy and thumb weaknessBMild nocturnal tinglingCTemporary relief with shakingDWrist discomfort after work

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Thenar atrophy and thumb weakness

Explanation Thenar wasting and impaired thumb opposition indicate motor involvement.

Question 6 of 6NPLEX-PM-320

Progressive weakness requires:

AReassurance onlyBElectrodiagnostic evaluation or referralCRepeated provocative testingDShoulder radiography

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Electrodiagnostic evaluation or referral

Explanation Motor loss or persistent sensory impairment warrants assessment of severity and possible decompression.

Reveal Case Review & NPLEX Trap

Orthopedic Test Source Case: 29 Test or topic: CARPAL TUNNEL SYNDROME NPLEX Examination Trap A negative Phalen test does not exclude carpal tunnel syndrome.

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71

Ulnar Neuropathy at the Elbow

6 questions · Physical Medicine · Orthopedic source case 30

Clinical Case

A 47-year-old patient reports numbness of the little finger and ulnar half of the ring finger, especially after prolonged elbow flexion. Grip strength has gradually decreased.

Question 1 of 6NPLEX-PM-321

Which test may reproduce the symptoms?

ATinel test at the cubital tunnelBFinkelstein testCPhalen testDSpeed test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Tinel test at the cubital tunnel

Explanation Tapping over the ulnar nerve behind the medial epicondyle may reproduce distal paresthesia.

Question 2 of 6NPLEX-PM-322

What constitutes a positive result?

ATingling into the fourth and fifth digitsBPain at the radial styloidCNumbness of the thumb onlyDLateral shoulder pain

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Tingling into the fourth and fifth digits

Explanation Paresthesia radiating through the ulnar distribution supports ulnar-nerve irritation.

Question 3 of 6NPLEX-PM-323

Which activity commonly aggravates cubital tunnel syndrome?

AProlonged elbow flexionBAnkle dorsiflexionCShoulder abduction onlyDLumbar extension

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Prolonged elbow flexion

Explanation Elbow flexion narrows the cubital tunnel and increases tension on the ulnar nerve.

Question 4 of 6NPLEX-PM-324

Which motor finding may develop?

AIntrinsic-hand weaknessBDeltoid weakness onlyCPlantar-flexion weaknessDHip-abductor weakness

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Intrinsic-hand weakness

Explanation The ulnar nerve supplies many intrinsic muscles of the hand.

Question 5 of 6NPLEX-PM-325

Which differential diagnosis should be considered?

AC8–T1 radiculopathyBL5 radiculopathyCRotator-cuff tearDAchilles rupture

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. C8–T1 radiculopathy

Explanation Lower cervical radiculopathy may produce similar sensory and motor findings.

Question 6 of 6NPLEX-PM-326

Progressive weakness and muscle wasting require:

ARoutine annual reviewBPrompt neurological assessmentCRepeated elbow percussionDComplete shoulder immobilization

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Prompt neurological assessment

Explanation Progressive motor loss suggests significant nerve compression requiring timely investigation.

Reveal Case Review & NPLEX Trap

Orthopedic Test Source Case: 30 Test or topic: ULNAR NEUROPATHY AT THE ELBOW NPLEX Examination Trap Tinel testing identifies nerve irritability but does not independently determine the compression level or severity.

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72

Digital Retinacular Test

6 questions · Physical Medicine · Orthopedic source case 31

Clinical Case

A 46-year-old patient presents with pain, swelling, and restricted movement of the right ring finger following immobilization. The proximal interphalangeal joint does not flex normally when the metacarpophalangeal joint is extended.

Question 1 of 6NPLEX-PM-327

Which test is most appropriate?

AFinkelstein testBPhalen testCRetinacular testDTinel test

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Retinacular test

Explanation The retinacular test evaluates whether limited proximal interphalangeal flexion is caused by tightness of the oblique retinacular ligament or joint-capsule restriction.

Question 2 of 6NPLEX-PM-328

How is the test performed?

ACompare PIP flexion with the MCP joint extended and flexedBFlex both wrists with the dorsal surfaces togetherCEnclose the thumb and deviate the wrist toward the ulnaDResist wrist extension and radial deviation

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Compare PIP flexion with the MCP joint extended and flexed

Explanation The examiner compares proximal interphalangeal flexion while changing the metacarpophalangeal-joint position.

Question 3 of 6NPLEX-PM-329

PIP flexion improves when the MCP joint is flexed. What does this suggest?

ARetinacular-ligament tightnessBFixed PIP capsular restrictionCMedian neuropathyDScaphoid fracture

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Retinacular-ligament tightness

Explanation Improvement when the MCP joint is flexed suggests that tension in the retinacular structures is limiting movement.

Question 4 of 6NPLEX-PM-330

PIP flexion remains restricted in both positions. What is more likely?

AFixed joint-capsule restrictionBDe Quervain tenosynovitisCCarpal tunnel syndromeDUlnar neuropathy

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Fixed joint-capsule restriction

Explanation Persistent limitation regardless of MCP position suggests intrinsic PIP joint or capsular restriction.

Question 5 of 6NPLEX-PM-331

Which history increases the likelihood of this problem?

AProlonged finger immobilizationBRepetitive ankle inversionCCervical extension injuryDLong-distance running

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Prolonged finger immobilization

Explanation Immobilization may lead to shortened soft tissues and joint contracture.

Question 6 of 6NPLEX-PM-332

Which finding warrants imaging or specialist assessment?

AMild stiffness improving with exerciseBFixed deformity after significant traumaCTemporary morning stiffnessDPainless motion asymmetry

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Fixed deformity after significant trauma

Explanation Fixed deformity following trauma may reflect fracture, tendon disruption, or joint injury.

Reveal Case Review & NPLEX Trap

Orthopedic Test Source Case: 31 Test or topic: DIGITAL RETINACULAR TEST NPLEX Examination Trap The retinacular test differentiates soft-tissue tightness from fixed joint restriction; it does not diagnose carpal tunnel syndrome.

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73

Elbow Medial-Ligament Injury

6 questions · Physical Medicine · Orthopedic source case 32

Clinical Case

A 22-year-old baseball pitcher develops medial elbow pain after a forceful throw. Examination shows tenderness along the medial joint line.

Question 1 of 6NPLEX-PM-333

Which test assesses the medial elbow ligament complex?

AValgus stress testBVarus stress testCCozen testDMill test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Valgus stress test

Explanation Valgus stress evaluates the ulnar, or medial, collateral ligament.

Question 2 of 6NPLEX-PM-334

How is valgus stress applied?

AStabilize the humerus and force the forearm laterallyBStabilize the humerus and force the forearm mediallyCResist wrist extensionDPassively flex the wrist

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Stabilize the humerus and force the forearm laterally

Explanation A valgus force opens the medial elbow joint and stresses the ulnar collateral ligament.

Question 3 of 6NPLEX-PM-335

What constitutes a positive result?

AMedial pain or excessive laxityBLateral wrist painCThumb paresthesiaDPosterior shoulder apprehension

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Medial pain or excessive laxity

Explanation Medial joint-line pain or increased opening compared with the other side supports ligament injury.

Question 4 of 6NPLEX-PM-336

Which activity commonly stresses this ligament?

ARepetitive overhead throwingBRepetitive ankle dorsiflexionCProlonged cervical flexionDLong-distance walking

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Repetitive overhead throwing

Explanation Throwing creates substantial valgus force across the medial elbow.

Question 5 of 6NPLEX-PM-337

Which nerve may produce symptoms near the medial elbow?

AUlnar nerveBRadial nerveCAxillary nerveDFemoral nerve

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Ulnar nerve

Explanation The ulnar nerve passes behind the medial epicondyle and may be irritated with medial elbow pathology.

Question 6 of 6NPLEX-PM-338

Acute instability after trauma requires:

ARepeated stress testingBActivity modification onlyCImaging and specialist assessmentDForceful manipulation

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Imaging and specialist assessment

Explanation Significant laxity after acute trauma may indicate a major ligament injury or associated fracture.

Reveal Case Review & NPLEX Trap

Orthopedic Test Source Case: 32 Test or topic: ELBOW MEDIAL-LIGAMENT INJURY NPLEX Examination Trap Medial pain during valgus stress may arise from ligament injury, flexor-pronator pathology, or ulnar-nerve irritation.

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74

Elbow Lateral-Ligament Injury

6 questions · Physical Medicine · Orthopedic source case 33

Clinical Case

A 36-year-old patient falls on an outstretched hand. The elbow subsequently feels unstable during pushing activities. Tenderness is greatest along the lateral joint line.

Question 1 of 6NPLEX-PM-339

Which test assesses the lateral elbow ligament complex?

ACozen testBPhalen testCValgus stress testDVarus stress test

Reveal Answer

Answer and Clinical Rationale

Correct answer: D. Varus stress test

Explanation Varus stress evaluates the lateral collateral-ligament complex.

Question 2 of 6NPLEX-PM-340

What constitutes a positive result?

ALateral pain or excessive openingBMedial wrist paresthesiaCRadial-styloid painDShoulder apprehension

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Lateral pain or excessive opening

Explanation Lateral joint-line pain or increased laxity compared with the opposite elbow suggests lateral ligament injury.

Question 3 of 6NPLEX-PM-341

Which mechanism may cause this injury?

AFall on an outstretched handBRepetitive thumb abduction onlyCProlonged wrist flexionDCervical traction

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Fall on an outstretched hand

Explanation A fall can transmit varus or rotational forces through the elbow.

Question 4 of 6NPLEX-PM-342

Which finding raises concern for fracture?

AFocal bony tenderness with reduced motionBMild pain during grippingCNormal painless movementDTemporary muscular fatigue

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Focal bony tenderness with reduced motion

Explanation Acute trauma with focal bony tenderness and restricted motion warrants fracture evaluation.

Question 5 of 6NPLEX-PM-343

Which initial study is most appropriate when fracture is suspected?

APlain elbow radiographsBBone-density scanCCervical MRIDAbdominal CT

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Plain elbow radiographs

Explanation Plain radiographs are the initial imaging study for most suspected elbow fractures.

Question 6 of 6NPLEX-PM-344

What should be avoided before fracture is excluded?

ADistal pulse assessmentBNeurological examinationCRepeated forceful stress testingDInspection for deformity

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Repeated forceful stress testing

Explanation Repeated stress may worsen pain, instability, or displacement.

Reveal Case Review & NPLEX Trap

Orthopedic Test Source Case: 33 Test or topic: ELBOW LATERAL-LIGAMENT INJURY NPLEX Examination Trap Always compare laxity with the unaffected side and interpret it in the context of the injury mechanism.

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75

FABER Test

6 questions · Physical Medicine · Orthopedic source case 34

Clinical Case

A 48-year-old patient reports deep right groin pain and reduced hip mobility. The hip is placed in flexion, abduction, and external rotation with the ankle resting above the opposite knee.

Question 1 of 6NPLEX-PM-345

Which test is being performed?

AFABER testBOber testCThomas testDTrendelenburg test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. FABER test

Explanation FABER represents flexion, abduction, and external rotation and is also called the Patrick test.

Question 2 of 6NPLEX-PM-346

Groin pain during the test most strongly suggests:

AHip-joint pathologyBLumbar radiculopathyCAchilles injuryDCarpal tunnel syndrome

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Hip-joint pathology

Explanation Anterior groin pain during FABER more strongly implicates the hip joint.

Question 3 of 6NPLEX-PM-347

Posterior pain near the sacroiliac region suggests:

ASacroiliac-region pathologyBBiceps tendinopathyCMeniscal injuryDCubital tunnel syndrome

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Sacroiliac-region pathology

Explanation Posterior pain may arise from the sacroiliac region, although FABER is not independently diagnostic.

Question 4 of 6NPLEX-PM-348

Which finding should be compared bilaterally?

AKnee-to-table distanceBRadial pulseCPatellar heightDWrist-flexion angle

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Knee-to-table distance

Explanation Increased knee-to-table distance may reflect restricted hip mobility or pain.

Question 5 of 6NPLEX-PM-349

Which condition may restrict passive hip movement?

AHip osteoarthritisBLateral epicondylopathyCCervical radiculopathyDCarpal tunnel syndrome

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Hip osteoarthritis

Explanation Hip osteoarthritis commonly causes pain and reduced internal rotation and flexion.

Question 6 of 6NPLEX-PM-350

Inability to bear weight after a fall requires:

AForceful FABER testingBUrgent fracture evaluationCRoutine home stretchingDRepeat testing in one month

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Urgent fracture evaluation

Explanation Inability to bear weight after trauma raises concern for hip or pelvic fracture.

Reveal Case Review & NPLEX Trap

Orthopedic Test Source Case: 34 Test or topic: FABER TEST NPLEX Examination Trap Interpret pain location—groin pain favors the hip, while posterior pain may implicate the sacroiliac region.

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76

Gaenslen Test

6 questions · Physical Medicine · Orthopedic source case 35

Clinical Case

A 39-year-old patient reports unilateral pain near the posterior superior iliac spine. One hip is maximally flexed while the opposite leg is extended beyond the examination table.

Question 1 of 6NPLEX-PM-351

Which test is being performed?

AEly testBGaenslen testCHibb testDThomas test

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Gaenslen test

Explanation The Gaenslen test applies torsional stress across the pelvis and sacroiliac joints.

Question 2 of 6NPLEX-PM-352

What constitutes a positive result?

AFamiliar sacroiliac-region painBLateral knee numbnessCAnterior shoulder painDLittle-finger paresthesia

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Familiar sacroiliac-region pain

Explanation Reproduction of familiar posterior pelvic pain supports sacroiliac-region involvement.

Question 3 of 6NPLEX-PM-353

Which structure is principally stressed?

ASacroiliac jointBAnterior cruciate ligamentCRotator cuffDCarpal tunnel

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Sacroiliac joint

Explanation Opposing hip flexion and extension produce torsional stress across the sacroiliac joints.

Question 4 of 6NPLEX-PM-354

Which condition contraindicates forceful testing?

ASuspected pelvic fractureBMild chronic stiffnessCStable muscular tendernessDPainless restricted motion

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Suspected pelvic fracture

Explanation Pelvic trauma or suspected fracture must be evaluated before stress testing.

Question 5 of 6NPLEX-PM-355

Which statement is most accurate?

AOne positive test confirms sacroiliac dysfunctionBA cluster of provocation tests is more informativeCImaging always confirms mechanical dysfunctionDPain location is irrelevant

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. A cluster of provocation tests is more informative

Explanation No single sacroiliac provocation test is sufficiently definitive when used alone.

Question 6 of 6NPLEX-PM-356

Fever with severe sacroiliac pain requires evaluation for:

ASeptic sacroiliitisBCarpal tunnel syndromeCLateral epicondylopathyDRotator-cuff disease

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Septic sacroiliitis

Explanation Fever and severe focal pain raise concern for infection and require urgent assessment.

Reveal Case Review & NPLEX Trap

Orthopedic Test Source Case: 35 Test or topic: GAENSLEN TEST NPLEX Examination Trap Sacroiliac tests reproduce pain but do not independently establish the exact pathological process.

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77

Yeoman Test

6 questions · Physical Medicine · Orthopedic source case 36

Clinical Case

A 44-year-old patient reports unilateral posterior pelvic pain. While prone, the examiner flexes the knee and extends the hip while stabilizing the pelvis.

Question 1 of 6NPLEX-PM-357

Which test is being performed?

AEly testBOber testCThomas testDYeoman test

Reveal Answer

Answer and Clinical Rationale

Correct answer: D. Yeoman test

Explanation The Yeoman test stresses the sacroiliac region by extending the hip with the knee flexed.

Question 2 of 6NPLEX-PM-358

Posterior pelvic pain suggests:

ASacroiliac-region involvementBCarpal tunnel syndromeCRotator-cuff tearDThoracic outlet syndrome

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Sacroiliac-region involvement

Explanation Pain localized over the sacroiliac region may indicate irritation of that joint or its supporting structures.

Question 3 of 6NPLEX-PM-359

Anterior thigh tightness during the test may reflect:

ARectus femoris tightnessBUlnar neuropathyCMeniscal injuryDCervical myelopathy

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Rectus femoris tightness

Explanation Knee flexion with hip extension stretches the rectus femoris.

Question 4 of 6NPLEX-PM-360

Which feature makes the test unsafe?

ASuspected hip or pelvic fractureBMild muscular tightnessCStable chronic discomfortDPainless reduced flexibility

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Suspected hip or pelvic fracture

Explanation Forceful hip extension should be avoided when fracture or severe acute injury is suspected.

Question 5 of 6NPLEX-PM-361

Which additional test may assess the sacroiliac region?

AGaenslen testBPhalen testCSpeed testDTinel test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Gaenslen test

Explanation Gaenslen testing is another sacroiliac provocation maneuver.

Question 6 of 6NPLEX-PM-362

Which finding requires urgent evaluation?

AMild posterior tightnessBSevere pain with feverCPain after prolonged standingDTemporary stiffness

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Severe pain with fever

Explanation Severe pelvic pain with fever raises concern for infection.

Reveal Case Review & NPLEX Trap

Orthopedic Test Source Case: 36 Test or topic: YEOMAN TEST NPLEX Examination Trap Anterior thigh discomfort may arise from muscle stretching rather than sacroiliac pathology.

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78

Thomas Test

6 questions · Physical Medicine · Orthopedic source case 37

Clinical Case

A 36-year-old runner reports anterior hip tightness and increased lumbar lordosis. While supine, the patient flexes one hip fully toward the chest. The opposite thigh rises from the table.

Question 1 of 6NPLEX-PM-363

Which test is being performed?

AOber testBThomas testCTrendelenburg testDYeoman test

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Thomas test

Explanation The Thomas test assesses hip-flexion contracture.

Question 2 of 6NPLEX-PM-364

What constitutes a positive result?

AOpposite thigh rises from the tableBContralateral pelvis dropsCKnee clicks during rotationDRadial pulse decreases

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Opposite thigh rises from the table

Explanation Elevation of the opposite thigh indicates inability of that hip to extend fully.

Question 3 of 6NPLEX-PM-365

Which muscle is commonly implicated when the thigh rises?

AIliopsoasBGluteus mediusCTibialis anteriorDSupraspinatus

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Iliopsoas

Explanation Iliopsoas tightness or contracture limits hip extension.

Question 4 of 6NPLEX-PM-366

The thigh remains flat, but the knee extends substantially. Which muscle may be tight?

ARectus femorisBPiriformisCGluteus maximusDTibialis posterior

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Rectus femoris

Explanation Rectus femoris crosses both the hip and knee; tightness may cause loss of knee flexion during the test.

Question 5 of 6NPLEX-PM-367

Why must the lumbar spine be observed?

ALumbar extension may mask hip-flexion tightnessBLumbar flexion confirms a meniscal tearCSpinal rotation evaluates the ACLDLordosis excludes hip pathology

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Lumbar extension may mask hip-flexion tightness

Explanation Anterior pelvic tilt and lumbar extension may compensate for limited hip extension.

Question 6 of 6NPLEX-PM-368

Which intervention is generally appropriate for uncomplicated muscle tightness?

AGraded stretching and corrective exerciseBImmediate surgeryCComplete immobilizationDHigh-force testing during pain

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Graded stretching and corrective exercise

Explanation Progressive flexibility and strengthening may address uncomplicated hip-flexor tightness.

Reveal Case Review & NPLEX Trap

Orthopedic Test Source Case: 37 Test or topic: THOMAS TEST NPLEX Examination Trap Stabilize the pelvis; otherwise lumbar extension can conceal the true hip restriction.

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79

Ober Test

6 questions · Physical Medicine · Orthopedic source case 38

Clinical Case

A 29-year-old distance runner reports lateral hip and lateral knee pain. While side-lying, the upper hip is extended and abducted, then allowed to adduct toward the table.

Question 1 of 6NPLEX-PM-369

Which test is being performed?

AEly testBOber testCOrtolani testDThomas test

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Ober test

Explanation The Ober test assesses flexibility of the iliotibial band and tensor fasciae latae.

Question 2 of 6NPLEX-PM-370

What constitutes a positive result?

AThe thigh remains abductedBThe pelvis drops contralaterallyCThe hip produces a clickDThe knee translates anteriorly

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. The thigh remains abducted

Explanation Failure of the thigh to adduct toward the table suggests iliotibial-band or tensor fasciae latae tightness.

Question 3 of 6NPLEX-PM-371

Which tissue is principally assessed?

AIliotibial band and tensor fasciae lataeBAnterior cruciate ligamentCAchilles tendonDLong-head biceps tendon

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Iliotibial band and tensor fasciae latae

Explanation These lateral structures resist hip adduction when shortened.

Question 4 of 6NPLEX-PM-372

Why should the pelvis be stabilized?

APelvic rotation may create a false-negative resultBIt increases cervical tensionCIt tests the sacroiliac ligaments onlyDIt prevents wrist movement

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Pelvic rotation may create a false-negative result

Explanation Pelvic tilting or rotation can permit apparent adduction despite persistent tissue tightness.

Question 5 of 6NPLEX-PM-373

Which condition may be associated with a tight iliotibial band?

ALateral knee pain in runnersBCarpal tunnel syndromeCCervical radiculopathyDMedial epicondylopathy

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Lateral knee pain in runners

Explanation Iliotibial-band–related pain commonly occurs over the lateral femoral epicondyle during repetitive running.

Question 6 of 6NPLEX-PM-374

Which initial management is appropriate?

ALoad modification and hip-strengthening programBComplete lower-limb immobilizationCEmergency surgeryDRepeated painful running

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Load modification and hip-strengthening program

Explanation Management may include temporary load adjustment and progressive hip-abductor and lower-limb rehabilitation.

Reveal Case Review & NPLEX Trap

Orthopedic Test Source Case: 38 Test or topic: OBER TEST NPLEX Examination Trap A positive Ober test identifies restricted lateral-tissue flexibility, not necessarily the sole cause of the patient’s pain.

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80

Trendelenburg Test

6 questions · Physical Medicine · Orthopedic source case 39

Clinical Case

A 67-year-old patient has a waddling gait and difficulty standing on the right leg. During right single-leg stance, the left side of the pelvis drops.

Question 1 of 6NPLEX-PM-375

Which test is positive?

AFABER testBThomas testCTrendelenburg testDYeoman test

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Trendelenburg test

Explanation Contralateral pelvic drop during single-leg stance constitutes a positive Trendelenburg test.

Question 2 of 6NPLEX-PM-376

Which side has the primary hip-abductor dysfunction?

ALeft sideBRight sideCBoth sides necessarilyDNeither side

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Right side

Explanation The hip abductors of the stance leg normally keep the opposite side of the pelvis level.

Question 3 of 6NPLEX-PM-377

Which muscles are principally assessed?

AGluteus medius and minimusBBiceps femoris and semitendinosusCTibialis anterior and posteriorDGastrocnemius and soleus

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Gluteus medius and minimus

Explanation Gluteus medius and minimus provide frontal-plane pelvic stability.

Question 4 of 6NPLEX-PM-378

Which nerve supplies these muscles?

ASuperior gluteal nerveBFemoral nerveCObturator nerveDTibial nerve

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Superior gluteal nerve

Explanation The superior gluteal nerve innervates gluteus medius, gluteus minimus, and tensor fasciae latae.

Question 5 of 6NPLEX-PM-379

Which condition may produce a positive test?

AHip osteoarthritis with abductor inhibitionBCarpal tunnel syndromeCRotator-cuff tearDCervical radiculopathy

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Hip osteoarthritis with abductor inhibition

Explanation Hip pain, abductor tendon disease, neurological injury, or postoperative weakness may impair abductor function.

Question 6 of 6NPLEX-PM-380

What is appropriate when weakness is progressive and unexplained?

ARepeated testing onlyBNeurological and hip evaluationCComplete arm immobilizationDCervical manipulation

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Neurological and hip evaluation

Explanation Progressive weakness requires assessment for tendon, joint, or neurological disease.

Reveal Case Review & NPLEX Trap

Orthopedic Test Source Case: 39 Test or topic: TRENDELENBURG TEST NPLEX Examination Trap The pelvis drops on the unsupported side, but the weakness is usually on the stance side.

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81

Ely Test

6 questions · Physical Medicine · Orthopedic source case 40

Clinical Case

A 35-year-old cyclist reports anterior thigh tightness. While prone, the examiner passively flexes the knee. The ipsilateral hip rises from the table and the pelvis tilts anteriorly.

Question 1 of 6NPLEX-PM-381

Which test is being performed?

AEly testBHibb testCOber testDOrtolani test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Ely test

Explanation The Ely test assesses rectus femoris tightness or contracture.

Question 2 of 6NPLEX-PM-382

What constitutes a positive result?

AIpsilateral hip rises during knee flexionBContralateral pelvis drops during standingCHip clicks during abductionDKnee translates posteriorly

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Ipsilateral hip rises during knee flexion

Explanation A tight rectus femoris pulls the pelvis anteriorly and causes hip flexion as the knee is flexed.

Question 3 of 6NPLEX-PM-383

Why does knee flexion stress the rectus femoris?

AIt crosses both the hip and kneeBIt attaches to the fibular headCIt plantar-flexes the ankleDIt externally rotates the shoulder

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. It crosses both the hip and knee

Explanation The rectus femoris extends the knee and flexes the hip, so knee flexion lengthens it across the knee.

Question 4 of 6NPLEX-PM-384

Which test also helps evaluate hip-flexor tightness?

AThomas testBPhalen testCSpeed testDValgus stress test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Thomas test

Explanation The Thomas test evaluates hip-flexion contracture and may help differentiate iliopsoas from rectus femoris restriction.

Question 5 of 6NPLEX-PM-385

Which observation improves accuracy?

AStabilize and monitor the pelvisBAllow unrestricted lumbar extensionCRotate the cervical spineDResist wrist flexion

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Stabilize and monitor the pelvis

Explanation Pelvic movement may compensate for muscle tightness and obscure the result.

Question 6 of 6NPLEX-PM-386

Which intervention is appropriate for uncomplicated rectus femoris tightness?

AGraded stretching and movement correctionBEmergency imagingCComplete immobilizationDForceful stretching into severe pain

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Graded stretching and movement correction

Explanation Progressive stretching and correction of contributing movement patterns are generally appropriate.

Reveal Case Review & NPLEX Trap

Orthopedic Test Source Case: 40 Test or topic: ELY TEST NPLEX Examination Trap Hip elevation—not anterior thigh sensation alone—is the important positive finding.

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82

Hibb Test

6 questions · Physical Medicine · Orthopedic source case 41

Clinical Case

A 42-year-old patient reports unilateral posterior pelvic pain. While prone, the examiner flexes the knee to 90 degrees and moves the lower leg laterally, producing internal rotation of the hip.

Question 1 of 6NPLEX-PM-387

Which test is being performed?

AEly testBHibb testCOber testDThomas test

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Hibb test

Explanation The Hibb test uses internal hip rotation to assess the hip and sacroiliac region.

Question 2 of 6NPLEX-PM-388

Posterior sacroiliac-region pain suggests:

ASacroiliac dysfunctionBCarpal tunnel syndromeCRotator-cuff tearDAchilles rupture

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Sacroiliac dysfunction

Explanation Posterior pain may indicate irritation of the sacroiliac joint or surrounding structures.

Question 3 of 6NPLEX-PM-389

Groin pain during the maneuver suggests:

AIntra-articular hip pathologyBCervical radiculopathyCUlnar neuropathyDMeniscal disease

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Intra-articular hip pathology

Explanation Groin pain with hip rotation more strongly suggests pathology within the hip joint.

Question 4 of 6NPLEX-PM-390

Which finding makes this test inappropriate?

ASuspected hip fractureBMild chronic stiffnessCStable muscular tendernessDPainless reduced flexibility

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Suspected hip fracture

Explanation Forceful hip rotation must be avoided until fracture or dislocation has been excluded.

Question 5 of 6NPLEX-PM-391

Which additional test may help distinguish hip from sacroiliac pain?

AFABER testBPhalen testCSpeed testDTinel test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. FABER test

Explanation The location of pain during FABER testing may help differentiate hip-joint from sacroiliac-region pathology.

Question 6 of 6NPLEX-PM-392

Severe groin pain with inability to bear weight requires:

ARepeated Hibb testingBUrgent imagingCHome stretchingDResistance exercise

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Urgent imaging

Explanation Severe pain and inability to bear weight raise concern for fracture or major hip pathology.

Reveal Case Review & NPLEX Trap

Orthopedic Test Source Case: 41 Test or topic: HIBB TEST NPLEX Examination Trap Interpret the location of reproduced pain; groin and posterior pelvic pain suggest different sources.

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83

Nachlas Test

6 questions · Physical Medicine · Orthopedic source case 42

Clinical Case

A 38-year-old patient reports anterior thigh discomfort and intermittent low-back pain. While prone, passive knee flexion brings the heel toward the buttock and reproduces the symptoms.

Question 1 of 6NPLEX-PM-393

Which test is being performed?

ANachlas testBOber testCThomas testDTrendelenburg test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Nachlas test

Explanation The Nachlas test uses prone knee flexion to stress the femoral nerve, upper lumbar roots, and anterior thigh structures.

Question 2 of 6NPLEX-PM-394

Anterior thigh radiating pain suggests irritation involving:

AFemoral nerve or upper lumbar rootsBSciatic nerve at S1CMedian nerveDUlnar nerve

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Femoral nerve or upper lumbar roots

Explanation Femoral neural tension may reproduce symptoms in the anterior thigh.

Question 3 of 6NPLEX-PM-395

Local anterior-thigh tightness without neurological symptoms may indicate:

ARectus femoris tightnessBACL ruptureCThoracic outlet syndromeDCarpal tunnel syndrome

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Rectus femoris tightness

Explanation Prone knee flexion lengthens the rectus femoris and may reproduce muscular tightness.

Question 4 of 6NPLEX-PM-396

Low-back pain during the maneuver may reflect:

ALumbar or sacroiliac-region irritationBRotator-cuff pathologyCElbow instabilityDAnkle-ligament injury

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Lumbar or sacroiliac-region irritation

Explanation The maneuver may extend the lumbar spine or stress the pelvic region.

Question 5 of 6NPLEX-PM-397

Which test also evaluates rectus femoris tightness?

AEly testBRoos testCSpeed testDValgus stress test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Ely test

Explanation The Ely test assesses pelvic and hip movement during passive knee flexion.

Question 6 of 6NPLEX-PM-398

Progressive quadriceps weakness with a reduced patellar reflex requires:

ARoutine stretching onlyBNeurological evaluationCComplete shoulder immobilizationDRepeated forceful testing

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Neurological evaluation

Explanation These findings may indicate significant femoral neuropathy or L3–L4 nerve-root dysfunction.

Reveal Case Review & NPLEX Trap

Orthopedic Test Source Case: 42 Test or topic: NACHLAS TEST NPLEX Examination Trap Anterior thigh stretching alone does not establish femoral neuropathy.

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84

Pediatric Hip Instability

6 questions · Physical Medicine · Orthopedic source case 43

Clinical Case

A 6-week-old infant is examined during a routine visit. One hip has limited abduction, and the thigh creases appear asymmetric.

Question 1 of 6NPLEX-PM-399

Which test attempts to reduce a dislocated infant hip?

AOrtolani testBThomas testCTrendelenburg testDYeoman test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Ortolani test

Explanation The Ortolani maneuver attempts to reduce a dislocated femoral head into the acetabulum.

Question 2 of 6NPLEX-PM-400

What constitutes a positive Ortolani test?

APalpable reduction clunkBSoft-tissue click onlyCCrying during examinationDSymmetric hip movement

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Palpable reduction clunk

Explanation A distinct palpable clunk as the femoral head reduces is clinically significant.

Question 3 of 6NPLEX-PM-401

Which condition is being assessed?

ADevelopmental dysplasia of the hipBSlipped capital femoral epiphysisCLegg–Calvé–Perthes diseaseDSeptic knee arthritis

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Developmental dysplasia of the hip

Explanation Ortolani testing is used during infancy to assess developmental hip instability.

Question 4 of 6NPLEX-PM-402

Which imaging study is preferred in a young infant?

AHip ultrasonographyBKnee MRICPelvic CTDBone-density testing

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Hip ultrasonography

Explanation Ultrasonography evaluates the cartilaginous infant hip before the femoral head is adequately ossified.

Question 5 of 6NPLEX-PM-403

A soft click without femoral-head movement is:

ADiagnostic of dislocationBLess specific than a true clunkCEvidence of fractureDAn indication for manipulation

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Less specific than a true clunk

Explanation Benign soft-tissue clicks may occur and are not equivalent to a reduction clunk.

Question 6 of 6NPLEX-PM-404

A positive Ortolani test requires:

AForceful repeated examinationBPrompt pediatric orthopedic referralCObservation until walking ageDResistance exercise

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Prompt pediatric orthopedic referral

Explanation Early specialist management improves hip development and long-term outcomes.

Reveal Case Review & NPLEX Trap

Orthopedic Test Source Case: 43 Test or topic: PEDIATRIC HIP INSTABILITY NPLEX Examination Trap A true palpable clunk—not an isolated click—is the important positive finding.

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85

ACL Injury

6 questions · Physical Medicine · Orthopedic source case 44

Clinical Case

A 24-year-old soccer player plants the right foot and changes direction. The knee gives way, followed by rapid swelling and difficulty continuing play.

Question 1 of 6NPLEX-PM-405

Which test is most appropriate?

ALachman testBMcMurray testCPatellar grind testDPosterior drawer test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Lachman test

Explanation The Lachman test is a principal examination for anterior cruciate ligament integrity.

Question 2 of 6NPLEX-PM-406

What constitutes a positive Lachman test?

AIncreased anterior translation with a soft endpointBIncreased posterior translationCMedial joint-line clickingDPatellar apprehension

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Increased anterior translation with a soft endpoint

Explanation Excessive anterior tibial translation with a soft or absent endpoint suggests ACL insufficiency.

Question 3 of 6NPLEX-PM-407

Which mechanism is most consistent with ACL injury?

ANoncontact pivot with the foot plantedBDirect blow to the anterior tibiaCForced ankle inversionDRepetitive wrist extension

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Noncontact pivot with the foot planted

Explanation Sudden deceleration, pivoting, or landing may rupture the ACL.

Question 4 of 6NPLEX-PM-408

Rapid swelling most likely represents:

AHemarthrosisBPrepatellar bursitisCChronic synovial thickeningDBaker cyst

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Hemarthrosis

Explanation Rapid post-traumatic swelling suggests bleeding into the joint.

Question 5 of 6NPLEX-PM-409

Which additional test assesses the ACL?

AAnterior drawer testBPosterior drawer testCVarus stress testDApley distraction test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Anterior drawer test

Explanation The anterior drawer test also assesses anterior tibial translation, although acute guarding may reduce sensitivity.

Question 6 of 6NPLEX-PM-410

Which next step is appropriate?

AAssess fracture risk, then arrange indicated imaging and follow-upBBegin forceful manipulationCResume sport immediatelyDImmobilize indefinitely

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Assess fracture risk, then arrange indicated imaging and follow-up

Explanation Acute knee trauma requires fracture assessment, management of swelling and instability, and appropriate imaging or referral.

Reveal Case Review & NPLEX Trap

Orthopedic Test Source Case: 44 Test or topic: ACL INJURY NPLEX Examination Trap Lachman testing is generally more sensitive than anterior drawer testing for ACL injury.

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86

PCL Injury

6 questions · Physical Medicine · Orthopedic source case 45

Clinical Case

A 29-year-old driver strikes the proximal tibia against the dashboard during a collision. The knee is swollen and painful posteriorly.

Question 1 of 6NPLEX-PM-411

Which ligament is most likely injured?

AACLBLCLCMCLDPCL

Reveal Answer

Answer and Clinical Rationale

Correct answer: D. PCL

Explanation A posterior force applied to the proximal tibia with the knee flexed is a classic mechanism for PCL injury.

Question 2 of 6NPLEX-PM-412

Which test is most appropriate?

ALachman testBMcMurray testCPosterior drawer testDValgus stress test

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. Posterior drawer test

Explanation Posterior drawer testing assesses posterior tibial translation and PCL integrity.

Question 3 of 6NPLEX-PM-413

What constitutes a positive result?

AExcessive posterior tibial translationBExcessive anterior translationCLateral joint-line painDPatellar crepitus

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Excessive posterior tibial translation

Explanation Increased posterior movement compared with the opposite knee suggests PCL insufficiency.

Question 4 of 6NPLEX-PM-414

What should be observed before performing the test?

APosterior tibial sagBPatellar apprehensionCAnkle inversionDHip-abductor strength

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Posterior tibial sag

Explanation A ruptured PCL may allow the tibia to sag posteriorly at rest.

Question 5 of 6NPLEX-PM-415

Which mechanism can also injure the PCL?

AFall onto a flexed kneeBRepetitive thumb movementCCervical rotationDWrist hyperextension only

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Fall onto a flexed knee

Explanation Direct force through the proximal tibia of a flexed knee can produce posterior displacement.

Question 6 of 6NPLEX-PM-416

Knee trauma with absent distal pulses requires:

ARoutine follow-upBUrgent vascular assessmentCExercise testingDRepeat drawer testing

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Urgent vascular assessment

Explanation Major knee trauma may injure the popliteal artery and threaten the limb.

Reveal Case Review & NPLEX Trap

Orthopedic Test Source Case: 45 Test or topic: PCL INJURY NPLEX Examination Trap Check for posterior sag before interpreting anterior drawer testing, because a sagging tibia can create misleading anterior translation.

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87

Meniscal Injury

6 questions · Physical Medicine · Orthopedic source case 46

Clinical Case

A 37-year-old patient twists the knee while squatting. The patient reports joint-line pain, intermittent catching, and delayed swelling.

Question 1 of 6NPLEX-PM-417

Which test is most appropriate?

AMcMurray testBPatellar grind testCPosterior drawer testDValgus stress test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. McMurray test

Explanation McMurray testing evaluates the menisci by combining knee movement with tibial rotation and joint-line loading.

Question 2 of 6NPLEX-PM-418

What constitutes a positive result?

AJoint-line pain or a palpable clickBAnterior tibial translationCPatellar apprehensionDMedial joint opening

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Joint-line pain or a palpable click

Explanation Reproduction of joint-line pain or a palpable click supports meniscal pathology.

Question 3 of 6NPLEX-PM-419

Which test also assesses the meniscus while the patient is prone?

AApley compression testBApley distraction testCLachman testDPatellar ballottement test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Apley compression test

Explanation Apley compression combines axial loading with tibial rotation to stress the menisci.

Question 4 of 6NPLEX-PM-420

Pain with compression greater than distraction suggests:

AMeniscal pathologyBCollateral-ligament injuryCACL ruptureDPatellar instability

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Meniscal pathology

Explanation Compression loads the menisci, whereas distraction places more stress on the collateral ligaments.

Question 5 of 6NPLEX-PM-421

Which symptom suggests a displaced meniscal tear?

ATrue mechanical lockingBMild crepitusCPain after running onlyDTemporary stiffness

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. True mechanical locking

Explanation Inability to fully extend the knee because of a mechanical block may indicate a displaced tear.

Question 6 of 6NPLEX-PM-422

A persistently locked knee requires:

ARoutine stretchingBPrompt orthopedic assessmentCRepeated McMurray testingDImmediate return to sport

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Prompt orthopedic assessment

Explanation A displaced meniscal fragment or another intra-articular loose body may require urgent management.

Reveal Case Review & NPLEX Trap

Orthopedic Test Source Case: 46 Test or topic: MENISCAL INJURY NPLEX Examination Trap A click without pain may be nonspecific; correlate it with joint-line symptoms and mechanical complaints.

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88

Collateral-Ligament Differentiation

6 questions · Physical Medicine · Orthopedic source case 47

Clinical Case

A 31-year-old skier sustains a blow to the lateral side of the right knee. Pain and tenderness are localized medially.

Question 1 of 6NPLEX-PM-423

Which ligament is most likely injured?

AACLBLCLCMCLDPCL

Reveal Answer

Answer and Clinical Rationale

Correct answer: C. MCL

Explanation A lateral force creates valgus stress and may injure the medial collateral ligament.

Question 2 of 6NPLEX-PM-424

Which test is most appropriate?

AValgus stress testBVarus stress testCLachman testDMcMurray test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Valgus stress test

Explanation Valgus stress evaluates the medial collateral ligament.

Question 3 of 6NPLEX-PM-425

What constitutes a positive result?

AMedial pain or excessive openingBLateral pain onlyCPosterior tibial translationDPatellar grinding

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Medial pain or excessive opening

Explanation Medial joint-line pain or increased valgus laxity supports MCL injury.

Question 4 of 6NPLEX-PM-426

Testing at approximately 30 degrees of knee flexion better isolates:

AMCLBPCLCPatellar tendonDMedial meniscus only

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. MCL

Explanation Slight flexion reduces the stabilizing contribution of the joint capsule and helps isolate the MCL.

Question 5 of 6NPLEX-PM-427

Marked laxity in full extension suggests:

AInjury involving additional stabilizersBIsolated mild MCL strainCPatellofemoral painDHamstring tightness

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Injury involving additional stabilizers

Explanation Instability in full extension raises concern for more extensive capsular or cruciate-ligament injury.

Question 6 of 6NPLEX-PM-428

Which force assesses the LCL?

AVarus stressBValgus stressCAnterior translationDPosterior translation

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Varus stress

Explanation Varus stress opens the lateral joint and assesses the lateral collateral ligament.

Reveal Case Review & NPLEX Trap

Orthopedic Test Source Case: 47 Test or topic: COLLATERAL-LIGAMENT DIFFERENTIATION NPLEX Examination Trap Laxity in full extension suggests a more extensive injury than isolated collateral-ligament damage.

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89

Small Knee Effusion

6 questions · Physical Medicine · Orthopedic source case 48

Clinical Case

A 45-year-old patient develops mild knee swelling after a long hike. There is no major trauma, instability, or inability to bear weight.

Question 1 of 6NPLEX-PM-429

Which test best detects a small effusion?

ABulge testBLachman testCMcMurray testDPosterior drawer test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Bulge test

Explanation The bulge test is used to detect a small amount of intra-articular fluid.

Question 2 of 6NPLEX-PM-430

How is the test performed?

AMilk fluid medially, then tap the lateral jointBPress the patella firmly against the femurCRotate the tibia during axial compressionDTranslate the tibia anteriorly

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Milk fluid medially, then tap the lateral joint

Explanation Fluid is moved from one side of the joint and observed returning as a medial bulge.

Question 3 of 6NPLEX-PM-431

What constitutes a positive result?

AVisible medial fluid waveBAnterior tibial translationCPatellar apprehensionDJoint-line clicking

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Visible medial fluid wave

Explanation Reappearance of a medial fluid bulge indicates a small effusion.

Question 4 of 6NPLEX-PM-432

Which test is more useful for a large effusion?

APatellar ballottement testBApley distraction testCVarus stress testDLachman test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Patellar ballottement test

Explanation A large effusion may cause the patella to float and tap against the femur when compressed.

Question 5 of 6NPLEX-PM-433

A hot, swollen knee with fever raises concern for:

ASeptic arthritisBIliotibial-band syndromeCCarpal tunnel syndromeDThoracic outlet syndrome

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Septic arthritis

Explanation Septic arthritis requires urgent joint aspiration and treatment.

Question 6 of 6NPLEX-PM-434

Which test is definitive for evaluating suspected septic arthritis?

ASynovial-fluid analysisBBulge testCPlain radiography aloneDPatellar grind test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Synovial-fluid analysis

Explanation Arthrocentesis with cell count, crystal analysis, Gram stain, and culture is required.

Reveal Case Review & NPLEX Trap

Orthopedic Test Source Case: 48 Test or topic: SMALL KNEE EFFUSION NPLEX Examination Trap Identifying an effusion does not determine its cause.

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90

Patellar Instability

6 questions · Physical Medicine · Orthopedic source case 49

Clinical Case

A 19-year-old patient reports that the kneecap shifted laterally while turning. Examination reveals tenderness along the medial patellar border and fear of recurrent displacement.

Question 1 of 6NPLEX-PM-435

Which test is most appropriate?

APatellar apprehension testBPatellar ballottement testCPatellofemoral grind testDPosterior drawer test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Patellar apprehension test

Explanation The patellar apprehension test assesses lateral patellar instability.

Question 2 of 6NPLEX-PM-436

How is the test performed?

ATranslate the patella laterallyBCompress the tibia posteriorlyCRotate the tibia under axial loadDApply valgus stress to the knee

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Translate the patella laterally

Explanation Gentle lateral translation attempts to reproduce apprehension associated with patellar instability.

Question 3 of 6NPLEX-PM-437

What constitutes a positive result?

AApprehension or quadriceps guardingBMild patellar mobilityCPosterior knee painDMedial joint opening

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Apprehension or quadriceps guarding

Explanation Fear, guarding, or an attempt to stop the maneuver indicates instability.

Question 4 of 6NPLEX-PM-438

Which structure is often injured during lateral dislocation?

AMedial patellofemoral ligamentBPosterior cruciate ligamentCLateral collateral ligamentDAchilles tendon

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Medial patellofemoral ligament

Explanation The medial patellofemoral ligament is a principal restraint to lateral patellar displacement.

Question 5 of 6NPLEX-PM-439

Which imaging may be appropriate after acute traumatic dislocation?

AKnee radiographsBBone-density scanCCervical CTDElbow ultrasonography

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Knee radiographs

Explanation Radiographs assess alignment and possible osteochondral fracture.

Question 6 of 6NPLEX-PM-440

A locked knee after patellar dislocation raises concern for:

AOsteochondral loose bodyBCarpal tunnel syndromeCUlnar neuropathyDLumbar radiculopathy

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Osteochondral loose body

Explanation An osteochondral fragment may create a mechanical block and requires prompt assessment.

Reveal Case Review & NPLEX Trap

Orthopedic Test Source Case: 49 Test or topic: PATELLAR INSTABILITY NPLEX Examination Trap Apprehension—not pain alone—is the principal positive finding.

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91

Patellofemoral Pain

6 questions · Physical Medicine · Orthopedic source case 50

Clinical Case

A 28-year-old runner reports anterior knee pain aggravated by stairs, squatting, and prolonged sitting. There is no instability or large effusion.

Question 1 of 6NPLEX-PM-441

Which test may reproduce patellofemoral pain?

APatellofemoral grind testBPosterior drawer testCApley distraction testDVarus stress test

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Patellofemoral grind test

Explanation The patellofemoral grind test loads the patellofemoral articulation during quadriceps contraction.

Question 2 of 6NPLEX-PM-442

What constitutes a positive result?

AFamiliar retropatellar painBPosterior tibial translationCMedial joint openingDJoint-line clicking

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Familiar retropatellar pain

Explanation Reproduction of the patient’s familiar anterior or retropatellar pain is the relevant finding.

Question 3 of 6NPLEX-PM-443

Why must the test be interpreted cautiously?

AIt may cause discomfort in asymptomatic kneesBIt specifically confirms ACL ruptureCIt cannot load the patellaDIt identifies the exact cartilage lesion

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. It may cause discomfort in asymptomatic knees

Explanation Patellar compression may be uncomfortable even without clinically important disease.

Question 4 of 6NPLEX-PM-444

Which symptom pattern supports patellofemoral pain?

APain with stairs and prolonged sittingBImmediate hemarthrosis after pivotingCPosterior sag after dashboard traumaDTrue locking after twisting

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Pain with stairs and prolonged sitting

Explanation Loading a flexed knee during stairs, squatting, or prolonged sitting commonly aggravates patellofemoral pain.

Question 5 of 6NPLEX-PM-445

Which initial intervention is appropriate?

AHip and knee strengthening with load modificationBComplete immobilizationCImmediate arthroscopic surgeryDRepeated painful grinding tests

Reveal Answer

Answer and Clinical Rationale

Correct answer: A. Hip and knee strengthening with load modification

Explanation Progressive hip and quadriceps strengthening and temporary activity modification are commonly recommended.

Question 6 of 6NPLEX-PM-446

Which finding requires investigation for another diagnosis?

AMild pain after runningBHot swollen knee with feverCPain during stairsDDiscomfort after sitting

Reveal Answer

Answer and Clinical Rationale

Correct answer: B. Hot swollen knee with fever

Explanation Fever with an acutely hot swollen joint raises concern for septic arthritis.

Reveal Case Review & NPLEX Trap

Orthopedic Test Source Case: 50 Test or topic: PATELLOFEMORAL PAIN NPLEX Examination Trap A positive grind test alone does not establish patellofemoral cartilage damage.

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