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RheumatologyMain41-50Q1A22-year-oldsoccerplayercomestotheemergencydepartmentwithkneepain.Duringpracticeearlierthatday;shetriedtorunaroundanotherplayerontherightandfeltapoppingsensationinherrightkneefollowedbypainandrapidswelling.Thepatienthasnootherinjurytotheknee.Shehashadnosignificantpriorkneeinjuries.Herpastmedicalhistoryisunremarkable.Onphysicalexamination,therightkneeissignificantlyswollenandtender.Ambulationappearsawkward,andthepatienthesitatestobearweightontherightleg.Aspirationofthekneeyieldsgrosslybloodyjointfluid.Whichofthefollowingisthemostlikelydiagnosis?A.AnteriorcruciateligamentinjuryB.MedialcollateralligamentInjuryC.MeniscalinjuryD.PatellofemoralpainsyndromeE.PoplitealcystruptureF.StressfractureofthetibialplateauA1Correctanswer:AInjuriestotheanteriorcruciateligament(ACL)arecommoninyoungathletes,especiallyinwomenparticipatinginsportsrequiringrapiddirectionchangesorpivotsonthelowerextremity(eg,soccer,basketball,tennis).ACLtearscanalsooccurinhigh-contactsportsorinjuriesinvolvingablowtothekneeorsignificanttwistingforce.Patientswithpartial-orfull-thicknessACLtearstypicallyexperienceapoppingsensationintheirkneeduringtheinjuryfollowedbyrapidonsetofhemarthrosisandafeelingofinstabilitywhenbearingweightontheaffectedside.PatientswithanACLtearwillshowlaxityatthekneewiththetibiaabletobepulledforwardrelativetothefemur.Twosuchmaneuvers-theLachmantestandtheanteriordrawersign-arehighlysensitive(90%)andspecificforACLinjuries,inaddition,thereIsusuallyasignificantkneeeffusionduetohemarthrosis.ThediagnosisisusuallyconfirmedonMRI.(ChoiceB)Medialcollateralligament(MCL)tearsmayalsooccurinpivoting/twistinginjuriesorifthekneeisstruckfromthelateralsidewiththefootplanted.Examinationshowstendernessatthemedialknee,andlaxitywhenthefootisgentlyforcedintoabductionwiththekneestationary(valgusstresstest).However,MCLinjuriesarenotusuallyassociatedwithsignificanthemarthrosisunlessthereisaconcurrentACLinjury.(ChoiceC)MeniscaltearsarepossibleinathletessubjectedtorapiddirectionchangesandarecharacterizedbyasubacuteorchronicSockingorpoppingsensationintheknee.However,immediatesymptomsatthetimeoftheinjurymaybemild.Effusionsarepossiblebuttypicallydevelopslowly,andhemarthrosisisrare.(ChoiceD)Patellofemoralpainiscommonlyseeninyoungfemaleathleteswithchronicoveruseratherthanacutetraumatotheknee.Patientsusuallydeveloppainovertheanteriorkneethatisreproducedbyextendingthekneewhilecompressingthepatella(patellofemoralcompressiontest).Althoughtheanteriorkneemayhaveswelling,truekneeeffusionsandhemarthrosisarenotseen.(ChoiceE)Ruptureofapoplitealcyst(Bakercyst)maycauseposteriorkneepain.However,thisismorecommoninolderadultsandisoftenassociatedwithosteoarthritisoftheknee.Patientsmayhaveswellingattheposteriorkneeandcalfresemblingdeepvenousthrombosis.Kneeeffusionsandhemarthrosisareusuallynotpresent.(ChoiceF)Stressfracturesofthetibialplateaumayoccurinfemaleathletes,especiallyfollowingabruptinitiationorchangesInexerciseregimen.However,stressfracturestypicallypresentwithprogressivelyworseningpainandaremuchlesscommonthanligamentInjuries.Educationalobjective:Anteriorcruciateligament(ACL)injuriesarecommon,especiallyinyoungathletesinsportsrequiringrapiddirectionchangesortwistingmovementsofthelowerextremity.ACLinjuriesusuallypresentwithrapidonsetofpainandswellingwithhemarthrosis.Examinationfindingsincludelaxityofanteriormotionofthetibiarelativetothefemur.Q2A55-year-oldmancomestotheofficeduetoelbowpain.Forthelast3weeks,thepatienthashadvague,achypainattheleftelbowthatradiatestotheforearmandisworsewithactivityandattheendoftheday.Hehasattemptedtreatmentwithover-the-counteracetaminophenwithoutrelief.Thepatientworksasanairportbaggagehandlerandhasbeenseenintheofficepreviouslyforminoroccupationalinjuries.Hismedicalhistoryisotherwiseunremarkable.Hesmokesahalf-packofcigarettesdailyanddoesnotusealcoholorillicitdrugs.Vitalsignsarenormal.Inspectionoftheleftelbowshowsnoerythemaorswelling.RangeofmotionIsnormal.Withtheelbowheldinextension,passiveflexionofthewristreproducesthepatient'spain.Whichofthefollowingisthemostlikelydiagnosisinthispatient?A.CervicalradiculopathyB.LateralepicondylitisC.OlecranonbursitisD.OsteoarthritisoftheelbowE.PseudogoutF.RadialtunnelsyndromeG.StressfractureoftheradiusA2Correctanswer:BThispatienthassubacutepainattheelbowandforearmthatisreproducedonstretchingofthewristextensors.Thisisconsistentwithlateralepicondylitis,oftencalledtenniselbowduetoitsfrequentoccurrenceincasualtennisplayers.LateralepicondylitisisduetooveruseoftheextensormuscEes,primarilytheextensorcarpiradiaiisbrevisandtheextensordigitorumcommunis.Theprimarypathologiclesionisnoninflammatoryangiofibroblastictendinosisatthecommonextensororiginonthelateralepicondyleofthehumerus.Ananalogousdisordercanoccurattheoriginofthewristflexorsatthemedialepicondyie(medialepicondylitis).Patientsusuallyhaveahistoryofrepetitive,forcefulextensionatthewrist.Examinationfindingsmayincludetendernessatthelateralepicondyleandreproductionofpainwithresistedextensionorpassiveflexionatthewrist.Managementincludesactivi