MCQs in Rheumatology:
Soft tissue rheumatism
Contributors: Dr Sachin Khetan, Dr A Abhishek, Prof A Hassall Prof N Arden
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Question 1
A 25 year old male bowler sustained an inversion injury of the right ankle during a
local cricket tournament. You see him in the emergency department. He is able to
walk with difficulty. On examination, he has swelling around the ankle. X-ray of the
ankle shows soft tissue swelling but no fracture. You suspect a ligament injury.
Which is the most common ligament involved in ankle inversion injury?
1.
2.
3.
4.
5.
Anterior talofibular ligament
Bifurcate ligament
Deltoid ligament
Dorsal cuneonavicular ligament
Posterior talofibular ligament
Question 2
Oliver, a 25 year old musician noticed difficulty in picking up a cup of tea with his
right hand because of weakness of thumb and index finger. There was no pain or
sensory symptoms. Examination showed weak flexion of terminal phalanx of right
thumb, and right index and middle finger. Sensory examination of the hand was
normal.
What is the most likely cause of his symptoms?
1.
2.
3.
4.
5.
Anterior interosseous nerve syndrome
Carpel tunnel syndrome
Cubital tunnel syndrome
Pronator teres syndrome
Ulnar tunnel syndrome
Question 3
A 75 year old patient with long standing Rheumatoid arthritis of 30 years duration
has pain and paresthesia in his distal right foot, radiating to the medial malleolus. His
symptoms were worse at night and improved marginally on walking. On examination
he had pes planus, and hind foot valgus in the right foot. Motor and sensory
examination of both feet was normal. His symptoms were reproduced by tapping
behind the right medial malleolus.
What is the most likely cause of his symptoms?
1.
2.
3.
4.
5.
Complex regional pain syndrome.
Morton’s Neuroma
Peripheral neuropathy
Peroneal nerve palsy
Tarsal tunnel syndrome
Question 4
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A 22 year old runner was referred to Rheumatology department with medial left knee
pain for 6 months. The pain is worsened running, by going up stairs and by sleeping
on either side at night. On examination, there is localized tenderness on the lower
medial aspect of the left knee. There is no joint line tenderness or swelling. X-ray of
the left knee (PA and sky line view) is unremarkable.
What is the most likely cause of her symptoms?
1. Osteoarthritis of the patella-femoral joint
2. Pes Anserinus Bursitis
3. Patellofemoral Syndrome
4. Hamstring Strain
5. Prepatellar Bursitis
Question 5
A 45 year old porter was referred by his GP with 6 months history of right lateral
elbow and forearm pain. The pain gets worse while lifting at work. He denies any
trauma, or similar symptoms in other joint. There are no other co morbidities. On
examination he has excruciating tenderness around the right lateral epicondyle, and
the elbow pain worsens on resisted wrist extension. There is no swelling. X-ray of
the right elbow is normal.
What’s the most likely cause for his symptoms?
1. Golfers elbow
2. Olicranon bursitis
3. Tennis elbow
4. Ulnar neuritis
5. Valgus extension overload
Question 6
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A 33 year old man was assessed in rheumatology outpatients with a 4 month history
of pain localised around the right lateral thigh. The pain occasionally radiates down
his thigh, and is worsened if he sleeps in right lateral position. He is otherwise fit and
healthy. He smokes 3 cigarettes per day & drinks 12 units of alcohol per week.
Palpation of the affected area reproduced similar symptoms. Abduction of the hip
against restistance reproduces pain over the trochanteric bursa. Hip movements are
intact. Straight leg raising test is negative. X-ray pelvis is unremarkable.
What’s the most likely cause for his symptoms?
1. Avascular necrosis of hip
2. Iliopsoas Tendinitis
3. Iliotibial Band Syndrome
4. Lumbosacral Radiculopathy
5. Trochanteric Bursitis
Question 7
A 24 year old lady was seen in rheumatology outpatients with pain and dysaesthesia
in her left forefoot for 6 months. The pain is sharp and burning in nature, and is
associated with numbness between 2nd & 3rd toes of the left foot. Narrow high-heeled
shoes aggravate her symptoms. The symptoms are intermittent in nature, and she
gets 2-3 episodes in a week. She has no other medical co-morbidities. Examinations
of her feet are normal. An ultrasound scan of the foot was requested. Image of the
scan is given below
What is the most likely diagnosis ?
1. Freiburg osteochondrosis
2. Ganglion
3. Intermetatarsal bursal fluid collection
4. Metatarsal head osteonecrosis
5. Morton’s Neuroma
Question 8
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A 55 year old man was seen in rheumatology outpatients with a 4 month history of
paresthesia and numbness on the lateral aspect of upper right thigh. This is
aggravated by walking and standing. He denies any back pain or weakness. Bowel &
bladder function is intact. He has diet controlled diabetes. He is a non-smoker, and
drinks 3 units of alcohol per week. He is overweight (BMI is 29 kg/m 2). Neurological
examination is unremarkable except for numbness on the anterolateral thigh.
What is the most likely cause for his symptoms?
1. Femoral mononeuropathy
2. L4 radiculopathy
3. L5 radiculopathy
4. Meralgia paresthetica
5. S1 radiculopathy
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Answers
Q1. 1.Anterior talofibular ligament
The anterior talofibular ligament passes from the anterior margin of the fibular
malleolus, forward and medially, to the talus bone, in front of its lateral articular facet.
It is one of the lateral ligaments of the ankle and prevents the foot from sliding
forward in relation to the shin. It is the most commonly injured ligament in a sprained
ankle, resulting from an inversion injury, and will allow a positive anterior drawer test
of the ankle if completely torn.
Q2. 1.Anterior interosseous nerve syndrome
The anterior interosseous nerve is a motor branch of the median nerve, which arises
just below the elbow. It passes distally in the anterior interosseous membrane and
innervates the long flexor muscles of the thumb, index and middle finger. Injuries of
the forearm with compression of the nerve is the most common cause. Fibrous
bands or arcuate ligaments may entrap the median as well as the anterior
interosseous nerves, in which case a patient may experience numbness as well as
pain. Rheumatoid disease and gouty arthritis may be a predisposing factor in
anterior interosseous nerve entrapment. Most patients experience poorly localised
pain in the forearm. The characteristic impairment of the pincer movement of the
thumb and index finger is most striking. In a pure lesion of the anterior interosseous
nerve there may be weakness of the long flexor muscle of the thumb (Flexor pollicis
longus), the deep flexor muscles of the index and middle fingers (Flexor digitorum
profundus I & II), and the pronator quadratus muscle.
Q3. 5. Tarsal tunnel syndrome
Tarsal tunnel syndrome is a known complication of longstanding Rheumatoid
arthritis. It causes sensory symptoms in the foot. Symptoms are reproduced by
tapping behind the right medial malleolus – Tinel’s sign.
Q4. 1.Pes Anserinus Bursitis
Pes anserine bursitis (or pes anserinus bursitis) is an inflammatory condition of the
medial knee. Pes anserinus is the anatomic term used to identify the insertion of the
conjoined tendons into the anteromedial proximal tibia. From anterior to posterior,
the pes anserinus is made up of the tendons of the sartorius, gracilis, and
semitendinosus muscles. The sartorius, gracilis, and semitendinosus muscles are
primary flexors of the knee. These 3 muscles also influence internal rotation of the
tibia and protect the knee against rotary and valgus stress. Theoretically, bursitis
results from stress to this area (eg, stress may result when an obese individual with
anatomic deformity from arthritis ascends or descends stairs). Pes anserine bursitis
can result from acute trauma to the medial knee, athletic overuse, or chronic
mechanical and degenerative processes. An occurrence of pes anserine bursitis
commonly is characterized by pain, tenderness, and local swelling.
Q5. 3. Tennis elbow
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Tennis elbow is the most common overuse syndrome is related to excessive wrist
extension. It is also commonly referred to as lateral epicondylitis. The tendons are
relatively hypovascular proximal to the tendon insertion. This hypovascularity may
predispose the tendon to hypoxic tendon degeneration and has been implicated in
the etiology of tendinopathies. The area of maximal tenderness is usually an area
just distal to the origin of the extensor muscles of the forearm at the lateral
epicondyle. Most typically the Extensor carpi radialis bravis (ECRB) is involved, but
others may include the extensor carpi radialis longus (ECRL), extensor digitorum,
and extensor carpi ulnaris. The patient complains of pain over the lateral elbow that
worsens with activity and improves with rest. The patient will also often describe
aggravating conditions such as a backhand stroke in tennis or the overuse of a
screwdriver.
Q6. 5. Trochanteric bursitis
Trochanteric bursitis is characterized by painful inflammation of the bursa that is
located just superficial to the greater trochanter of the femur. Patients typically
complain of lateral hip pain, although the hip joint itself is not involved, because pain
may radiate down the lateral aspect of the thigh. Inflammation of the affected bursa
between the femoral trochanteric process and the gluteus medius/iliotibial tract may
be due to acute or repetitive (cumulative) trauma. The most classic finding in
trochanteric bursitis is the elicitation of point tenderness over the greater trochanter,
which reproduces the presenting symptoms.
Q7. 5. Morton’s Neuroma
Morton neuroma (interdigital neuroma), is a perineural fibrosis and nerve
degeneration of the common digital nerve. It results in neuropathic pain in the
distribution of the interdigital nerve secondary to repetitive irritation of the nerve. The
most frequent location is between the third and fourth metatarsals (third webspace).
Other, less common locations are between the second and third metatarsals (second
webspace). Episodes of pain are intermittent. Patients may experience 2 attacks in a
week and then none for a year. Recurrences are variable and tend to become more
frequent. Between attacks, no symptoms or physical signs occur. The female-tomale ratio for Morton's neuroma is 51.
Q8. 4. Meralgia paresthetica
Meralgia paresthetica is painful mononeuropathy of the lateral femoral cutaneous
nerve.Meralgia paresthetica is commonly due to focal entrapment of this nerve as it
passes through the inguinal ligament. The clinical history and examination is usually
sufficient for making the diagnosis. However, the diagnosis can be confirmed by
nerve conduction studies. The lateral femoral cutaneous nerve (LFCN) is responsible
for the sensation of the anterolateral thigh. It is a purely sensory nerve and has no
motor component. The LFCN is a nerve of the lumbar plexus. It arises from the
dorsal divisions of the second and third lumbar nerves. When the LFCN is
entrapped, paresthesias and numbness of the upper lateral thigh area are the
presenting symptoms. The paresthesias may be quite painful. Walking or standing
may aggravate the symptoms; sitting tends to relieve them.
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