Physician Assistant National Certifying Examination (PANCE) Musculoskeletal and Rheumatology Syllabus

What are Heberden and Bouchard nodes, and which disease causes them?

In osteoarthritis: Heberden nodes are bony enlargements of the distal interphalangeal (DIP) joints; Bouchard nodes are at the proximal interphalangeal (PIP) joints. The DIP involvement helps distinguish OA from rheumatoid arthritis (which spares the DIP).

How does the joint stiffness of osteoarthritis differ from rheumatoid arthritis?

OA: brief morning stiffness lasting $<30$ minutes, worsens with activity/use, improves with rest. RA: prolonged morning stiffness lasting $>1$ hour (often >60 min), improves with use.

What are the four muscles of the rotator cuff and their mnemonic?

SITS: Supraspinatus (abduction, most commonly injured), Infraspinatus (external rotation), Teres minor (external rotation), Subscapularis (internal rotation).

Which rotator cuff special tests assess the supraspinatus and impingement?

Empty can (Jobe) test isolates the supraspinatus; the drop arm test suggests a full-thickness supraspinatus tear. Neer and Hawkins-Kennedy tests assess subacromial impingement.

What is lateral epicondylitis ('tennis elbow'), and which test reproduces pain?

Overuse tendinopathy of the wrist extensor origin (extensor carpi radialis brevis) at the lateral epicondyle. Pain is reproduced by resisted wrist extension. Medial epicondylitis ('golfer's elbow') affects the flexor-pronator origin and pain occurs with resisted wrist flexion/pronation.

What is de Quervain tenosynovitis and the test for it?

Inflammation of the abductor pollicis longus and extensor pollicis brevis tendons at the radial styloid, common in new mothers ('mommy thumb'). Finkelstein test is positive: pain over the radial styloid when the thumb is flexed into the palm and the wrist is ulnar-deviated.

What nerve is compressed in carpal tunnel syndrome, and what is the sensory distribution?

The median nerve under the transverse carpal ligament. Paresthesias affect the palmar thumb, index, middle, and radial half of the ring finger. Thenar atrophy occurs in severe/chronic cases. Risk factors include pregnancy, hypothyroidism, diabetes, and repetitive use.

Name two provocative tests for carpal tunnel syndrome and the confirmatory test.

Tinel sign (tapping over the median nerve at the wrist produces tingling) and Phalen sign (wrist flexion for 60 seconds reproduces symptoms). Nerve conduction studies/EMG confirm the diagnosis.

What is cubital tunnel syndrome?

Ulnar nerve entrapment at the elbow (cubital tunnel), causing paresthesias of the 5th and ulnar half of the 4th finger, with weakness of grip and intrinsic hand muscles. Positive Tinel sign at the medial elbow; symptoms worsen with elbow flexion.

What are the red flags in acute low back pain that warrant urgent imaging/workup?

Bowel/bladder dysfunction or saddle anesthesia (cauda equina), fever/IV drug use (infection), unexplained weight loss or age >50 with cancer history (malignancy), major trauma/osteoporosis (fracture), and progressive neurologic deficit. Most simple mechanical back pain needs no early imaging.

Which lumbar disc herniations affect which nerve roots and reflexes/findings?

L4-L5 herniation usually affects the L5 root (weak great toe dorsiflexion/foot drop, no major reflex change). L5-S1 affects the S1 root (weak plantarflexion, diminished ankle/Achilles reflex). L3-L4 affects the L4 root (weak knee extension, diminished patellar reflex).

What is a positive straight leg raise test indicative of?

Lumbar nerve root irritation/radiculopathy from disc herniation (sciatica). Pain radiating below the knee when the leg is raised 30-70 degrees is positive. A crossed straight leg raise (pain in the affected leg when raising the opposite leg) is more specific.

How does the claudication of lumbar spinal stenosis differ from vascular claudication?

Neurogenic claudication (spinal stenosis): leg pain with standing/walking, relieved by sitting/leaning forward/flexion ('shopping cart sign'); pulses normal. Vascular claudication: pain relieved by rest (standing still), worse walking uphill, with diminished pulses. Stenosis worsens with extension.

What is spondylolisthesis, and what is spondylolysis?

Spondylolysis is a defect/stress fracture of the pars interarticularis (often L5). Spondylolisthesis is anterior slippage of one vertebra over another (most common at L5-S1), graded by the Meyerding classification (Grade I = $<25\%$ slip up to Grade IV/V). Can cause back pain and radiculopathy.

What is cauda equina syndrome and why is it a surgical emergency?

Compression of the lumbosacral nerve roots (cauda equina), classically from a large central disc herniation. It causes saddle anesthesia, bilateral leg pain/weakness, urinary retention with overflow incontinence, decreased rectal tone, and bowel incontinence. It requires emergent MRI and surgical decompression to prevent permanent deficits.

How are scoliosis and the indication for treatment defined?

Scoliosis is a lateral curvature of the spine measured by the Cobb angle. Generally: $<10°$ is not scoliosis; $10-25°$ observe; $25-45°$ bracing (in skeletally immature patients) to halt progression; $>45-50°$ consider surgery. Adolescent idiopathic scoliosis is the most common type.

What is hyperkyphosis, and what is the most common pathologic cause in adolescents vs the elderly?

Excessive anterior curvature (rounding) of the thoracic spine. In adolescents, Scheuermann disease (anterior wedging of $\geq 5°$ in $\geq 3$ adjacent vertebrae) is a common rigid cause. In the elderly, osteoporotic vertebral compression fractures are the most common cause.

What are the characteristic joint involvement and deformities of rheumatoid arthritis?

Symmetric polyarthritis of small joints - MCP, PIP, and wrists - sparing the DIP. Deformities include ulnar deviation, swan-neck (PIP hyperextension, DIP flexion), boutonniere (PIP flexion, DIP hyperextension), and atlantoaxial subluxation of the cervical spine.

What antibodies and lab findings support a diagnosis of rheumatoid arthritis?

Anti-cyclic citrullinated peptide (anti-CCP) is most specific; rheumatoid factor (RF) is sensitive but less specific. Elevated ESR/CRP indicate inflammation. X-rays show periarticular osteopenia, joint space narrowing, and marginal erosions.

What is the first-line disease-modifying drug (DMARD) for rheumatoid arthritis, and a key toxicity?

Methotrexate is first-line. Toxicities include hepatotoxicity, myelosuppression, pneumonitis, and oral ulcers; it is teratogenic (contraindicated in pregnancy). Supplement with folic acid. Monitor CBC, LFTs, and renal function.

What are the seronegative spondyloarthropathies and their shared features?

Ankylosing spondylitis, reactive arthritis, psoriatic arthritis, and enteropathic (IBD-associated) arthritis. Shared features: RF-negative, HLA-B27 association, axial/sacroiliac involvement, enthesitis, dactylitis, and extra-articular features like uveitis.

What are the classic features and X-ray finding of ankylosing spondylitis?

Young male with chronic inflammatory low back pain and stiffness improving with exercise, reduced chest expansion, and sacroiliitis. HLA-B27 positive. The X-ray shows a 'bamboo spine' from vertebral fusion/syndesmophytes. Associated with anterior uveitis and aortitis.

What is the classic triad of reactive arthritis (formerly Reiter syndrome)?

Arthritis, urethritis (or cervicitis), and conjunctivitis/uveitis - 'can't see, can't pee, can't climb a tree.' It follows GI (Shigella, Salmonella, Campylobacter, Yersinia) or genitourinary (Chlamydia) infection and is HLA-B27 associated.

How do gout crystals and pseudogout crystals differ on polarized microscopy?

Gout: monosodium urate crystals are needle-shaped and negatively birefringent (yellow when parallel to the compensator). Pseudogout (CPPD): calcium pyrophosphate crystals are rhomboid and positively birefringent (blue when parallel). Pseudogout shows chondrocalcinosis on X-ray.

What is the acute and chronic management of gout?

Acute flare: NSAIDs, colchicine, or corticosteroids (do NOT start or stop urate-lowering therapy during an acute attack). Chronic/preventive: xanthine oxidase inhibitors (allopurinol, febuxostat) to lower uric acid; the most commonly affected joint is the first MTP (podagra).

What mnemonic captures the diagnostic criteria of systemic lupus erythematosus?

SOAP BRAIN MD: Serositis, Oral ulcers, Arthritis, Photosensitivity, Blood (cytopenias), Renal, ANA, Immunologic (anti-dsDNA, anti-Sm), Neurologic, Malar rash, Discoid rash. ANA is sensitive; anti-dsDNA and anti-Smith are specific. Malar (butterfly) rash spares the nasolabial folds.

Which autoantibodies are associated with limited (CREST) vs diffuse systemic sclerosis?

Limited/CREST scleroderma: anti-centromere antibody. Diffuse scleroderma: anti-Scl-70 (anti-topoisomerase I) and anti-RNA polymerase III. CREST = Calcinosis, Raynaud, Esophageal dysmotility, Sclerodactyly, Telangiectasias.

What defines osteoporosis by DEXA T-score, and what is osteopenia?

Osteoporosis: T-score $\leq -2.5$. Osteopenia (low bone mass): T-score between $-1.0$ and $-2.5$. Normal: T-score $\geq -1.0$. The T-score compares bone density to a young healthy adult; the Z-score compares to age-matched controls.

How does osteomalacia differ from osteoporosis in pathology and labs?

Osteoporosis is decreased bone quantity with normal mineralization and normal calcium/phosphate/ALP. Osteomalacia is defective mineralization (usually vitamin D deficiency) with low vitamin D, low/normal calcium and phosphate, elevated ALP and PTH, and Looser zones (pseudofractures) on X-ray; rickets is the childhood form.

What is the first-line pharmacologic treatment for osteoporosis and a key administration caution?

Bisphosphonates (e.g., alendronate) are first-line. Take on an empty stomach with a full glass of water and remain upright for $\geq 30$ minutes to prevent esophagitis. Rare adverse effects include osteonecrosis of the jaw and atypical femoral fractures. Ensure adequate calcium and vitamin D.

What is the most common organism in osteomyelitis overall and in sickle cell disease?

Staphylococcus aureus is the most common cause overall. In sickle cell disease, Salmonella is classically associated (though S. aureus is still common). Pseudomonas is associated with puncture wounds through a shoe and IV drug use.

How is septic arthritis diagnosed, and what is the most common pathogen overall vs in young sexually active adults?

Arthrocentesis showing purulent synovial fluid with WBC typically $>50{,}000/\mu L$ (often $>50\%$ neutrophils), positive Gram stain/culture. Staphylococcus aureus is most common overall; Neisseria gonorrhoeae is most common in young, sexually active adults. It is an emergency requiring drainage and IV antibiotics.