Rehabilitation medicine curriculum standards (adult)
Knowledge guides
LG 16: Musculoskeletal conditions
Key presentations and conditions
Advanced Trainees will have a comprehensive depth of knowledge of these presentations and conditions.
Less common or more complex presentations and conditions
Advanced Trainees will understand these presentations and conditions.
Advanced Trainees will understand the resources that should be used to help manage patients with these presentations and conditions.
Epidemiology, pathophysiology, and clinical sciences
Advanced Trainees will describe the principles of the foundational sciences.
Investigations, procedures, and clinical assessment tools
Advanced Trainees will know the indications for and how to interpret the results of these investigations, procedures, and clinical assessments tools.
Advanced Trainees will know how to explain the investigation, procedure, or clinical assessment tool to patients, families, and carers.
Important specific issues
Advanced Trainees will identify important specialty-specific issues and the impact of these on diagnosis and management.
Regional musculoskeletal (MSK) presentations
- Cervical:
- cervical fracture/immobilisation
- cervical radicular pain
- cervical radiculopathy
- cervical segmental pain patterns
- cervical spondylosis >myelopathy
- disc conditions
- torticollis
- whiplash
- zygapophysial joint pain
- Dentofacial:
- malocclusion
- maxillary and jaw asymmetry
- temporomandibular joint dysfunction, arthralgia,articular disc disorder
- traumatic dentofacial anomaly (LeFort fracture)
- Lower limb:
- acquired deformity
- foot and ankle
- knee
- limb deficiency
- pelvis, hip, and thigh
- Thoracic and lumbar spine:
- anklyosing hyperostosis/DISH/ Forestier disease
- Baastrup’s disease (kissing spine)
- buttock pain – gluteal, hip, piriformis, sacroiliac joint (SIJ)
- chest wall pain syndrome
- coccygeal disorders – dislocation, fracture, pain
- costochondral junction syndrome (Tietze) costochondritis
- costovertebral joints
- degenerative disc changes
- disc diseases – internaldisc disruption, discitis
- kyphoscoliosis
- myelopathy
- pelvic sacral insufficiency and pelvic fractures, tumours, osteitis pubis
- post-surgical pain syndrome (post-laminectomy pain and FBSS)
- radiculopathy and radicular pain
- somatic referred pain (sclerotomal,myotomal, dermatomal pain)
- sacroiliac joints
- spinal and foraminal stenosis
- spinal muscles – erector spinae, multifidus
- thoracic outlet syndrome
- ‘trigger point’ syndromes
- vertebral body – fractures, tumours, infections, endplate diseases
- zygapophysial joints
- Upper limb:
- acquired deformity
- elbow
- neuropathies – diseases, entrapment
- osteoarthritis
- shoulder conditions
- soft tissue and synovium
- wrist and hand
General musculoskeletal (MSK) presentations
- Bursopathy:
- bursitis
- calcium deposit in bursa
- infection of bursa
- Cartilage disorders:
- chondrolysis
- chondromalacia
- relapsing polychondritis
- osteoarthritis
- Disorders of bone density and structure:
- bone cysts
- fibrous dysplasia
- fractures – atraumatic, pathological, stress
- hypertrophic osteoarthropathy
- osteitis condensans ilii
- osteolysis
- osteomalacia
- osteomyelitis
- osteonecrosis
- osteopathy secondary to neurological conditions, such as poliomyelitis and paralysis
- osteoporosis
- Paget’s disease of bone
- skeletal fluorosis
- Disorders of synovium, ligament, and tendon:
- enthesopathies
- ganglion
- spontaneous rupture of synovium and tendon
- synovial hypertrophy
- synovitis and tenosynovitis
- transient synovitis
- Fibrous tissue disorders:
- Garrod’s pad (knuckle pad)
- necrotising fasciitis
- palmar-fascial fibromatosis (dupuytren contracture)
- plantar fasciitis
- plantar-fascial fibromatosis
- pseudosarcomatous fibromatosis (nodular fasciitis)
- Muscle disorders:
- calcification and ossification of muscle tissue
- contraction, atrophy, sarcopenia
- degeneration of muscle tissue
- drug-induced myopathy, including alcoholic myopathy
- injury to muscle tissue
- muscle cramp, spasm, and myalgia
- muscle ‘trigger points’
- myositis
- sarcomere separation, rupture, infarction, haematoma, rhabdomyolysis
- stiff person syndrome
For each presentation and condition, Advanced Trainees will know how to:
Synthesise
- recognise the clinical presentation
- identify relevant epidemiology, prevalence, pathophysiology, and clinical science
- take a comprehensive clinical history
- conduct an appropriate examination
- establish a differential diagnosis
- plan and arrange appropriate investigations
- consider the impact of illness and disease on patients and their quality of life when developing a management plan
Manage
- provide evidence-based management
- prescribe therapies tailored to patients' needs and conditions
- recognise potential complications of disease and its management, and initiate preventative strategies
- involve multidisciplinary teams
Consider other factors
- identify individual and social factors and the impact of these on diagnosis and management
Systemic disease with MSK manifestations
- Developmental and genetic:
- achondroplasia
- alkaptonuria, ochronosis, and ochronotic arthropathy/tendinopathy
- disorders of the physeal plate, bone development, and growth
- Duchenne muscular dystrophy
- Ehlers–Danlos syndrome (EDS); hypermobility syndromes
- Marfan syndrome
- osteogenesis imperfecta
- Gastrointestinal:
- enteropathic arthropathies
- Infectious diseases:
- direct infections of joint in infectious bacterial, viral, and parasitic disease
- pyogenic arthritis
- spinal infection – vertebral osteomyelitis, vertebrodiscitis, epidural abscess MSK medicine in specific populations:
- MSK medicine in specific populations:
- functional MSK disorders and medically unexplained symptoms
- metabolic disorders and extremes of weight
- occupational medicine and MSK injury
- operative and postoperative MSK presentations
- sports medicine – athlete populations
- Oncology and haematology:
- arthropathy in neoplastic disease/secondary to underlying neoplasm (leukemia, malignant histiocytosis, multiple myeloma)
- chemotherapy complications
- dermatomyositis secondary to malignant or neoplastic disease
- haematological disorder with arthropathy
- primary malignancy of musculoskeletal tissue
- radiotherapy complications
- Rheumatological, inflammatory and autoimmune:
- autoinflammatory syndromes – Blau syndrome, DIRA, Majeed syndrome, PAPA, PFAPA
- cryopyrin associated periodic syndromes (CAPS)
- gout and other crystal arthropathies
- inflammatory polyarthropathies
- inflammatory spondyloarthropathies
- juvenile arthritis and related disorders
- osteoarthritis – primary, secondary
- other arthritis and arthropathies
- periodic fever syndromes – familial Mediterranean fever, hyperimmunoglobin D syndrome, mevaolonate kinase deficiency, TNF receptor associated periodic syndrome (TRAPS)
- seronegative rheumatoid arthritis
- Skin and connective tissue disease:
- mixed connective tissue disorders
- polymyositis and dermatomyositis (Types I-V)
- psoriatic arthropathy
- Sjögren syndrome
- SLE
- systemic sclerosis/scleroderma/CREST
- vasculitides
For each presentation and condition, Advanced Trainees will know how to:
Synthesise
- recognise the clinical presentation
- identify relevant epidemiology, prevalence, pathophysiology, and clinical science
- take a comprehensive clinical history
- conduct an appropriate examination
- establish a differential diagnosis
- plan and arrange appropriate investigations
- consider the impact of illness and disease on patients and their quality of life when developing a management plan
Manage
- provide evidence-based management
- prescribe therapies tailored to patients' needs and conditions
- recognise potential complications of disease and its management, and initiate preventative strategies
- involve multidisciplinary teams
Consider other factors
- identify individual and social factors and the impact of these on diagnosis and management
Anatomy and physiology
- Biomechanics and gait:
- biomechanics of wheelchair mobility and prescription
- normal gait parameters relative to demographics
- rationale of gait aids and assistive devices
- Bones, bursae, capsules, epiphyses, and joints
- Developmental/ontogeny considerations:
- age, maturity, and senescence
- cellular and molecular development and progression
Pathophysiology
- Central and peripheral neurological development, structure, and function
- Common cellular, molecular, and structural pathology
- Healing, regeneration, and plasticity
- Hereditary neuromuscular conditions
- Neuromuscular junction and motor points
- Normal developmental milestones
- Orthosis prescription
- Physiological responses to disease, injury, and activity:
- response and adaptation to exercise
- response and adaptation to injury
- tissue injury cycle – acute, recovery, and maintenance phases of rehabilitation, Woolf’s Law
- Regional motor and sensory innervation:
- voluntary/somatic muscle innervation and muscle function (muscle origin, insertion, action, innervation, range of motion)
- Tendons and ligaments
- Understanding NNT, nocebo, placebo, statistical significance, and success rates, with respect to clinical assessment and treatment
- Understanding negative predictive value (NPV), positive predictive value (PPV), reliability, sensitivity, specificity, and validity, with respect to examination and investigation
- Age-related variations of structure and function
- Examination and clinical assessment
- Interpretation of diagnostic tests:
- CT scan
- diagnostic interventions – epidural injections, joint injections, medial branch nerve blocks, peripheral nerve blocks
- diagnostic ultrasound
- dual-energy x-ray absorptiometry (DEXA) and bone mineral density (BMD) scans
- electromyography (EMG)/nerve conduction study (NCS)
- joint aspiration (pathology)
- MRI
- provocative discography
- x-rays
- Provocative tests – NPV, PPV, sensitivity, specificity
- Relevant diagnostic and therapeutic procedures and their interpretation:
- electrodiagnostic evaluation
- epidural steroid injection
- facet (zygoapophyseal) joint injections joint aspiration and injection
- medial branch nerve block, selective spinal nerve root block, sacroiliac joint block
- radiofrequency ablation/neurotomy
- sympathetic block
- trigger point injection
Assessment and outcome measures
- Disease-specific patient-related outcome measures
- Joint-specific patient-related outcome measures
- Oswestry Disability Index, Roland–Morris Questionnaire
Activity modification
- Disease modifying anti-rheumatic drugs (DMARDs)
- Evaluation of how sport, work, or domestic activity can contribute to/perpetuate injury or MSK dysfunction
- Growth factors
- Heterotopic ossification management
- Injury prevention principles
- Muscle relaxants
- Negative effects of cast-immobilisation
- Negative effects of prolonged body rest and disuse
- Osteoporosis management
- Pharmacotherapy, including opioids
- Principles and practice of pain management (refer to KG11)
- Principles for orthosis use (refer to KG12) and assistive technology
- Principles of self-management
- Role of relative rest in acute and chronic injury
- Steroids – corticosteroids, glucocorticoids
- Task modification principles
Diet
- Caloric management for optimal MSK rehabilitation in setting of deconditioning and frailty
- Causes of malnutrition and metabolic risk
- Metabolic impact of refeeding syndrome
- Nutritional risk screening and assessment
- Obesity and impact on MSK function
- Role of a structured weight loss program in alleviating MSK dysfunction
Exercise
- Exercise capacity testing
- Principles of exercise prescription
- Risk factor assessment
Injection/Interventional/Procedural
- Corticosteroids/Anaesthetic
- Dextrose prolotherapy
- Diagnostic versus therapeutic
- Disc-related procedures (coblation nucleoplasty, transdiscal biacuplasty, basivertebral nerve ablation)
- Epidural adhesiolysis
- Fluid (hydrodilatation)
- Minimally invasive interventions versus surgical options Perineural, intra-articular
- Platelet rich plasma
- Stem cells
- Thermal and pulsed neurotomies
- Viscosupplementation (hyaluronan)
Psychosocial adjustment to disability
- Behavioural responses
- Family and intimacy
- Hobbies and enjoyment
- Resource availability, affordability, and accessibility
- Social roles and participation
- Societal responses
- Task mastery and self-fulfilment
Surgical intervention
- Complications of implanted orthopaedic prosthetic devices, implants, and grafts
- Implantable pain therapies – intrathecal medication delivery, spinal cord stimulator
- Percutaneous disc decompression
- Periprosthetic fracture
- Post-fracture syndrome
- Post-laminectomy syndrome
- Reduction of dislocation or fracture
- Vertebral augmentation – kyphoplasty, vertebroplasty
Therapies
- Acupuncture
- Application of local heating and cooling
- Hydrotherapy
- Interferential therapy
- Joint mobilisation
- Low level laser therapy
- Pulsed EM field therapy (PEMF)
- Shortwave diathermy
- Soft-tissue therapies
- TENS
- Traction
- Ultrasound