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
