Domain – Musculoskeletal presentations (guiding topics)

• Assess and manage a patient presenting with an injury.

Neck conditions

• Identify, evaluate and manage neck conditions:
  • acute neck pain
  • cervical spondylosis
  • acute torticollis
  • whiplash – accelerated hyperextension
  • cervical disc disruption.

Condition	Etiology	Clinical Presentation	Diagnosis	Treatment Options
Acute Neck Pain	Muscle strain ligament sprain poor posture	Localized neck pain muscle spasm limited range of motion	Clinical exam, X-rays (if indicated)	Rest NSAIDs physical therapy heat/ice therapy
Cervical Spondylosis	Degenerative changes age-related wear and tear	Chronic neck pain stiffness possible radiculopathy headaches	Clinical exam, X-rays, MRI	NSAIDs physical therapy corticosteroid injections, surgery (in severe cases)
Acute Torticollis	Sudden muscle spasm sleep posture minor trauma	Neck pain head tilted to one side limited range of motion	Clinical exam	Gentle Stretching Exercises Isometric Neck Exercises – Resistance is applied by pressing against the head with the hands or against a fixed object. Range of Motion Exercises – Controlled Motion: Movements are performed slowly and gently within a pain-free range.Usually performed in sets of 10-15 repetitions. Heat and Cold Therapy muscle relaxants physical therapy heat therapy
Whiplash (Accelerated Hyperextension)	Rapid extension-flexion injury (e.g., car accident)	Neck pain stiffness headaches shoulder pain dizziness	Clinical exam, X-rays, MRI (if severe)	Range of Motion Exercises: Gentle movements to maintain and improve neck flexibility. Strengthening Exercises: Focus on neck and shoulder muscles to support the cervical spine. Postural Training: Techniques to improve and maintain good posture. Myofascial Release: Gentle, sustained pressure to stretch and release tension in the fascia. Heat and Cold Therapy Ergonomic Modifications Exercise: Regular, low-impact aerobic exercise (e.g., walking, swimming) to improve overall fitness and reduce pain. gradual return to activity
Cervical Disc Disruption	Disc herniation degenerative disc disease	Neck pain radiating arm pain numbness weakness	MRI, CT scan, clinical exam	NSAIDs physical therapy corticosteroid injections surgery (for severe cases)

Shoulder pain

• Identify, evaluate and manage shoulder pain:
  • impingement syndrome
  • rotator cuff tendinosis/tear
  • biceps tendinitis and/or rupture
  • labral tear related to overuse or trauma
  • shoulder instability
  • acromioclavicular joint arthritis
  • frozen shoulder or adhesive capsulitis.

Condition	Etiology	Clinical Presentation	Diagnosis	Treatment Options
Impingement Syndrome	Repetitive overhead activities subacromial bursitis bony spurs	Pain with overhead activity night pain limited range of motion	Clinical exam Neer and Hawkins tests MRI	Physical therapy, NSAIDs, corticosteroid injections, surgery
Rotator Cuff Tendinosis/Tear	Chronic overuse acute injury degenerative changes	Shoulder pain weakness especially with abduction and external rotation	MRI ultrasound clinical tests (e.g., empty can test)	Physical therapy, NSAIDs, corticosteroid injections, surgery (for tears)
Biceps Tendinitis/Rupture	Overuse degenerative changes acute trauma	Anterior shoulder pain “Popeye” muscle (for rupture) pain with biceps use	Clinical exam Speed’s and Yergason’s tests MRI	Rest, NSAIDs, physical therapy, surgery (for rupture)
Labral Tear (Overuse or Trauma)	Repetitive overhead activities acute trauma	Deep shoulder pain clicking/popping instability	MRI with arthrogram clinical tests (e.g., O’Brien’s test)	Physical therapy, NSAIDs, surgery
Shoulder Instability	Traumatic dislocation repetitive overhead motion congenital laxity	Recurrent dislocations/subluxations feeling of instability	Clinical exam apprehension test MRI	Physical therapy, activity modification, surgery
Acromioclavicular Joint Arthritis	Degenerative changes previous trauma	Pain over AC joint pain with cross-body adduction	Clinical exam, X-rays, MRI	NSAIDs, corticosteroid injections, physical therapy, surgery
Frozen Shoulder (Adhesive Capsulitis)	Idiopathic post-surgical, or post-injury immobilization	Progressive shoulder stiffness pain limited range of motion	Clinical exam, MRI (to rule out other conditions)	Anterior and Posterior Capsule Stretch Gentle stretches targeting the anterior and posterior portions of the shoulder capsule to improve external and internal rotation. Passive Range of Motion Active Range of Motion Exercises: Exercises performed by the patient to maintain and improve shoulder mobility. Strengthening Exercises: Focus on the rotator cuff and scapular stabilizers to support shoulder function. Stretching Exercises: Daily stretching to improve flexibility and reduce stiffnes NSAIDs, corticosteroid injections, manipulation under anesthesia

• Identify, evaluate and manage shoulder weakness:
  • axillary nerve mononeuropathy
  • suprascapular nerve palsy
  • long thoracic nerve injury
  • cervical radiculopathy
  • spinal accessory nerve injury.

Condition	Etiology	Clinical Presentation	Diagnosis	Treatment Options
Axillary Nerve Mononeuropathy	Shoulder dislocation, humeral fracture, compression	Weakness in deltoid muscle loss of sensation over deltoid	Clinical exam, EMG/NCS, MRI (if trauma-related)	Physical therapy, NSAIDs, surgical repair (if severe)
Suprascapular Nerve Palsy	Traction injury, repetitive overhead activity, cysts	Weakness in shoulder abduction and external rotation atrophy of supraspinatus and infraspinatus muscles	Clinical exam, EMG/NCS, MRI	Physical therapy, NSAIDs, surgical decompression (if necessary)
Long Thoracic Nerve Injury	Trauma, repetitive activities, surgical injury (e.g., mastectomy)	Scapular winging difficulty with shoulder elevation	Clinical exam, EMG/NCS	Physical therapy, surgical nerve repair (if persistent)
Cervical Radiculopathy	Disc herniation, cervical spondylosis, foraminal stenosis	Neck pain radiating to the arm, numbness, tingling, weakness in the distribution of the affected nerve root	MRI, clinical exam, EMG/NCS	NSAIDs, physical therapy, corticosteroid injections, surgery (for severe cases)
Spinal Accessory Nerve Injury	Trauma (e.g., neck surgery, blunt trauma), tumors	Weakness in shoulder shrugging, atrophy of trapezius muscle, shoulder droop	Clinical exam, EMG/NCS, MRI	Physical therapy, surgical nerve repair (if indicated)

• Classify causes of back pain, and use a biopsychosocial approach to investigate and manage them:
  • mechanical:
    • myofascial or soft tissue injury or disorder
    • facet joint dysfunction/degeneration
    • spondylosis
    • spondylolysis
    • spondylolisthesis
    • neural foraminal narrowing with radiculopathy and sciatica
    • spinal canal stenosis
  • congenital and deformities:
    • kyphosis
    • scoliosis
    • congenital spinal deformity
  • tumours:
    • multiple myeloma
    • metastatic disease
  • other:
    • discitis
    • sacro-ileitis
    • metabolic bone disease, such as osteoporosis
    • referred pain.

Elbow Pain

Identify, evaluate and manage elbow pain:

• olecranon bursitis
• medial and lateral epicondylitis
• ulnar nerve subluxation
• fracture.

Condition	Identification	Evaluation	Management
Olecranon Bursitis	– Swelling, pain, redness, warmth over the olecranon. – Causes: repetitive trauma, infection, gout, RA.	– Physical exam: palpable fluid-filled sac. – Aspiration: fluid analysis (infection, crystals, blood). – Imaging: rarely needed.	Conservative: – Rest, avoid pressure. – Elbow padding. – Ice application. – NSAIDs. Aspiration and Injection: – Aspiration for pressure relief. – Corticosteroid injection (if non-infectious). Infection Management: – Antibiotics. – Surgical drainage if necessary.
Medial Epicondylitis (Golfer’s Elbow)	– Pain, tenderness over medial epicondyle. – Pain with wrist flexion, forearm pronation.	– Physical exam: pain with resisted wrist flexion. – Tenderness over medial epicondyle. – Imaging: MRI or ultrasound if needed.	Conservative: – Rest, modify activities. – Ice application. – NSAIDs. – Physical therapy (stretching, strengthening). – Forearm bracing/straps. Injections: – Corticosteroid injections. – PRP injections. Surgical: – For persistent symptoms (6-12 months).
Lateral Epicondylitis (Tennis Elbow)	– Pain, tenderness over lateral epicondyle. – Pain with wrist extension, forearm supination.	– Physical exam: pain with resisted wrist extension. – Tenderness over lateral epicondyle. – Imaging: MRI or ultrasound if needed.	Conservative: – Rest, modify activities. – Ice application. – NSAIDs. – Physical therapy (stretching, strengthening). – Forearm bracing/straps. Injections: – Corticosteroid injections. – PRP injections. Surgical: – For persistent symptoms (6-12 months).
Ulnar Nerve Subluxation	– Snapping/popping sensation at elbow. – Medial elbow pain with bending or gym – Numbness/tingling in ulnar distribution – little finger	– Physical exam: palpate for ulnar nerve subluxation. – Tinel’s sign at elbow. – Electrodiagnostic studies if needed.	Conservative: – Activity modification. – Avoid prolonged elbow flexion. – Elbow padding. – NSAIDs. Surgical: – Ulnar nerve transposition or stabilization if conservative measures fail.

Wrist and Hand Conditions

Identify, evaluate and manage wrist and hand pain:

• carpal tunnel syndrome
• De Quervain’s tenosynovitis
• ganglion cyst
• extensor carpi ulnaris tendinopathy
• trigger finger
• fractures.

Condition	Identification	Evaluation	Management
Carpal Tunnel Syndrome	– Numbness, tingling in the thumb, index, middle fingers. – Weakness, clumsiness in hand.	– Physical exam: Tinel’s sign, Phalen’s test. – Electrodiagnostic studies (nerve conduction, EMG).	Conservative: – Wrist splinting (especially at night). – Activity modification. – NSAIDs. Injections: – Corticosteroid injections. Surgical: – Carpal tunnel release if severe or refractory to conservative treatment.
De Quervain’s Tenosynovitis	– Pain, swelling at the base of the thumb. – Pain with thumb movement, wrist deviation.	– Physical exam: Finkelstein’s test. – Ultrasound if needed for confirmation.	Conservative: – Rest, thumb spica splint. – Ice application. – NSAIDs. Injections: – Corticosteroid injections. Surgical: – Surgical release of the first dorsal compartment if conservative treatment fails.
Ganglion Cyst	– Visible or palpable lump, typically on the dorsal wrist. – May fluctuate in size, sometimes painful.	– Physical exam: Transillumination of the cyst. – Ultrasound or MRI if diagnosis is unclear.	Conservative: – Observation if asymptomatic. – Aspiration if symptomatic or bothersome. Surgical: – Excision if recurrent or persistent symptoms.
Extensor Carpi Ulnaris Tendinopathy	– Pain, swelling along the ulnar side of the wrist. – Pain with wrist extension, ulnar deviation.	– Physical exam: Pain with resisted wrist extension and ulnar deviation. – Ultrasound or MRI if needed.	Conservative: – Rest, avoid aggravating activities. – Wrist splinting. – NSAIDs. Physical Therapy: – Stretching and strengthening exercises. Injections: – Corticosteroid injections if persistent pain.
Trigger Finger	– Finger catches or locks in a bent position. – Pain at the base of the affected finger.	– Physical exam: Palpable nodule at the base of the finger. – Triggering during finger movement.	Conservative: – Activity modification. – Splinting of the affected finger. – NSAIDs. Injections: – Corticosteroid injections. Surgical: – A1 pulley release if conservative treatment fails.

Hip Conditions

Identify, evaluate and manage hip pain:

intra-articular/anterior:

• hip fracture
• avascular necrosis
• septic arthritis/transient synovitis
• osteoarthritis
• femoroacetabular impingement
• labral tear

Condition	Identification	Evaluation	Management
Hip Fracture	– Severe hip or groin pain, inability to bear weight. – Leg may appear shortened and externally rotated.	– Physical exam: Pain on palpation, inability to perform straight leg raise. – X-ray, MRI if X-ray is inconclusive.	Acute Management: – Pain management. – Immobilization. – Surgical intervention (fixation or hip replacement). Post-Surgical: – Physical therapy for rehabilitation.
Avascular Necrosis	– Gradual onset of hip pain, groin pain. – Pain with weight-bearing, limited range of motion.	– Physical exam: Decreased range of motion, pain with internal rotation. – MRI for early detection, X-ray may show late changes.	Conservative: – NSAIDs for pain management. – Activity modification. Surgical: – Core decompression, osteotomy, or hip replacement depending on severity.
Septic Arthritis/Transient Synovitis	– Acute onset hip pain, fever (septic arthritis). – Limping, limited range of motion.	– Physical exam: Pain with hip movement, fever (septic arthritis). – Blood tests (WBC, ESR, CRP). – Joint aspiration for culture (septic arthritis). – Ultrasound or MRI.	Septic Arthritis: – Intravenous antibiotics. – Surgical drainage. Transient Synovitis: – Rest. – NSAIDs. – Observation and follow-up.
Osteoarthritis	– Gradual onset hip pain, stiffness, worse with activity, relieved by rest. – Limited range of motion.	– Physical exam: Decreased range of motion, crepitus. – X-ray shows joint space narrowing, osteophytes.	Conservative: – NSAIDs. – Physical therapy. – Activity modification. – Weight management. Advanced Treatment: – Corticosteroid injections. – Hip replacement surgery.
Femoroacetabular Impingement (FAI)	– Hip pain, especially with flexion or rotation. – Clicking, locking, or catching sensation.	– Physical exam: Positive FADIR (flexion, adduction, internal rotation) test. – X-ray, MRI or CT scan for bony abnormalities.	Conservative: – NSAIDs. – Activity modification. – Physical therapy. Surgical: – Arthroscopic or open surgery to correct impingement.
Labral Tear	– Hip or groin pain, clicking, locking, or catching sensation. – Pain with hip rotation.	– Physical exam: Positive impingement tests (FABER, FADIR). – MRI arthrogram for detailed view of the labrum.	Conservative: – NSAIDs. – Physical therapy. – Activity modification. Surgical: – Arthroscopic repair or debridement of the labrum.

Hip and Pelvic Conditions

These tables provide a concise overview of the identification, evaluation, and management strategies for common hip conditions.

extra-articular/posterior:

• iliopsoas bursitis
• pubic symphysitis
• muscle and tendon injuries

Condition	Identification	Evaluation	Management
Iliopsoas Bursitis	– Anterior hip pain, may radiate to the groin or thigh. – Pain exacerbated by hip flexion, extension.	– Physical exam: Tenderness over the iliopsoas bursa, pain with resisted hip flexion. – Ultrasound or MRI for confirmation.	Conservative: – Rest, activity modification. – NSAIDs. – Ice application. Injections: – Corticosteroid injections into the bursa. Physical Therapy: – Stretching and strengthening exercises for hip flexors.
Pubic Symphysitis	– Pain localized to the pubic symphysis, may radiate to the groin, inner thighs. – Worsened by activities like running, kicking.	– Physical exam: Tenderness over the pubic symphysis, pain with resisted hip adduction. – X-ray or MRI to rule out other conditions.	Conservative: – Rest, avoid aggravating activities. – NSAIDs. – Ice application. Physical Therapy: – Strengthening exercises for pelvic stabilizers. – Gradual return to activity.
Muscle and Tendon Injuries	– Localized pain, swelling, bruising depending on severity. – Weakness, limited range of motion.	– Physical exam: Tenderness over the affected muscle or tendon, pain with muscle contraction. – Ultrasound or MRI for severe cases.	Conservative: – Rest, avoid aggravating activities. – Ice application initially, then heat. – NSAIDs. Physical Therapy: – Gradual stretching and strengthening exercises. – Progressive return to activity.

postero-lateral:

• greater trochanteric pain syndrome
• piriformis syndrome.

Condition	Identification	Evaluation	Management
Greater Trochanteric Pain Syndrome	– Lateral hip pain, tenderness over the greater trochanter. – Pain worsens with lying on the affected side, walking, or climbing stairs.	– Physical exam: Tenderness over the greater trochanter, pain with resisted hip abduction. – Ultrasound or MRI to confirm bursitis or tendinopathy.	Conservative: – Rest, avoid aggravating activities. – NSAIDs. – Ice application. Physical Therapy: – Stretching and strengthening exercises for hip abductors. Injections: – Corticosteroid injections into the bursa. Advanced Treatment: – Platelet-rich plasma (PRP) injections. – Shockwave therapy.
Piriformis Syndrome	– Buttock pain, may radiate down the leg mimicking sciatica. – Pain exacerbated by sitting, climbing stairs, or hip movements.	– Physical exam: Tenderness over the piriformis muscle, positive piriformis test (pain with hip flexion, adduction, internal rotation). – MRI or nerve conduction studies if diagnosis is uncertain.	Conservative: – Rest, avoid aggravating activities. – NSAIDs. – Ice application followed by heat. Physical Therapy: – Stretching exercises for the piriformis muscle. – Strengthening exercises for hip and gluteal muscles. Injections: – Corticosteroid or anesthetic injections into the piriformis muscle. Advanced Treatment: – Botox injections for muscle relaxation. – Surgical release in severe, refractory cases.

Knee

These tables provide a concise overview of the identification, evaluation, and management strategies for greater trochanteric pain syndrome and piriformis syndrome.

Identify, evaluate and manage knee pain:

anterior:

• patellofemoral syndrome
• patellar tendinopathy
• pre-patellar bursitis
• patellar dislocation

Condition	Identification	Evaluation	Management
Patellofemoral Syndrome	– Anterior knee pain, worsened by activities like squatting, climbing stairs, or prolonged sitting. – Pain behind or around the patella.	– Physical exam: Tenderness along the patellar edges, positive Clarke’s test (patellar compression). – X-ray or MRI to rule out other conditions.	Conservative: – Rest, avoid aggravating activities. – NSAIDs. – Ice application. Physical Therapy: – Strengthening exercises for the quadriceps and hip abductors. – Stretching exercises for the hamstrings and iliotibial band. – Patellar taping or bracing.
Patellar Tendinopathy	– Anterior knee pain localized to the patellar tendon. – Pain worsened by jumping, running, or squatting.	– Physical exam: Tenderness over the patellar tendon, pain with resisted knee extension. – Ultrasound or MRI to assess tendon pathology.	Conservative: – Rest, avoid aggravating activities. – NSAIDs. – Ice application. Physical Therapy: – Eccentric strengthening exercises for the quadriceps. – Stretching exercises for the quadriceps and hamstrings. Injections: – Platelet-rich plasma (PRP) injections. Advanced Treatment: – Shockwave therapy. – Surgical debridement in severe cases.
Pre-Patellar Bursitis	– Swelling and pain over the front of the knee. – Redness and warmth if infected. – Pain exacerbated by kneeling.	– Physical exam: Swelling, tenderness over the pre-patellar bursa, possible signs of infection. – Aspiration and fluid analysis if infection is suspected. – Ultrasound if diagnosis is uncertain.	Conservative: – Rest, avoid kneeling. – NSAIDs. – Ice application. Infection Management: – Antibiotics if infection is confirmed. Injections: – Corticosteroid injections for non-infectious cases. Advanced Treatment: – Aspiration and drainage. – Surgical removal of the bursa in chronic cases.
Patellar Dislocation	– Sudden onset of severe knee pain and deformity. – Knee appears misshapen, patella displaced laterally.	– Physical exam: Visible or palpable patellar displacement, swelling, and limited knee movement. – X-ray to confirm dislocation and rule out fractures. – MRI to assess soft tissue damage.	Acute Management: – Reduction of the dislocation, performed by a trained professional. – Immobilization with a knee brace or splint. – NSAIDs for pain and inflammation. Rehabilitation: – Physical therapy to strengthen the quadriceps and improve knee stability. – Bracing to prevent recurrence. Surgical: – Considered if recurrent dislocations or associated structural damage.

These tables provide a concise overview of the identification, evaluation, and management strategies for patellofemoral syndrome, patellar tendinopathy, pre-patellar bursitis, and patellar dislocation.

posterior:

• distal hamstring tendinopathy
• ruptured baker’s cyst

Condition	Identification	Evaluation	Management
Distal Hamstring Tendinopathy	– Posterior knee pain, worsened by activities like running, jumping, or prolonged sitting. – Tenderness at the distal hamstring attachment.	– Physical exam: Tenderness at the distal hamstring, pain with resisted knee flexion. – Ultrasound or MRI to confirm tendinopathy.	Conservative: – Rest, avoid aggravating activities. – NSAIDs. – Ice application. Physical Therapy: – Eccentric strengthening exercises for the hamstrings. – Stretching exercises for the hamstrings. Injections: – Platelet-rich plasma (PRP) injections. Advanced Treatment: – Shockwave therapy. – Surgical debridement in severe cases.
Ruptured Baker’s Cyst	– Sudden onset of pain and swelling in the calf, may mimic deep vein thrombosis (DVT). – Visible or palpable fluid collection in the popliteal fossa.	– Physical exam: Swelling in the popliteal fossa, calf pain and tenderness. – Ultrasound to confirm cyst rupture and rule out DVT. – MRI if further evaluation is needed.	Conservative: – Rest, elevate the leg. – Compression bandage. – NSAIDs for pain and inflammation. Physical Therapy: – Gentle range of motion exercises once acute pain subsides. Aspiration: – Aspiration of the cyst fluid if symptomatic relief is needed. Advanced Treatment: – Treat underlying joint conditions (e.g., arthritis) to prevent recurrence. – Surgical removal of the cyst in recurrent cases.

These tables provide a concise overview of the identification, evaluation, and management strategies for distal hamstring tendinopathy and ruptured Baker’s cyst.

medial/lateral:

• pes anserine bursitis
• ilio-tibial band syndrome

Condition	Identification	Evaluation	Management
Pes Anserine Bursitis	– Medial knee pain, tenderness below the joint line. – Pain exacerbated by activities like climbing stairs or squatting.	– Physical exam: Tenderness over the pes anserine bursa (medial tibia below the knee joint). – Ultrasound or MRI to confirm diagnosis and rule out other conditions.	Conservative: – Rest, avoid aggravating activities. – NSAIDs for pain and inflammation. – Ice application to reduce swelling. Physical Therapy: – Stretching and strengthening exercises for the hamstrings and quadriceps. – Correction of any biomechanical issues. Injections: – Corticosteroid injections into the bursa if pain persists.
Iliotibial Band Syndrome (ITBS)	– Lateral knee pain, often described as sharp or burning. – Pain worsened by activities like running, especially downhill, or prolonged sitting.	– Physical exam: Tenderness over the lateral femoral epicondyle. – Positive Ober’s test (tight IT band). – Ultrasound or MRI to confirm diagnosis and assess for other conditions.	Conservative: – Rest, avoid aggravating activities. – NSAIDs for pain and inflammation. – Ice application to reduce swelling. Physical Therapy: – Stretching exercises for the iliotibial band and surrounding muscles. – Strengthening exercises for the hip abductors and gluteal muscles. – Foam rolling to release tension in the IT band. Injections: – Corticosteroid injections if pain persists. Advanced Treatment: – Consider surgical release in chronic, refractory cases.

intra-articular:

• ligamentous injuries – collateral and cruciate
• meniscal injuries – medial and lateral
• osteoarthritis
• gout and pseudo-gout
• septic arthritis.

Condition	Identification	Evaluation	Management
Ligamentous Injuries (Collateral and Cruciate)	Signs and Symptoms: – Collateral Ligament Injuries: – Medial or lateral knee pain. – Swelling and bruising along the ligament. – Instability when moving the knee sideways. – Tenderness over the injured ligament. – Cruciate Ligament Injuries: – Anterior or posterior knee pain. – Swelling, often immediate (hemarthrosis). – Feeling of instability or “giving way” in the knee. – Positive Lachman test (ACL), Anterior Drawer test (ACL), or Posterior Drawer test (PCL).	– Collateral Ligament Injuries: Valgus (MCL) or varus (LCL) stress tests. – Cruciate Ligament Injuries: Lachman test, Anterior Drawer test, Posterior Drawer test. – MRI for confirmation and to assess the extent of the injury.	Conservative: – Rest, ice, compression, elevation (RICE). – NSAIDs for pain and inflammation. – Bracing or splinting. Physical Therapy: – Strengthening and stability exercises. Surgical: – Considered for severe injuries or if conservative treatment fails (e.g., ACL reconstruction).
Meniscal Injuries (Medial and Lateral)	Signs and Symptoms: – Pain localized to the medial or lateral knee joint line. – Swelling, often delayed. – Locking or catching sensation in the knee. – Difficulty fully extending or flexing the knee. – Joint line tenderness. – Positive McMurray test, Apley’s compression test.	– Physical exam: Joint line tenderness, McMurray test, Apley’s compression test. – MRI to confirm the diagnosis and determine the extent of the injury.	Conservative: – Rest, ice, NSAIDs. – Activity modification. Physical Therapy: – Strengthening and range of motion exercises. Surgical: – Arthroscopic repair or partial meniscectomy if conservative treatment fails or if there is significant mechanical symptoms.
Osteoarthritis	Signs and Symptoms: – Gradual onset knee pain, worsened by activity and relieved by rest. – Morning stiffness lasting less than 30 minutes. – Crepitus with joint movement. – Decreased range of motion. – Joint swelling and tenderness.	– Physical exam: Decreased range of motion, crepitus, joint line tenderness. – X-ray showing joint space narrowing, osteophytes, subchondral sclerosis.	Conservative: – NSAIDs, acetaminophen for pain relief. – Weight management. – Physical therapy: Strengthening exercises. – Activity modification. Injections: – Corticosteroid or hyaluronic acid injections. Surgical: – Total or partial knee arthroplasty for advanced cases.
Gout and Pseudogout	Signs and Symptoms: – Sudden onset of intense knee pain. – Swelling, redness, warmth over the affected joint. – Limited range of motion. – Fever in some cases. – Gout: Tophi (chronic cases). – Pseudogout: Calcium pyrophosphate deposition.	– Physical exam: Joint swelling, redness, tenderness. – Synovial fluid analysis: Crystals under polarized light (monosodium urate for gout, calcium pyrophosphate for pseudogout). – X-ray: May show chondrocalcinosis in pseudogout.	Acute Management: – NSAIDs, colchicine, or corticosteroids for pain relief. – Rest and ice application. Long-term Management (Gout): – Uric acid-lowering agents (e.g., allopurinol, febuxostat). Pseudogout: – Manage acute attacks and underlying metabolic conditions.
Septic Arthritis	Signs and Symptoms: – Acute onset of severe knee pain. – Significant swelling, redness, warmth. – Fever and chills. – Severe limitation of joint movement. – Pain with passive motion.	– Physical exam: Joint swelling, redness, warmth, severe tenderness. – Synovial fluid analysis: Elevated WBC, positive Gram stain and culture. – Blood tests: Elevated ESR, CRP, blood cultures. – Imaging: X-ray, MRI to assess joint damage.	Acute Management: – Intravenous antibiotics based on culture results. – Joint aspiration for both diagnostic and therapeutic purposes. – Surgical drainage if needed. – Rest and immobilization during acute phase. Rehabilitation: – Physical therapy to restore joint function after infection is controlled.

Ankle and Foot pain

Identify, evaluate and manage ankle and foot pain:

• ankle sprain and associated ligamentous injuries
• Achilles tendinitis and rupture
• tarsal tunnel syndrome
• posterior tibial tendonitis
• osteoarthritis
• hindfoot pain:
  • plantar fasciitis
  • heel pad syndrome
• midfoot pain:
  • tarsometatarsal fracture/dislocation
  • midfoot arthritis
• forefoot pain:
  • Morton’s syndrome
  • bunion
• other:
  • stress fractures.

Condition	Identification	Evaluation	Management
Ankle Sprain and Associated Ligamentous Injuries	Signs and Symptoms: – Pain, swelling, bruising around the ankle. – Difficulty bearing weight. – Instability and tenderness over the affected ligaments. – Lateral sprain: Injury to the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL). – Medial sprain: Injury to the deltoid ligament. – Syndesmotic (high ankle) sprain: Injury to the syndesmotic ligaments.	– Physical exam: Palpation, anterior drawer test, talar tilt test. – X-ray to rule out fractures. – MRI if diagnosis is unclear or to assess severity.	Conservative: – Rest, ice, compression, elevation (RICE). – NSAIDs for pain and inflammation. – Bracing or taping. Physical Therapy: – Strengthening, proprioception, and balance exercises. – Gradual return to activity. Surgical: – Rarely needed, considered for severe or recurrent sprains.
Achilles Tendinitis and Rupture	Signs and Symptoms: – Tendinitis: Gradual onset posterior heel pain, stiffness, tenderness along the Achilles tendon. – Rupture: Sudden onset of sharp pain, “popping” sound, difficulty walking, visible gap above the heel.	– Physical exam: Thompson test (for rupture), palpation, pain with resisted plantar flexion. – Ultrasound or MRI to confirm tendinitis or rupture.	Tendinitis: Conservative: – Rest, ice, NSAIDs. – Heel lifts or orthotics. – Eccentric strengthening exercises. Rupture: – Surgical repair or conservative management with casting/boot. – Post-surgical or post-casting physical therapy for rehabilitation.
Tarsal Tunnel Syndrome	Signs and Symptoms: – Pain, burning, tingling, or numbness on the medial ankle and sole. – Symptoms worsen with activity, relieved by rest.	– Physical exam: Tinel’s sign over the tarsal tunnel, palpation. – Nerve conduction studies, MRI if needed.	Conservative: – Rest, ice, NSAIDs. – Orthotics to support the arch. Injections: – Corticosteroid injections. Surgical: – Tarsal tunnel release if conservative treatment fails.
Posterior Tibial Tendonitis	Signs and Symptoms: – Medial ankle pain, swelling. – Pain worsens with activity, especially walking or standing on tiptoes. – Flatfoot deformity in advanced cases.	– Physical exam: Tenderness along the posterior tibial tendon, pain with resisted inversion. – MRI or ultrasound to confirm diagnosis.	Conservative: – Rest, ice, NSAIDs. – Orthotics or bracing. Physical Therapy: – Strengthening exercises for the posterior tibial tendon. – Stretching exercises. Surgical: – Tendon repair or reconstruction in severe cases.
Osteoarthritis (Foot and Ankle)	Signs and Symptoms: – Gradual onset of joint pain, stiffness. – Swelling, decreased range of motion. – Pain worsened by activity, relieved by rest.	– Physical exam: Joint tenderness, crepitus, decreased range of motion. – X-ray showing joint space narrowing, osteophytes.	Conservative: – NSAIDs, acetaminophen for pain relief. – Weight management. – Orthotics for support. Physical Therapy: – Strengthening and range of motion exercises. Injections: – Corticosteroid injections. Surgical: – Joint fusion or replacement for severe cases.
Plantar Fasciitis (Hindfoot Pain)	Signs and Symptoms: – Sharp heel pain, especially with the first steps in the morning or after prolonged sitting. – Pain localized to the medial calcaneal tubercle.	– Physical exam: Tenderness at the medial calcaneal tubercle, pain with dorsiflexion of toes. – Ultrasound to assess plantar fascia thickness.	Conservative: – Rest, ice, NSAIDs. – Stretching exercises for the plantar fascia and Achilles tendon. – Orthotics or heel pads. Injections: – Corticosteroid injections. Advanced Treatment: – Shockwave therapy. – Surgical release in severe, refractory cases.
Heel Pad Syndrome (Hindfoot Pain)	Signs and Symptoms: – Deep, bruising pain in the center of the heel. – Pain worsened by walking or standing on hard surfaces.	– Physical exam: Tenderness over the heel pad, no specific points of tenderness like in plantar fasciitis. – Ultrasound to assess heel pad thickness.	Conservative: – Rest, ice, NSAIDs. – Soft-soled shoes or heel cushions. – Activity modification to reduce heel stress.
Tarsometatarsal Fracture/Dislocation (Midfoot Pain)	Signs and Symptoms: – Severe midfoot pain, swelling, bruising. – Inability to bear weight. – Visible deformity in severe cases.	– Physical exam: Tenderness over the tarsometatarsal joint. – X-ray, CT scan to confirm diagnosis and assess the extent of injury.	Acute Management: – Reduction and immobilization with a cast or boot. – NSAIDs for pain and inflammation. Surgical: – Open reduction and internal fixation if necessary. – Post-surgical physical therapy for rehabilitation.
Midfoot Arthritis (Midfoot Pain)	Signs and Symptoms: – Chronic midfoot pain, swelling, stiffness. – Pain worsened by weight-bearing activities.	– Physical exam: Tenderness and swelling over the midfoot joints. – X-ray showing joint space narrowing, osteophytes.	Conservative: – NSAIDs, acetaminophen for pain relief. – Orthotics for support. Physical Therapy: – Strengthening and range of motion exercises. Injections: – Corticosteroid injections. Surgical: – Joint fusion in severe cases.
Morton’s Neuroma (Forefoot Pain)	Signs and Symptoms: – Sharp, burning pain in the ball of the foot. – Pain radiates to the toes, often between the third and fourth toes. – Numbness or tingling in the toes.	– Physical exam: Palpable mass between the metatarsal heads, positive Mulder’s sign (clicking sound). – Ultrasound or MRI to confirm diagnosis.	Conservative: – Rest, avoid aggravating activities. – NSAIDs. – Metatarsal pads or orthotics. Injections: – Corticosteroid or alcohol sclerosing injections. Surgical: – Neurectomy if conservative treatment fails.
Bunion (Forefoot Pain)	Signs and Symptoms: – Bony bump at the base of the big toe. – Pain, redness, swelling over the bunion. – Difficulty wearing shoes.	– Physical exam: Visible deformity, tenderness over the bunion. – X-ray to assess the severity of the deformity.	Conservative: – Wearing wider shoes – bunion pads. – NSAIDs for pain relief. – Orthotics to reduce pressure on the bunion. Surgical: – Bunionectomy if conservative treatment fails.
Stress Fractures (Various Locations)	Signs and Symptoms: – Gradual onset of localized pain, worsened by activity and relieved by rest. – Tenderness and swelling over the affected area.	– Physical exam: Localized tenderness, swelling. – X-ray, MRI or bone scan to confirm diagnosis.	Conservative: – Rest, avoid weight-bearing activities. – NSAIDs for pain relief. – Use of a walking boot or crutches if necessary. Physical Therapy: – Gradual return to activity once healed. – Addressing biomechanical issues to prevent recurrence.

• Interpret common rheumatological investigations for recurrent non-specific musculoskeletal symptoms, such as myalgia and arthralgia:
  • positive ANA, anti-dsDNA antibodies
  • HLA-B27
  • rheumatoid factor, anti-CCP antibodies
  • role of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR)
  • extractable nuclear antigen (EBA) antibody profile
  • bilateral hand X-rays.

Investigation	Definitive Diagnosis	Prevalence in Disease (%)	Prevalence in Normal Population (%)	Reasons for False Positives	Notes on Interpretation
ANA (Antinuclear Antibodies)	Not definitive	SLE: 95-99%	5-15%	Healthy individuals, elderly, infections, malignancies, certain medications	High sensitivity for SLE but not specific; used as a screening tool
Anti-dsDNA Antibodies	SLE	SLE: 60-80%	Very rare	Chronic infections, other autoimmune diseases	High specificity for SLE; used to monitor disease activity
HLA-B27	Seronegative spondyloarthropathies	Ankylosing Spondylitis: ~90%	6-9% (varies by ethnicity)	Healthy carriers	Not diagnostic alone; supportive in clinical context
Rheumatoid Factor (RF)	RA (not specific)	RA: 70-80%	Up to 10% (especially in elderly)	Chronic infections, liver disease, other autoimmune diseases	Used in conjunction with clinical findings and other tests
Anti-CCP Antibodies	RA	RA: 60-70%	Very rare	Rarely found in non-RA conditions	High specificity for RA; useful for early diagnosis and prognosis
CRP (C-Reactive Protein)	Inflammation marker	Variable	Variable	Infections, malignancies, chronic diseases	Rapid response to changes in inflammation; used to monitor disease
ESR (Erythrocyte Sedimentation Rate)	Inflammation marker	Variable	Variable	Infections, malignancies, chronic diseases	Slower response than CRP; used to monitor chronic inflammation
ENA (Extractable Nuclear Antigen) Antibody Profile	Specific autoimmune diseases	SLE: varies (e.g., anti-Smith: 30-40%)	Very rare	Generally low false positives, highly specific antibodies	Identifies specific antibodies associated with autoimmune diseases

1. ANA (Antinuclear Antibodies):

• Definition: A group of autoantibodies that target substances within the nucleus of cells.
• Common Diseases: Systemic lupus erythematosus (SLE), Sjögren’s syndrome, scleroderma, mixed connective tissue disease, rheumatoid arthritis.
• Prevalence:
  • Positive in Disease: 95-99% in SLE, lower in other autoimmune diseases.
  • Positive in Normal Population: 5-15%, increases with age.
• False Positives: Can be seen in healthy individuals, elderly, infections, malignancies, certain medications.
• False Negatives: Rare, but possible if the antibody titer is low or the test method is not sensitive enough.
• Testing Method: Indirect immunofluorescence assay (IFA) is the most common method.

2. ENA (Extractable Nuclear Antigen) Antibodies:

• Definition: A subset of ANA, targeting specific nuclear antigens such as Ro, La, Sm, RNP, Jo-1, and Scl-70.
• Common Diseases:
  • Anti-Ro/SSA and Anti-La/SSB: Sjögren’s syndrome, SLE.
  • Anti-Sm: Highly specific for SLE.
  • Anti-RNP: Mixed connective tissue disease, SLE.
  • Anti-Scl-70: Scleroderma.
  • Anti-Jo-1: Polymyositis and dermatomyositis.
• Prevalence:
  • Positive in Disease: Varies (e.g., Anti-Sm in 20-30% of SLE).
  • Positive in Normal Population: Very rare.
• False Positives: Generally low, highly specific antibodies.
• False Negatives: Possible if the disease is in early stages or antibody levels are low.
• Testing Method: ELISA or immunoblotting.

3. dsDNA (Double-stranded DNA):

• Definition: The natural form of DNA, which can be targeted by autoantibodies in certain autoimmune diseases.
• Associated Antibodies: Anti-dsDNA.
• Role in Disease: Anti-dsDNA antibodies specifically target double-stranded DNA and are highly specific for SLE.

4. Anti-dsDNA (Antibodies against Double-stranded DNA):

• Definition: Autoantibodies directed against dsDNA.
• Common Diseases: Anti-dsDNA antibodies are highly specific for SLE, with a specificity of approximately 97-99%. They are less commonly seen in other autoimmune diseases.
• Prevalence:
  • Positive in Disease: 60-80% of patients with SLE.
  • Positive in Normal Population: Very rare.
• False Positives: Rare, but can occur in chronic infections or other autoimmune diseases.
• False Negatives: Possible in SLE if the disease is in remission or the antibodies are below detectable levels.
• Testing Methods:
  • ELISA: Common screening method, high sensitivity.
  • Farr Assay: High specificity, measures high-affinity antibodies.
  • Indirect Immunofluorescence (IIF) on Crithidia luciliae: Gold standard for specificity.
  • Radioimmunoassay (RIA): Highly sensitive and specific, less commonly used.

Summary Table

Test	Target	Diseases Associated	Positive in Disease (%)	Positive in Normal Population (%)	False Positives	False Negatives	Testing Methods
ANA	Nuclear components	SLE, Sjögren’s, scleroderma, MCTD, RA	SLE: 95-99%	5-15%	Healthy individuals, elderly, infections, malignancies, medications	Rare, low antibody titer, insensitive methods	Indirect immunofluorescence assay (IFA)
ENA	Specific nuclear antigens	Sjögren’s, SLE, scleroderma, MCTD, polymyositis	Varies (e.g., Anti-Sm in 20-30% of SLE)	Very rare	Generally low, highly specific antibodies	Early disease, low antibody levels	ELISA, immunoblotting
dsDNA	Double-stranded DNA	SLE	N/A	N/A	N/A	N/A	N/A
Anti-dsDNA	Double-stranded DNA	SLE	60-80%	Very rare	Chronic infections, other autoimmune diseases	Disease remission, low antibody levels	ELISA, Farr Assay, IIF on Crithidia luciliae, Radioimmunoassay

• Classify and manage different types of crystal deposition arthritis in a patient presenting with acute pain and swelling of a joint:
  • gout
  • pseudo-gout.

Differences Between Gout and Pseudogout: Pathology, Diagnosis, and Treatment

Feature	Gout	Pseudogout
Pathology
Crystal Type	Monosodium urate (MSU) crystals	Calcium pyrophosphate dihydrate (CPPD) crystals
Crystal Shape	Needle-shaped	Rhomboid-shaped
Birefringence	Negative birefringence under polarized light	Positive birefringence under polarized light
Deposits	Crystals deposit in joints, tendons, and surrounding tissues	Crystals deposit in articular cartilage and fibrocartilage
Common Sites	First metatarsophalangeal joint (big toe), ankles, knees	Knees, wrists, shoulders, hips
Pathogenesis
Cause	Hyperuricemia due to overproduction or underexcretion of uric acid	Increased production or decreased clearance of pyrophosphate leading to CPPD crystal formation
Triggers	Diet rich in purines, alcohol, dehydration, certain medications	Joint trauma, surgery, metabolic disorders (e.g., hyperparathyroidism, hemochromatosis)
Inflammatory Response	Intense inflammatory response to MSU crystals	Inflammatory response to CPPD crystals
Diagnosis
Clinical Presentation	Acute onset of severe joint pain, swelling, redness, warmth	Acute or subacute joint pain, swelling, redness, warmth
Common Attacks	Sudden onset, often at night, lasting days to weeks	Gradual onset, can be acute or chronic
Synovial Fluid Analysis	Presence of needle-shaped MSU crystals with negative birefringence	Presence of rhomboid-shaped CPPD crystals with positive birefringence
Serum Uric Acid	Elevated during or after attacks (though can be normal)	Often normal
Imaging
X-ray	Can show punched-out erosions with overhanging edges (chronic gout)	Chondrocalcinosis (calcification of cartilage)
Ultrasound	Double contour sign (urate crystal deposition on cartilage)	Hyperechoic bands within the cartilage
MRI/CT Scan	Detect tophi, joint damage	Detect chondrocalcinosis and joint damage
Additional Tests
Blood Tests	Serum uric acid levels	Not specific, but may check for underlying metabolic disorders
Diagnosis Confirmation	Identification of MSU crystals in synovial fluid or tophi	Identification of CPPD crystals in synovial fluid
Associated Conditions	Metabolic syndrome, hypertension, renal insufficiency	Hyperparathyroidism, hemochromatosis, hypothyroidism
Treatment
Acute Management
NSAIDs	First-line treatment for acute attacks (e.g., ibuprofen, naproxen)	First-line treatment for acute attacks (e.g., ibuprofen, naproxen)
Colchicine	Effective if started early in the attack	Effective if started early in the attack
Corticosteroids	Oral or intra-articular injections if NSAIDs and colchicine are contraindicated	Oral or intra-articular injections if NSAIDs and colchicine are contraindicated
Long-term Management
Lifestyle Modifications	Diet low in purines, reduce alcohol intake, increase hydration	Address underlying metabolic disorders (e.g., manage hyperparathyroidism, hemochromatosis)
Medications
Urate-lowering Therapy	Allopurinol, febuxostat (reduce uric acid production)	Not typically required for pseudogout, focus on managing acute attacks and underlying conditions
Uricosuric Agents	Probenecid (increase uric acid excretion)	Not applicable
Regular Monitoring	Monitor serum uric acid levels	Regular follow-up to manage recurrent episodes
Joint Protection
Physical Therapy	Strengthening exercises, joint protection techniques	Strengthening exercises, joint protection techniques
Patient Education	Importance of adherence to treatment, dietary modifications	Importance of managing underlying conditions, avoiding triggers

Summary

• Pathology: Gout involves monosodium urate crystals, while pseudogout involves calcium pyrophosphate dihydrate crystals.
• Diagnosis: Confirmed by synovial fluid analysis showing respective crystals. Imaging and clinical presentation support diagnosis.
• Treatment: Acute attacks managed with NSAIDs, colchicine, and corticosteroids. Long-term management of gout includes urate-lowering therapy and lifestyle modifications, while pseudogout management focuses on treating underlying conditions and preventing recurrent episodes.

identify the infectious causes of polyarthritis and polyarthralgia in a patient presenting with systemic symptoms such as fever and multiple joint involvement:

• rheumatic fever
• Ross River virus fever
• Barmah Forest virus fever
• glandular fever
• other viral infections.

Rheumatic Fever

• Systemic Symptoms: Fever, malaise, arthralgia, fatigue.
• Signs: Migratory polyarthritis, carditis, Sydenham’s chorea, erythema marginatum, subcutaneous nodules, elevated ESR, CRP, positive throat culture, or elevated ASO titers.
• Management:
  • Acute: Penicillin or other antibiotics, NSAIDs, corticosteroids for severe carditis, bed rest.
  • Long-term: Prophylactic antibiotics, regular follow-up with cardiology.

Ross River Virus Fever

• Systemic Symptoms: Fever, fatigue, myalgia, arthralgia.
• Signs: Polyarthritis or polyarthralgia, maculopapular rash.
• Management: Supportive care (rest, NSAIDs, hydration), no specific antiviral treatment.

Barmah Forest Virus Fever

• Systemic Symptoms: Fever, fatigue, myalgia, arthralgia.
• Signs: Polyarthritis or polyarthralgia, rash.
• Management: Supportive care (rest, NSAIDs, hydration), no specific antiviral treatment.

Glandular Fever (Infectious Mononucleosis)

• Systemic Symptoms: Fever, fatigue, sore throat, headache, myalgia.
• Signs: Pharyngitis with exudates, lymphadenopathy, splenomegaly, hepatomegaly, atypical lymphocytosis.
• Management: Supportive care (rest, hydration, NSAIDs or acetaminophen, avoid contact sports), corticosteroids for severe cases.

• Identify, evaluate and manage a patient presenting with symptoms like Raynaud’s phenomenon, suggestive of systemic sclerosis and scleroderma.
• Evaluate and manage a patient with fibromyalgia and chronic fatigue syndrome/myalgic encephalomyelitis using a biopsychosocial approach.
• Identify, evaluate and manage musculoskeletal and rheumatological conditions in children:
  • transient synovitis
  • Legg-Calve-Perthes disease
  • Osgood-Schlatter disease
  • slipped capital femoral epiphysis
  • malignancies:
    • osteosarcoma
    • neuroblastoma
    • leukaemia
  • juvenile idiopathic arthritis
  • growing pains
  • bowed legs
  • knock knees
  • scoliosis
  • pulled elbow
  • torticollis.
• Identify, evaluate and manage patients presenting with red flag symptoms involving musculoskeletal systems:
  • osteomyelitis
  • fractures, including growth plate injuries in children
  • septic arthritis
  • dislocations
  • vertebral injuries and instability
  • cauda equina syndrome.
• Manage patients presenting with non-specific undifferentiated musculoskeletal pain.
• Evaluate and manage patients presenting with non-accidental injuries:
  • domestic violence victims
  • child abuse victims.