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The universal GP Training website for everyone, not just Bradford.Β  Β Created in 2002 by Dr Ramesh Mehay

History of Bradford VTS
Musculoskeletal Health for GPs: Your Survival Guide
⚠️ Updated Guidelines 2026:

NICE NG100 Rheumatoid Arthritis updated November 2024 - new treat-to-target strategies and biologic pathways revised. NICE CG146 Osteoporosis guidance updated October 2024 - FRAX score thresholds revised.

🩺

Musculoskeletal Health for GPs: Your Survival Guide

Joint effort required - no bones about it, this guide will get you moving in the right direction

🍡 Tea-Friendly Learning ⏰ For GP Trainees Short on Time 🚩 Red Flag Focused

Date Updated: March 2026

βœ… Executive Summary: What You'll Master Today

Because you have 47 other things to do before lunch, and that's just the morning list

βœ… What This Page Covers:

  • β€’ Red flags & conditions not to miss
  • β€’ Structured MSK consultation & GALS examination
  • β€’ Joint injections & MSK procedures
  • β€’ Inflammatory vs mechanical pain patterns
  • β€’ All common MSK conditions (OA, RA, gout, fibromyalgia)
  • β€’ Spinal disorders & chronic pain syndromes
  • β€’ Osteoporosis & metabolic bone disease
  • β€’ Soft tissue disorders & MSK trauma
  • β€’ Paediatric MSK (limping child, SCFE)
  • β€’ Prescribing safety & DMARD monitoring
  • β€’ MDT working & referral pathways
  • β€’ AKT/SCA/WPBA exam preparation

πŸ“Š Quick Facts at a Glance:

  • β€’ 20% of GP consultations are MSK-related
  • β€’ Early RA referral within 3 weeks = better outcomes
  • β€’ 85% of back pain is mechanical (self-limiting)
  • β€’ GALS screen takes 2 minutes, catches 96%
  • β€’ Morning stiffness >30 mins = inflammatory
  • β€’ FRAX score >20% = high fracture risk
  • β€’ Fibromyalgia affects 2-4% of population
  • β€’ Septic arthritis = orthopaedic emergency

🎯 Quick Navigation - Jump to Section

⚠️ Red Flags πŸ“‹ Data Gathering πŸ’Š Conditions 🎯 Regional Pain πŸ’‰ Procedures πŸ‘₯ MDT Working πŸ“š MRCGP Exams

πŸ“₯ Resources & Downloads

πŸ“₯ Downloads

path: MUSCULOSKELETAL HEALTH

πŸ”— Web Resources

Shoulder Doc
Comprehensive shoulder diagnosis guide
πŸ”—
CSP Muscle Joint Exercise Videos
Chartered Society of Physiotherapy resources
πŸ”—
Airedale Muscle Joint Exercise Videos & Leaflets
Patient exercise resources and information
πŸ”—
Versus Arthritis - Video Exercises
Exercise videos for arthritis management
πŸ”—
Versus Arthritis - Patient Leaflets
Information resources for patients
πŸ”—
Versus Arthritis - Clinical Examination of MSK
Regional examination techniques
πŸ”—
Moving Medicine - Fabulous Resource!
Go look at it - comprehensive movement medicine
πŸ”—

🧠 Brainy Bites - Quick Learning Nuggets

πŸ›‘οΈ Golden Rules

βœ… GALS first: 2-minute screen catches 96% of MSK problems
βœ… Hot joint + fever = septic arthritis until proven otherwise
βœ… Morning stiffness >30 mins = inflammatory pattern
βœ… Bilateral sciatica + bladder = cauda equina (emergency MRI)
βœ… Age >50 + night pain + weight loss = malignancy until proven otherwise

⚠️ Red Flags - What Not to Miss!

❌ Saddle anaesthesia + bladder dysfunction - cauda equina
❌ Jaw claudication + visual symptoms - giant cell arteritis
❌ Symmetrical small joint swelling - early RA (refer <3 weeks)
❌ Limping child + fever - septic arthritis or osteomyelitis
❌ Pain out of proportion + tight compartment - compartment syndrome

🚨 Red Flags & Conditions Not to Miss

Life- or limb-threatening causes that require urgent recognition or same-day referral

⚠️
Classic triad: Bilateral sciatica, saddle anaesthesia, bladder/bowel dysfunction

Symptoms

  • β€’ Bilateral leg pain/weakness
  • β€’ Saddle anaesthesia (perineum, buttocks)
  • β€’ Urinary retention or incontinence
  • β€’ Faecal incontinence or constipation
  • β€’ Progressive motor weakness
  • β€’ Loss of anal tone

Action

  • β€’ EMERGENCY MRI within 24 hours
  • β€’ Urgent neurosurgical referral
  • β€’ Document bladder function carefully
  • β€’ Post-void bladder scan if available
  • β€’ Do NOT delay for "normal" office hours

SCA Consultation Script

"I need to ask some specific questions about your bladder and bowel function. Have you noticed any difficulty passing urine, or any loss of sensation around your back passage or genitals? These symptoms, combined with your leg pain, could indicate pressure on important nerves that needs urgent investigation."

⚠️
Hot swollen joint + fever + systemically unwell = septic arthritis until proven otherwise

Clinical Features

  • β€’ Acute onset severe joint pain
  • β€’ Hot, red, swollen joint
  • β€’ Fever, rigors, malaise
  • β€’ Unable to weight bear
  • β€’ Restricted range of motion
  • β€’ Systemically unwell

Risk Factors

  • β€’ Immunocompromised (diabetes, steroids)
  • β€’ Joint prosthesis
  • β€’ IV drug use
  • β€’ Recent joint injection
  • β€’ Skin infection/cellulitis
  • β€’ Age extremes (infants, elderly)

Immediate Action

  • β€’ Same-day orthopaedic assessment
  • β€’ Joint aspiration for microscopy, culture, crystal analysis
  • β€’ Blood cultures, FBC, CRP, ESR
  • β€’ IV antibiotics (flucloxacillin + gentamicin)
  • β€’ Surgical washout may be required
  • β€’ Consider osteomyelitis if bone pain
⚠️
Pain out of proportion to injury + pain on passive stretch = compartment syndrome

Clinical Features

  • β€’ Severe pain disproportionate to injury
  • β€’ Pain on passive stretch of muscles
  • β€’ Tense, swollen compartment
  • β€’ Paraesthesia in nerve distribution
  • β€’ Late signs: pulselessness, paralysis

Common Sites

  • β€’ Anterior compartment of leg
  • β€’ Forearm (Volkmann's contracture)
  • β€’ Hand (especially after crush injury)
  • β€’ Thigh (rare but devastating)

Emergency Management

  • β€’ Emergency surgical decompression
  • β€’ Do NOT wait for loss of pulses
  • β€’ Remove all constricting dressings
  • β€’ Elevate limb to heart level (not above)
  • β€’ Urgent orthopaedic/plastic surgery referral

Red Flag Features

  • β€’ Age >50 or <20 years
  • β€’ History of cancer
  • β€’ Unexplained weight loss
  • β€’ Severe night pain
  • β€’ Thoracic back pain
  • β€’ Progressive neurological deficit
  • β€’ Unexplained pathological fracture

Common Primary Sites

  • β€’ Breast (women)
  • β€’ Prostate (men)
  • β€’ Lung
  • β€’ Kidney
  • β€’ Thyroid
  • β€’ Multiple myeloma

Investigation & Referral

  • β€’ Urgent MRI spine within 2 weeks
  • β€’ FBC, ESR, CRP, bone profile, PSA (men)
  • β€’ Chest X-ray
  • β€’ 2WW cancer referral if primary suspected
  • β€’ Oncology referral if known primary
  • β€’ Consider myeloma screen if >60 years
⏰
Window of opportunity: Early DMARD therapy within 3 months prevents joint damage (NICE NG100)

Suspect RA if:

  • β€’ Symmetrical polyarthritis (β‰₯3 joints)
  • β€’ Small joints: MCPs, PIPs, wrists
  • β€’ Morning stiffness >30 minutes
  • β€’ Improves with activity
  • β€’ Systemic symptoms: fatigue, weight loss
  • β€’ Positive squeeze test (MCPs/MTPs)

Initial Tests

  • β€’ Rheumatoid factor
  • β€’ Anti-CCP antibodies (more specific)
  • β€’ ESR, CRP
  • β€’ FBC, U&E, LFTs
  • β€’ X-rays hands/feet
  • β€’ Ultrasound if available (early synovitis)

NICE NG100 Referral Criteria

Refer within 3 weeks if persistent synovitis of undetermined cause, especially if:

  • β€’ Small joints of hands/feet affected
  • β€’ Multiple joints affected
  • β€’ Morning stiffness >30 minutes
  • β€’ Positive anti-CCP or RF
⚠️
Progressive neurological deficit = spinal cord compression until proven otherwise

Clinical Features

  • β€’ Progressive weakness below level of lesion
  • β€’ Sensory level
  • β€’ Bladder/bowel dysfunction
  • β€’ Hyperreflexia, upgoing plantars
  • β€’ Band-like pain at level of compression

Common Causes

  • β€’ Metastatic disease (most common)
  • β€’ Disc prolapse (cervical/thoracic)
  • β€’ Epidural abscess
  • β€’ Haematoma (anticoagulated patients)
  • β€’ Primary spinal tumours

Emergency Management

  • β€’ Emergency MRI within 24 hours
  • β€’ High-dose dexamethasone if malignancy suspected
  • β€’ Urgent neurosurgical/oncology referral
  • β€’ Document neurological level carefully

πŸ“‹ Data Gathering & Examination Tips

Structured MSK consultation in primary care with psychosocial integration

Structured MSK Consultation Framework

Joint vs Muscle vs Bone vs Referred Pain

Joint Pain
  • β€’ Swelling, stiffness, reduced ROM
  • β€’ Worse with movement
  • β€’ May have effusion/warmth
Muscle Pain
  • β€’ Aching, cramping quality
  • β€’ Worse with contraction
  • β€’ May have trigger points
Bone Pain
  • β€’ Deep, constant, boring
  • β€’ Often worse at night
  • β€’ May indicate fracture/malignancy
Referred Pain
  • β€’ Hip pain β†’ knee
  • β€’ Cervical spine β†’ shoulder
  • β€’ Visceral β†’ back/shoulder

Psychosocial Integration (Curriculum Theme)

  • β€’ Work impact: "How is this affecting your work/daily activities?"
  • β€’ Mood: "How are you coping emotionally with this pain?"
  • β€’ Function: "What can't you do now that you could before?"
  • β€’ Beliefs: "What do you think is causing this?"
  • β€’ Fears: "What worries you most about this condition?"
  • β€’ Expectations: "What were you hoping we could do today?"

Extra-articular Symptoms (Systemic Disease)

Skin
  • β€’ Psoriasis (PsA)
  • β€’ Rash (SLE, vasculitis)
  • β€’ Nodules (RA)
Eyes
  • β€’ Uveitis (AS, PsA)
  • β€’ Dry eyes (SjΓΆgren's)
  • β€’ Conjunctivitis (reactive)
GI
  • β€’ IBD (enteropathic arthritis)
  • β€’ Diarrhoea (reactive arthritis)
  • β€’ Mouth ulcers (SLE, BehΓ§et's)

Pain Analysis Framework

Inflammatory vs Mechanical Pattern

Inflammatory
  • β€’ Morning stiffness >30 mins
  • β€’ Improves with activity
  • β€’ Night pain (2nd half of night)
  • β€’ Systemic symptoms
  • β€’ Alternating buttock pain
  • β€’ Age <35 years (IBP)
Mechanical
  • β€’ Activity-related pain
  • β€’ Stiffness <30 mins
  • β€’ Worse end of day
  • β€’ No systemic features
  • β€’ Asymmetrical pattern

SOCRATES for MSK Pain

  • Site: Which joints? Symmetrical? Migratory?
  • Onset: Sudden vs gradual? Trauma? Triggers?
  • Character: Aching, sharp, burning, throbbing?
  • Radiation: Nerve distribution? Referred?
  • Associations: Stiffness, swelling, systemic
  • Timing: Morning vs evening? Duration of stiffness?
  • Exacerbating: Activity, rest, weather, stress?
  • Severity: 0-10 scale, functional impact, sleep

Inflammatory Back Pain Screening

Less Common but Important

Usually lumbar pain with prolonged morning stiffness. Pain often wakes patient in 2nd half of night.

Key Screening Questions

  • β€’ "Does your back pain wake you in the early hours?"
  • β€’ "How long does morning stiffness last?"
  • β€’ "Does the pain improve with activity/exercise?"
  • β€’ "Does the pain alternate from buttock to buttock?"
  • β€’ "Any family history of back problems or arthritis?"

Associated Conditions to Screen For

  • β€’ Uveitis (eye inflammation)
  • β€’ Enthesitis (heel/Achilles pain)
  • β€’ Psoriasis
  • β€’ Inflammatory bowel disease
  • β€’ Peripheral joint inflammation
  • β€’ Recent GI/GU infection

Important: Absence of sacroiliitis on plain X-ray does NOT exclude the diagnosis. Refer to rheumatology if IBP suspected.

Functional & Occupational Impact

ICE Framework

  • Ideas: "What do you think might be causing this?"
  • Concerns: "What worries you most about this pain?"
  • Expectations: "What were you hoping we could do today?"

Functional Assessment

  • β€’ Activities of daily living affected
  • β€’ Work capability and fit note needs
  • β€’ Sleep disturbance and quality
  • β€’ Exercise tolerance and hobbies
  • β€’ Driving ability and safety
  • β€’ Mood and coping strategies
  • β€’ Social isolation and relationships

Work-Related Implications

  • β€’ Manual vs sedentary work
  • β€’ Repetitive strain factors
  • β€’ Workplace adjustments needed
  • β€’ Fit note duration and restrictions
  • β€’ Occupational health referral
  • β€’ Compensation claims considerations

Hidden Agendas

  • β€’ Fear of disability/wheelchair
  • β€’ Work-related compensation claims
  • β€’ Family history concerns (arthritis)
  • β€’ Previous bad experiences with healthcare
  • β€’ Medication fears (steroids, side effects)

Red Flag Screening Questions

Spinal Red Flags

  • β€’ "Have you had any problems with your bladder or bowels?"
  • β€’ "Any numbness around your back passage or genitals?"
  • β€’ "Any weakness in your legs?"
  • β€’ "Have you lost weight recently without trying?"
  • β€’ "Do you have pain that wakes you at night?"
  • β€’ "Have you ever had cancer?"
  • β€’ "Any fever or feeling unwell?"

Joint Red Flags

  • β€’ "Have you felt feverish or unwell?"
  • β€’ "Is the joint hot and swollen?"
  • β€’ "How long does morning stiffness last?"
  • β€’ "Are other joints affected?"
  • β€’ "Any skin rashes or eye problems?"
  • β€’ "Any family history of arthritis?"
  • β€’ "Any recent infections or travel?"
🩺
GALS screening examination takes 2 minutes and identifies 96% of MSK abnormalities. Always start here before focused examination. AKT gold standard.

GALS Screening Examination

G - Gait

  • β€’ "Walk to the end and back"
  • β€’ Observe: symmetry, limp, balance, arm swing
  • β€’ "Walk on your tiptoes, now heels"
  • β€’ Note: antalgic gait, Trendelenburg, foot drop

A - Arms

  • β€’ Inspect: swelling, deformity, muscle wasting
  • β€’ "Put your hands behind your head" (shoulder abduction/ER)
  • β€’ "Stretch arms out, turn palms up and down" (elbow/wrist)
  • β€’ "Make a fist, squeeze my fingers" (hand function)
  • β€’ Squeeze MCPs for tenderness (synovitis screen)

L - Legs

  • β€’ Inspect standing: alignment, swelling, deformity
  • β€’ Lying: "Bend hip and knee up" (hip/knee flexion)
  • β€’ Passive internal rotation of hip
  • β€’ Squeeze MTPs for tenderness
  • β€’ Check for leg length discrepancy

S - Spine

  • β€’ Inspect: posture, deformity, muscle wasting
  • β€’ "Touch your toes" (lumbar flexion)
  • β€’ Lateral flexion left and right
  • β€’ Cervical spine movements (flexion, extension, rotation)
  • β€’ Schober test if indicated (<5cm expansion abnormal)

Focused Joint Examination

Look, Feel, Move, Special Tests

Look

Swelling, erythema, deformity, muscle wasting, scars, skin changes, asymmetry

Feel

Temperature, tenderness, effusion, crepitus, pulses, lymph nodes

Move

Active ROM, passive ROM, resisted movements, end-feel assessment

Special Tests

Joint-specific tests (e.g., McMurray, Lachman, impingement, drawer tests)

Recognising Acutely Inflamed Joint (AKT Focus)

  • β€’ Heat: Compare with contralateral joint
  • β€’ Swelling: Effusion vs synovial thickening
  • β€’ Erythema: Overlying skin changes
  • β€’ Tenderness: Joint line vs periarticular
  • β€’ Reduced ROM: Active and passive limitation
  • β€’ Systemic signs: Fever, malaise, lymphadenopathy

Key Examination Findings

  • β€’ Effusion: Patellar tap, bulge test, cross-fluctuation
  • β€’ Synovitis: Boggy swelling, warmth, tenderness
  • β€’ Crepitus: Coarse (OA) vs fine (inflammation)
  • β€’ Deformity: Ulnar deviation (RA), Heberden nodes (OA)
  • β€’ Muscle wasting: Disuse, nerve lesion, systemic disease

Spine Examination

Cervical Spine

  • β€’ Flexion/extension
  • β€’ Lateral flexion
  • β€’ Rotation
  • β€’ Spurling test (nerve root compression)
  • β€’ Upper limb neurological assessment

Thoracic Spine

  • β€’ Inspect for kyphosis
  • β€’ Rotation (seated)
  • β€’ Chest expansion (<5cm abnormal)
  • β€’ Rib springing
  • β€’ Costovertebral angle tenderness

Lumbar Spine

  • β€’ Flexion (Schober test)
  • β€’ Extension
  • β€’ Lateral flexion
  • β€’ Straight leg raise
  • β€’ Femoral stretch test
  • β€’ Lower limb neurology
⚠️
Limping child: Always examine the hip when child presents with knee pain. Hip pathology commonly refers to knee.

Limping Child/Adolescent Examination

Systematic Approach

  • β€’ Observe gait (antalgic vs Trendelenburg)
  • β€’ Examine from spine down to feet
  • β€’ Always examine hip in knee pain
  • β€’ Compare with contralateral side
  • β€’ Check temperature and general wellness
  • β€’ Assess range of motion (active then passive)

Hip Examination in Knee Pain

  • β€’ Hip flexion, abduction, external rotation
  • β€’ Internal rotation (most sensitive for hip pathology)
  • β€’ Log roll test (passive rotation)
  • β€’ Trendelenburg test (if able to stand)
  • β€’ Leg length measurement

Age-Related Differential

0-5 years: DDH, septic arthritis, osteomyelitis
5-10 years: Perthes disease, transient synovitis
10-16 years: SCFE, juvenile arthritis

Red Flag Paediatric Presentations

SCFE (Slipped Capital Femoral Epiphysis)

  • β€’ Age 10-16, often overweight boys
  • β€’ Hip/knee pain, limp
  • β€’ Limited internal rotation and abduction
  • β€’ External rotation with hip flexion
  • β€’ Urgent orthopaedic referral

Septic Arthritis/Osteomyelitis

  • β€’ Fever, systemically unwell
  • β€’ Refusal to weight bear
  • β€’ Hot, swollen joint
  • β€’ Severe pain on movement
  • β€’ Same-day hospital admission

Transient Synovitis

  • β€’ Age 3-8, often post-viral
  • β€’ Mild limp, low-grade fever
  • β€’ Limited hip movement but not severe
  • β€’ Diagnosis of exclusion
  • β€’ Monitor closely, may need USS

Malignancy

  • β€’ Night pain, weight loss
  • β€’ Bone pain (osteosarcoma, Ewing's)
  • β€’ Systemic symptoms (leukaemia)
  • β€’ Urgent paediatric referral
⚠️
Investigation stewardship: Most MSK conditions are clinical diagnoses. Investigate only when it will change management or exclude serious pathology.

Blood Tests

When to Test

  • β€’ Suspected inflammatory arthritis
  • β€’ Systemic symptoms (fever, weight loss)
  • β€’ Multiple joint involvement
  • β€’ Monitoring DMARD therapy
  • β€’ Suspected malignancy or infection

Inflammatory Markers

  • β€’ ESR: >30 suggests inflammation (age-dependent)
  • β€’ CRP: More specific, faster response (>6 abnormal)
  • β€’ Normal: Doesn't exclude inflammatory arthritis
  • β€’ Very high ESR (>100): Malignancy, infection, GCA

Autoantibodies

  • β€’ Rheumatoid Factor: 70% RA, many false positives
  • β€’ Anti-CCP: 95% specific for RA, prognostic
  • β€’ ANA: Screening for connective tissue disease
  • β€’ HLA-B27: Ankylosing spondylitis (90% positive)
  • β€’ Anti-dsDNA: SLE (specific)

Other Tests

  • β€’ Bone profile: Calcium, phosphate, ALP, vitamin D
  • β€’ Uric acid: Gout (may be normal during attack)
  • β€’ CK: Muscle disease (polymyositis)
  • β€’ PSA: Prostate cancer (men >50 with bone pain)

Imaging

X-rays

  • β€’ Trauma: Suspected fracture (Ottawa rules)
  • β€’ Red flags: Malignancy, infection
  • β€’ Chronic pain: Exclude structural causes
  • β€’ NOT routine for: Mechanical back pain <6 weeks
  • β€’ RA: Hands/feet for erosions, monitoring

MRI Indications

  • β€’ Suspected cauda equina (emergency)
  • β€’ Progressive neurological deficit
  • β€’ Suspected malignancy
  • β€’ Persistent sciatica >6 weeks
  • β€’ Early inflammatory arthritis (if available)

Ultrasound

  • β€’ Soft tissue masses
  • β€’ Guided joint injections
  • β€’ Early synovitis detection
  • β€’ Rotator cuff tears
  • β€’ Baker's cyst vs DVT

DEXA Scan

  • β€’ Osteoporosis risk assessment
  • β€’ Post-menopausal women with risk factors
  • β€’ Men >75 or with risk factors
  • β€’ Monitoring treatment response

Risk & Scoring Tools (AKT Focus)

FRAX Score (Fracture Risk)

  • β€’ 10-year probability of major osteoporotic fracture
  • β€’ Includes age, sex, BMI, risk factors
  • β€’ >20% = high risk (consider treatment)
  • β€’ 10-20% = intermediate (consider DEXA)
  • β€’ <10% = low risk (lifestyle advice)

Oxford Knee/Hip Scores

  • β€’ Patient-reported outcome measures
  • β€’ 12 questions, 0-48 scale
  • β€’ Higher score = better function
  • β€’ Used for surgical referral decisions
  • β€’ Monitoring treatment response

πŸ’Š Common MSK Conditions GPs Should Manage Confidently

Evidence-based management following NICE CKS guidelines

βœ…
NICE NG226: Clinical diagnosis - investigations NOT routinely required. Focus on non-pharmacological treatments first.

Clinical Diagnosis

Key Features

  • β€’ Age >45, activity-related pain
  • β€’ Morning stiffness <30 minutes
  • β€’ Affects weight-bearing joints
  • β€’ Crepitus, bony swelling
  • β€’ No systemic symptoms

Common Sites

  • β€’ Knees, hips (weight-bearing)
  • β€’ Hands: DIPs, CMC thumb
  • β€’ Spine: cervical, lumbar
  • β€’ First MTP (hallux rigidus)

Management (NICE NG226)

πŸƒβ€β™‚οΈ Exercise is KEY for OA Management

GPs don't emphasise this enough: Specific exercises can be more effective than any medication for OA pain. Show patients HOW to do exercises, don't just say "exercise more".

Many patients can become completely pain-free with the right exercise program - no medication needed!

Non-pharmacological (First-line)

  • β€’ Exercise: strengthening and aerobic (MOST IMPORTANT)
  • β€’ Weight loss if BMI >25
  • β€’ Walking aids, supportive footwear
  • β€’ Thermotherapy (heat/ice)
  • β€’ Physiotherapy referral for specific exercise programs

Pharmacological

  • β€’ Topical NSAIDs first-line (knee/hand)
  • β€’ Oral paracetamol (limited evidence)
  • β€’ Oral NSAIDs (short-term, lowest dose)
  • β€’ Intra-articular corticosteroids
  • β€’ Avoid: glucosamine, chondroitin

Surgical Referral Thresholds

Consider Referral When:

  • β€’ Severe symptoms affecting quality of life
  • β€’ Conservative management failed
  • β€’ Significant functional limitation
  • β€’ Patient willing to consider surgery
  • β€’ Fit for anaesthesia

Use Oxford Scores:

  • β€’ Oxford Knee Score <27
  • β€’ Oxford Hip Score <27
  • β€’ Objective measure for referral
  • β€’ Monitor treatment response

Rheumatoid Arthritis (NICE NG100)

Early Recognition

  • β€’ Symmetrical polyarthritis (MCPs, PIPs, wrists)
  • β€’ Morning stiffness >30 minutes
  • β€’ Positive squeeze test
  • β€’ Systemic symptoms: fatigue, weight loss
  • β€’ Extra-articular: nodules, lung involvement

Urgent Referral (<3 weeks)

  • β€’ Persistent synovitis of small joints
  • β€’ Multiple joints affected
  • β€’ Morning stiffness >30 minutes
  • β€’ Positive RF or anti-CCP

Systemic Lupus Erythematosus (SLE)

Clinical Features

  • β€’ Young women (9:1 female predominance)
  • β€’ Malar rash, photosensitivity
  • β€’ Non-erosive polyarthritis
  • β€’ Mouth ulcers, alopecia
  • β€’ Raynaud's phenomenon
  • β€’ Renal, cardiac, CNS involvement

Investigations

  • β€’ ANA positive (95%)
  • β€’ Anti-dsDNA (specific, correlates with activity)
  • β€’ Anti-Sm, Anti-Ro, Anti-La
  • β€’ Low C3, C4 (active disease)
  • β€’ FBC (cytopenias), ESR, CRP
  • β€’ Urinalysis (proteinuria, haematuria)

Psoriatic Arthropathy

Clinical Patterns

  • β€’ Asymmetrical oligoarthritis (most common)
  • β€’ DIP joint involvement
  • β€’ Dactylitis ("sausage digits")
  • β€’ Enthesitis (Achilles, plantar fascia)
  • β€’ Axial involvement (sacroiliitis)
  • β€’ Nail changes (pitting, onycholysis)

Key Features

  • β€’ Psoriasis may precede arthritis
  • β€’ Family history of psoriasis/PsA
  • β€’ HLA-B27 positive (axial disease)
  • β€’ Rheumatoid factor negative
  • β€’ X-ray: "pencil in cup" deformity
  • β€’ Early rheumatology referral essential

Ankylosing Spondylitis

Clinical Features

  • β€’ Age <40, insidious back pain
  • β€’ Morning stiffness >30 minutes
  • β€’ Improves with exercise
  • β€’ Nocturnal pain, alternating buttock pain
  • β€’ Reduced spinal mobility (Schober <5cm)
  • β€’ HLA-B27 positive (90%)

Management

  • β€’ Regular exercise and physiotherapy
  • β€’ NSAIDs continuously (not PRN)
  • β€’ Smoking cessation
  • β€’ Rheumatology referral for DMARDs
  • β€’ Anti-TNF biologics if severe

Schober's Test (Spinal Mobility Assessment)

Technique:
  1. Patient standing upright
  2. Mark over L5 (level with top of iliac crests)
  3. Mark 10cm above first mark along spine
  4. Patient bends forward maximally (knees straight)
  5. Measure distance between marks in flexion

Normal: Distance increases by β‰₯5cm upon flexion
Abnormal: Increase <5cm indicates reduced lumbar flexibility (AS)

Note: Reduced mobility can occur in other conditions, but valuable for monitoring AS progression and treatment response.

Giant Cell Arteritis (GCA)

⚠️
MEDICAL EMERGENCY: Prompt identification prevents sight loss. High index of suspicion required - patients need high-dose steroids.

Clinical Features

  • β€’ Age >50 (usually >65)
  • β€’ New headache, scalp tenderness
  • β€’ Jaw claudication
  • β€’ Visual disturbances
  • β€’ Constitutional symptoms
  • β€’ Often associated with PMR (40-60%)

Urgent Management

  • β€’ Same day bloods: ESR, CRP, FBC
  • β€’ Start steroids immediately if highly probable
  • β€’ Phone rheumatology same day
  • β€’ IMMEDIATE ophthalmology if visual symptoms
  • β€’ High-dose prednisolone (40-60mg daily)

Long-term Management

  • β€’ Regular shared care follow-up for steroid monitoring
  • β€’ Monitor for hypertension, diabetes, osteoporosis
  • β€’ Steroid treatment card and emergency card
  • β€’ Bone protection (calcium + vitamin D, bisphosphonate)
  • β€’ Gastro-protection (PPI)

GCA-PMR Overlap

40-60% of GCA patients have PMR. Both are immune-mediated inflammatory conditions managed by rheumatology.

  • β€’ PMR: Shoulder & hip girdle stiffness
  • β€’ GCA: Headache, scalp tenderness, jaw claudication

Gout

Acute Attack

  • β€’ Sudden onset severe pain
  • β€’ First MTP joint (podagra) most common
  • β€’ Hot, red, swollen, exquisitely tender
  • β€’ Triggers: alcohol, red meat, dehydration
  • β€’ Serum uric acid may be normal during attack

Acute Management

  • β€’ NSAIDs (indomethacin) first-line
  • β€’ Colchicine if NSAIDs contraindicated
  • β€’ Corticosteroids (oral/IA injection)
  • β€’ Start within 24 hours of onset
  • β€’ Continue until 1-2 days after resolution

Prevention (Urate-lowering)

  • β€’ Allopurinol after acute attack settles
  • β€’ Target serum uric acid <300 ΞΌmol/L
  • β€’ Lifestyle: reduce alcohol, weight loss
  • β€’ Avoid purine-rich foods

Pseudogout (CPPD)

Clinical Features

  • β€’ Elderly patients, knee most common
  • β€’ Less severe than gout
  • β€’ Chondrocalcinosis on X-ray
  • β€’ Calcium pyrophosphate crystals
  • β€’ Positively birefringent under polarized light

Management

  • β€’ Similar to gout: NSAIDs, colchicine
  • β€’ Intra-articular corticosteroids effective
  • β€’ No specific urate-lowering therapy
  • β€’ Treat underlying conditions (hyperparathyroidism)

Polymyalgia Rheumatica (PMR)

Clinical Features

  • β€’ Age >50 (usually >65)
  • β€’ Bilateral shoulder and pelvic girdle pain
  • β€’ Morning stiffness >45 minutes
  • β€’ Difficulty rising from chair
  • β€’ Difficulty combing hair/dressing
  • β€’ Constitutional symptoms (fatigue, weight loss)

Investigations

  • β€’ ESR >40mm/hr (usually >50)
  • β€’ CRP elevated
  • β€’ Normal CK (excludes myositis)
  • β€’ Rheumatoid factor negative
  • β€’ Screen for GCA (temporal artery symptoms)

Management

Initial Treatment
  • β€’ Prednisolone 15mg daily
  • β€’ Dramatic response within 48-72 hours
  • β€’ If no response, reconsider diagnosis
Long-term Management
  • β€’ Slow taper over 12-24 months
  • β€’ Bone protection (calcium + vitamin D)
  • β€’ Monitor for GCA symptoms
  • β€’ Regular ESR/CRP monitoring

Fibromyalgia (WPBA Reference)

Diagnostic Criteria Evolution

ACR 1990 Criteria (Traditional)
  • β€’ Widespread pain >3 months (all 4 quadrants + axial)
  • β€’ β‰₯11/18 tender points positive on examination
  • β€’ Note: Often confused with "trigger points" (myofascial pain syndrome)
ACR 2010 Criteria (Current)
  • β€’ Widespread Pain Index (WPI) score
  • β€’ Symptom Severity Scale (SSS) score
  • β€’ Broader understanding: not just localized pain
  • β€’ Includes fatigue, sleep, cognitive symptoms
  • β€’ No alternative explanation for symptoms

Associated Features

  • β€’ Sleep disturbance, non-restorative sleep
  • β€’ Fatigue, cognitive dysfunction
  • β€’ Mood disorders (anxiety, depression)
  • β€’ IBS, headaches, restless legs
  • β€’ Hypervigilance to pain

Biopsychosocial Management

Physical
  • β€’ Graded exercise program
  • β€’ Pacing strategies
  • β€’ Sleep hygiene
  • β€’ Heat therapy
Psychological
  • β€’ CBT for pain management
  • β€’ Mindfulness, relaxation
  • β€’ Address catastrophizing
  • β€’ Goal setting
Pharmacological
  • β€’ Amitriptyline 10-75mg
  • β€’ Pregabalin 150-600mg
  • β€’ Duloxetine 60-120mg
  • β€’ Avoid opioids
βœ…
Exercise is KEY: The most important treatment for chronic LBP is exercise. GPs don't spend enough time emphasising this - exercises can result in patients not needing ANY medication!

Chronic Low Back Pain Management

πŸƒβ€β™‚οΈ Exercise is the MOST Important Treatment

GPs often underestimate the power of exercise. Specific, targeted exercises can be more effective than any medication and can result in patients becoming completely pain-free without needing any drugs.

  • β€’ Show patients specific exercises, don't just say "exercise more"
  • β€’ Refer to physiotherapy for structured exercise programs
  • β€’ Use resources like Escape Pain, CSP videos, and Airedale MSK
  • β€’ Emphasise that movement is medicine - not harmful
  • β€’ Start with gentle exercises and gradually increase

Back Pain Classification & Management

Categorise into 4 Groups:
  • β€’ Non-specific low back pain (most common)
  • β€’ Radicular symptoms (sciatica)
  • β€’ Inflammatory back pain (AS, SpA)
  • β€’ Red flags (TTI - Trauma, Tumour, Infection)
DE-MEDICALISE: DON'T CALL IT ARTHRITIS
  • β€’ Most patients have non-specific LBP - reassure no serious pathology
  • β€’ Expect to settle over WEEKS not days - give realistic timeframes
  • β€’ Do NOT do imaging (X-rays/MRIs) for non-specific LBP
  • β€’ Do NOT use strong opioids, gabapentinoids, or benzodiazepines
  • β€’ Address obesity and inactivity - the "elephant in the room"

Sciatica Management

  • β€’ Most cases settle spontaneously in 2-3 months - reassure and refer to physio
  • β€’ Do NOT use strong opioids, gabapentinoids, or benzodiazepines
  • β€’ Do NOT do imaging (X-rays/MRIs) unless red flags
  • β€’ Address obesity and inactivity
  • β€’ Refer to MSK service if not resolved by 2-3 months
  • β€’ CONSIDER IT > EXAMINE IT > RECORD IT (cauda equina screening)

Biopsychosocial Model

Biological
  • β€’ Disc degeneration
  • β€’ Muscle deconditioning
  • β€’ Inflammation
  • β€’ Central sensitization
Psychological
  • β€’ Fear avoidance beliefs
  • β€’ Catastrophizing
  • β€’ Depression, anxiety
  • β€’ Pain-related distress
Social
  • β€’ Work-related stress
  • β€’ Family dynamics
  • β€’ Benefits system
  • β€’ Social isolation

Yellow Flags (Psychosocial Risk Factors)

  • β€’ Belief that pain is harmful/disabling
  • β€’ Fear avoidance behaviors
  • β€’ Low mood, anxiety, stress
  • β€’ Passive coping strategies
  • β€’ Work dissatisfaction, poor job control
  • β€’ Compensation claims, litigation
  • β€’ Family overprotectiveness

Exercise Prescription for Chronic LBP

Specific Exercise Types
  • β€’ Core strengthening (planks, bridges)
  • β€’ Flexibility exercises (cat-cow, knee-to-chest)
  • β€’ Aerobic exercise (walking, swimming)
  • β€’ Postural exercises
  • β€’ Functional movement training
Patient Education Points
  • β€’ "Movement is medicine, not harmful"
  • β€’ "Some discomfort during exercise is normal"
  • β€’ "Start slowly and build up gradually"
  • β€’ "Consistency is more important than intensity"
  • β€’ "Exercise can be more effective than tablets"

🎯 Regional Joint Pain: Focused Clinical Assessment

Key history questions and examination findings for common joint presentations

⚠️
🚨 SEPTIC ARTHRITIS RED FLAG: Fever + acute knee pain + hot/swollen joint Β± inability to weight-bear Β± nearby wound/cellulitis β†’ URGENT same-day referral for joint aspiration and IV antibiotics.
βœ…
3 Most Important Things: 1) Injury mechanism (especially twisting), 2) Swelling timing (immediate = worrying), 3) Pain patterns (stairs, bending, extending)
⚠️
Post-injury knee: Sudden large swelling = haemarthrosis (serious injury). Twisting injuries almost always cause damage - ask specifically about mechanism.

Focused History Questions

🚨 Critical Questions

  • β€’ "Did your knee swell up immediately?" (haemarthrosis = ACL/fracture)
  • β€’ "Was there a twisting injury?" (meniscus/ligament damage)
  • β€’ "Does your knee lock or catch?" (meniscal tear, loose body)
  • β€’ "Does your knee give way?" (ligament instability)
  • β€’ "Can you fully straighten it?" (mechanical block vs pain)
  • β€’ "Any fever or feeling unwell?" (septic arthritis red flag)
  • β€’ "Any cuts or wounds near the knee?" (infection source)

🚨 SEPTIC ARTHRITIS WARNING

Fever + knee pain + hot joint + wound nearby = SEPTIC ARTHRITIS

Same-day orthopaedic referral for joint aspiration, blood cultures, and IV antibiotics

πŸ“‹ Swelling Patterns

  • β€’ Immediate swelling (0-2 hours) = haemarthrosis (ACL, fracture)
  • β€’ Delayed swelling (6-24 hours) = meniscal tear, bone bruise
  • β€’ Gradual swelling over days = inflammatory arthritis
  • β€’ Recurrent swelling = chronic meniscal tear, OA
  • β€’ No swelling but pain = muscle strain, patellofemoral pain

🎯 Mechanism-Specific Questions

  • β€’ "Foot planted, knee twisted?" = ACL + meniscus
  • β€’ "Direct blow to knee?" = PCL, fracture
  • β€’ "Hyperextension injury?" = ACL, posterior capsule
  • β€’ "Squatting/kneeling pain?" = patellofemoral, meniscus

Key Examination Findings

Joint Line Tenderness

Medial/lateral joint line tenderness = meniscal tear (high sensitivity). Palpate with knee flexed 90Β°, feel along joint line.

Ligament Tests

  • β€’ Lachman Test: 30Β° flexion, anterior draw = ACL
  • β€’ Posterior Drawer: 90Β° flexion, push tibia back = PCL
  • β€’ Valgus Stress: 30Β° flexion, stress medially = MCL
  • β€’ Varus Stress: 30Β° flexion, stress laterally = LCL

Meniscal Tests

  • β€’ McMurray Test: Flex knee, rotate + extend = click/pain
  • β€’ Thessaly Test: Single leg squat + rotation = meniscal pain
  • β€’ Joint Line Tenderness: Most sensitive for meniscal tears

Effusion Assessment

  • β€’ Patellar Tap: Large effusions
  • β€’ Bulge Test: Small effusions
  • β€’ Cross-fluctuation: Moderate effusions

Knee Popping by Activity (Clinical Pearls)

  • β€’ Extending only: Gas bubbles (harmless), plica syndrome, patellofemoral pain
  • β€’ Bending only: Meniscus tear, chondromalacia patella
  • β€’ Both extending & bending: Joint surface damage, arthritis
  • β€’ With twisting + swelling: ACL/MCL injury - seek immediate attention
  • β€’ When walking: Could be any of the above - look for other symptoms
  • β€’ No pain: Usually harmless gas bubbles
⚠️
Red flags: Progressive neurological deficit, myelopathy signs, severe trauma, or systemic symptoms require urgent assessment.

Focused History Questions

🚨 Critical Questions

  • β€’ "Any weakness in your arms or hands?" (myelopathy)
  • β€’ "Difficulty with buttons or writing?" (fine motor loss)
  • β€’ "Any numbness/tingling in arms?" (radiculopathy)
  • β€’ "Problems with balance or walking?" (myelopathy)
  • β€’ "Any recent trauma or whiplash?" (fracture risk)

πŸ“‹ Pattern Recognition

  • β€’ Arm pain worse than neck pain = radiculopathy
  • β€’ Pain worse with coughing/sneezing = nerve root irritation
  • β€’ Morning stiffness >30 mins = inflammatory (RA, AS)
  • β€’ Occipital headaches = upper cervical dysfunction
  • β€’ Bilateral arm symptoms = central pathology

🎯 Mechanism Questions

  • β€’ "What makes it worse?" (movement patterns)
  • β€’ "Better or worse looking up/down?" (extension vs flexion)
  • β€’ "Pain when turning head?" (facet joint vs disc)
  • β€’ "Pillow comfort at night?" (sleeping position tolerance)

Key Examination Findings

Spurling Test (Nerve Root Compression)

Technique: Extend and rotate neck to affected side, apply downward pressure. Positive: Reproduces arm pain = cervical radiculopathy

Myelopathy Signs (Upper Motor Neuron)

  • β€’ Hyperreflexia (biceps, triceps, brachioradialis)
  • β€’ Upgoing plantars (Babinski positive)
  • β€’ Clonus at ankle
  • β€’ Hoffman's sign (finger flick reflex)
  • β€’ Gait disturbance, hand clumsiness

Dermatome Testing

  • β€’ C5: Lateral arm (deltoid patch)
  • β€’ C6: Thumb and index finger
  • β€’ C7: Middle finger
  • β€’ C8: Little finger and medial hand

Focused History Questions

🚨 Critical Questions

  • β€’ "Can you lift your arm above your head?" (rotator cuff function)
  • β€’ "Pain reaching behind your back?" (internal rotation loss)
  • β€’ "Shoulder feels like it pops out?" (instability/dislocation)
  • β€’ "Night pain disturbing sleep?" (rotator cuff tear, frozen shoulder)
  • β€’ "Any recent fall on outstretched hand?" (FOOSH injury)

πŸ“‹ Pattern Recognition

  • β€’ Painful arc 60-120Β° = subacromial impingement
  • β€’ Sudden severe pain + weakness = acute rotator cuff tear
  • β€’ Gradual stiffness + night pain = frozen shoulder
  • β€’ Pain with overhead activities = impingement syndrome
  • β€’ Anterior shoulder pain = biceps tendinopathy

🎯 Functional Questions

  • β€’ "Can you wash your hair?" (abduction + external rotation)
  • β€’ "Can you reach your back pocket?" (internal rotation)
  • β€’ "Pain lifting objects overhead?" (impingement)
  • β€’ "Weakness or just pain?" (distinguish pain inhibition vs true weakness)

Key Examination Tests

Impingement Tests

  • β€’ Hawkins Test: Flex shoulder 90Β°, internally rotate = pain
  • β€’ Neer Test: Passive forward flexion = pain at end range
  • β€’ Painful Arc: Pain between 60-120Β° abduction

Rotator Cuff Tests

  • β€’ Supraspinatus (Empty Can): Abduct 90Β°, thumbs down, resist
  • β€’ External Rotation: Elbows at side, resist external rotation
  • β€’ Lift-off Test: Hand behind back, lift off = subscapularis
  • β€’ Drop Arm Test: Can't control arm lowering = massive tear

Instability Tests

  • β€’ Apprehension Test: Abduct + externally rotate = fear of dislocation
  • β€’ Sulcus Sign: Downward traction = inferior instability

Focused History Questions

🚨 Critical Questions

  • β€’ "Where exactly is the pain?" (true hip = groin, not lateral)
  • β€’ "Pain in your knee too?" (hip pathology refers to knee)
  • β€’ "Difficulty putting on socks/shoes?" (hip flexion loss)
  • β€’ "Limping or walking differently?" (antalgic vs Trendelenburg gait)
  • β€’ "Any clicking or catching?" (labral tear, loose body)

πŸ“‹ Pattern Recognition

  • β€’ Groin pain + stiffness = hip joint pathology (OA, AVN)
  • β€’ Lateral hip pain = trochanteric bursitis (not true hip)
  • β€’ Buttock pain = referred from lumbar spine
  • β€’ Young athlete + groin pain = FAI or labral tear
  • β€’ Night pain + stiffness = inflammatory arthritis

🎯 Age-Specific Questions

  • β€’ Adolescent: "Any hip/knee pain?" (SCFE, Perthes)
  • β€’ Young adult: "Sports involving twisting?" (FAI, labral tears)
  • β€’ Middle-aged: "Steroid use? Alcohol?" (AVN risk factors)
  • β€’ Elderly: "Any falls? Osteoporosis?" (fracture risk)

Key Examination Findings

Hip-Specific Tests

  • β€’ FABER Test: Flexion, ABduction, External Rotation = hip pathology
  • β€’ Internal Rotation: Most sensitive for hip OA (loss of IR)
  • β€’ Log Roll: Passive rotation in supine = intra-articular pathology
  • β€’ Trendelenburg Test: Single leg stand = abductor weakness

Differential Diagnosis Clues

  • β€’ Groin pain + limited internal rotation = hip OA
  • β€’ Lateral hip pain + tender greater trochanter = trochanteric bursitis
  • β€’ Buttock pain + positive SLR = referred from spine
  • β€’ Young + clicking + C-sign = labral tear/FAI

Red Flag Signs

  • β€’ Fixed flexion deformity (severe OA, infection)
  • β€’ External rotation + shortening (fracture)
  • β€’ Unable to weight bear (fracture, severe pathology)
  • β€’ Systemically unwell + hot joint (septic arthritis)

Focused History Questions

🚨 Critical Questions

  • β€’ "Could you weight bear immediately after injury?" (Ottawa rules)
  • β€’ "Which way did your foot twist?" (inversion vs eversion)
  • β€’ "Where exactly is the pain?" (lateral = ligament, medial = deltoid)
  • β€’ "Any numbness in your foot?" (nerve injury)
  • β€’ "Ankle feels unstable or gives way?" (chronic instability)

πŸ“‹ Injury Patterns

  • β€’ Inversion injury (90%) = lateral ligament sprain (ATFL, CFL)
  • β€’ Eversion injury = deltoid ligament, syndesmosis, fracture
  • β€’ High ankle sprain = syndesmosis injury (worse prognosis)
  • β€’ Plantarflexion + inversion = ATFL tear
  • β€’ Dorsiflexion + external rotation = syndesmosis

🎯 Functional Questions

  • β€’ "Can you walk normally?" (functional assessment)
  • β€’ "Pain going up/down stairs?" (dorsiflexion limitation)
  • β€’ "Ankle stiff in the morning?" (arthritis, tendinopathy)
  • β€’ "Recurrent ankle sprains?" (chronic instability)

Ottawa Ankle Rules & Examination

Ottawa Ankle Rules (X-ray if:)

  • β€’ Bone tenderness at posterior edge/tip of lateral malleolus
  • β€’ Bone tenderness at posterior edge/tip of medial malleolus
  • β€’ Unable to weight bear both immediately and in ED (4 steps)

Ottawa Foot Rules (X-ray if:)

  • β€’ Bone tenderness at base of 5th metatarsal
  • β€’ Bone tenderness at navicular bone
  • β€’ Unable to weight bear both immediately and in ED (4 steps)

Ligament Tests

  • β€’ Anterior Drawer: Plantarflex foot, pull heel forward = ATFL
  • β€’ Talar Tilt: Invert heel in neutral = CFL
  • β€’ Squeeze Test: Compress tibia/fibula mid-calf = syndesmosis
  • β€’ External Rotation: Dorsiflex + externally rotate = syndesmosis

Grading Ankle Sprains

  • β€’ Grade 1: Mild stretch, minimal swelling, can weight bear
  • β€’ Grade 2: Partial tear, moderate swelling, painful weight bearing
  • β€’ Grade 3: Complete tear, severe swelling, unable to weight bear

πŸ’‰ MSK Procedures & Prescribing Safety

πŸ’‰
Joint injections: Ensure sterile technique, exclude infection, document consent and post-injection advice.

Indications & Contraindications

Indications

  • β€’ Osteoarthritis (knee, shoulder, hip)
  • β€’ Inflammatory arthritis (bridging therapy)
  • β€’ Soft tissue conditions (tennis elbow, bursitis)
  • β€’ Diagnostic (suspected septic arthritis)

Contraindications

  • β€’ Suspected joint infection
  • β€’ Overlying skin infection
  • β€’ Bleeding disorders/anticoagulation
  • β€’ Prosthetic joint (relative)

Technique & Safety

Preparation

  • β€’ Sterile gloves, skin preparation
  • β€’ Local anaesthetic (lidocaine 1%)
  • β€’ Triamcinolone 40mg or methylprednisolone
  • β€’ 21G needle for large joints

Post-injection Advice

  • β€’ Rest joint for 24-48 hours
  • β€’ Ice if painful/swollen
  • β€’ Return if increasing pain/fever
  • β€’ Effect may take 2-7 days
  • β€’ Duration 3-6 months typically

πŸ’‰ Injection Frequency & Safety Limits

Maximum Frequency

3-4 injections per knee per year maximum (UK MSK guidelines). Most clinicians prefer no more than 3 per year for the same joint.

❗ Why Repeated Injections Aren't Good

  • β€’ Cartilage damage: Accelerates cartilage thinning over time
  • β€’ Joint infection risk: Each injection carries septic arthritis risk
  • β€’ Masks deterioration: Delays definitive treatments
  • β€’ Systemic effects: Glucose rise, bone impact
  • β€’ Tendon weakening: Risk of rupture with peri-tendinous injection
  • β€’ Reduced effectiveness: Diminishing returns over time

🧠 Patient Explanation Script

"Steroid injections can help with pain, but they aren't good to repeat too often because too many can weaken the joint over time. Most people shouldn't have more than 3 injections in the same knee in a year."

⚠️
DMARD monitoring: Regular blood tests essential to detect serious side effects. Follow local shared care protocols.

Methotrexate Monitoring (Most Common)

Baseline Tests

  • β€’ FBC, U&E, LFTs
  • β€’ Chest X-ray
  • β€’ Hepatitis B/C, HIV screen
  • β€’ Pregnancy test (women of childbearing age)

Ongoing Monitoring

  • β€’ FBC, U&E, LFTs every 2 weeks initially
  • β€’ Then monthly once stable
  • β€’ 3-monthly once established
  • β€’ Annual chest X-ray

Stop Methotrexate If:

  • β€’ WBC <3.5, neutrophils <2.0, platelets <150
  • β€’ ALT/AST >2x upper limit normal
  • β€’ Creatinine rise >30% from baseline
  • β€’ Persistent cough, breathlessness
  • β€’ Mouth ulcers, nausea, diarrhoea

NSAID Prescribing Safety

Contraindications

  • β€’ Active peptic ulcer disease
  • β€’ Severe heart failure
  • β€’ Severe renal impairment (eGFR <30)
  • β€’ Severe hepatic impairment
  • β€’ Pregnancy (especially 3rd trimester)

Risk Mitigation

  • β€’ Use lowest effective dose
  • β€’ Shortest duration possible
  • β€’ PPI if GI risk factors
  • β€’ Monitor renal function
  • β€’ Consider topical NSAIDs first

Opioid Stewardship

Avoid Opioids For:

  • β€’ Chronic non-malignant pain
  • β€’ Fibromyalgia
  • β€’ Chronic low back pain
  • β€’ Osteoarthritis (long-term)

If Opioids Necessary (Short-term)

  • β€’ Clear indication and time limit
  • β€’ Start low, go slow
  • β€’ Regular review and tapering plan
  • β€’ Warn about dependence risk
  • β€’ Consider naloxone if high dose

πŸ‘₯ MDT Working & Referral Pathways

Physiotherapy Referrals

Appropriate Referrals

  • β€’ Mechanical low back pain
  • β€’ Osteoarthritis (exercise therapy)
  • β€’ Post-fracture rehabilitation
  • β€’ Chronic pain management
  • β€’ Falls prevention

Information to Include

  • β€’ Clear diagnosis and symptoms
  • β€’ Functional limitations
  • β€’ Red flags excluded
  • β€’ Patient goals and expectations
  • β€’ Work/activity requirements

Rheumatology Referrals

Urgent Referrals (<3 weeks)

  • β€’ Suspected inflammatory arthritis
  • β€’ Persistent synovitis
  • β€’ Positive autoantibodies
  • β€’ Systemic symptoms

Routine Referrals

  • β€’ Established RA needing DMARD review
  • β€’ Suspected connective tissue disease
  • β€’ Complex pain syndromes
  • β€’ Diagnostic uncertainty

Occupational Health & Social Care

Occupational Health

  • β€’ Work-related MSK disorders
  • β€’ Workplace adjustments needed
  • β€’ Fitness for work assessment
  • β€’ Return to work planning

Social Services

  • β€’ Disability living allowance
  • β€’ Personal independence payment
  • β€’ Equipment and adaptations
  • β€’ Care package assessment

Voluntary Sector

  • β€’ Arthritis Action
  • β€’ Versus Arthritis
  • β€’ Local support groups
  • β€’ Exercise classes

πŸ“š MRCGP Exam Preparation: AKT, SCA & WPBA

High-Yield AKT Topics

Must-Know Facts

  • β€’ GALS examination (96% sensitivity)
  • β€’ RA referral criteria (<3 weeks)
  • β€’ FRAX score interpretation (>20% = high risk)
  • β€’ Cauda equina red flags
  • β€’ Septic arthritis management
  • β€’ Osteoarthritis NICE guidelines

Common Exam Scenarios

  • β€’ Limping child (age-specific causes)
  • β€’ Back pain with red flags
  • β€’ Polyarthritis in young woman
  • β€’ Elderly patient with hip fracture
  • β€’ Gout vs pseudogout
  • β€’ Fibromyalgia diagnosis

Key Guidelines & Evidence

NICE Guidelines to Know

  • β€’ NG100: Rheumatoid Arthritis (updated Nov 2024)
  • β€’ NG226: Osteoarthritis in adults
  • β€’ CG146: Osteoporosis (updated Oct 2024)
  • β€’ NG59: Low back pain and sciatica
  • β€’ NG193: Chronic pain assessment

SCA Consultation Skills

Opening & Data Gathering

"I can see you've come in today with some joint pain. Before we start, can you tell me what's been worrying you most about this?"

  • β€’ Explore ICE early
  • β€’ Screen for red flags systematically
  • β€’ Assess functional impact
  • β€’ Consider psychosocial factors

Explaining & Planning

"The good news is that your examination and symptoms suggest this is osteoarthritis, which is very common and manageable. Let me explain what this means and what we can do to help..."

  • β€’ Use simple language, avoid jargon
  • β€’ Check understanding regularly
  • β€’ Involve patient in decision-making
  • β€’ Provide written information

Safety-Netting

"I want you to come back if the pain gets much worse, if you develop a fever, or if you notice any weakness or numbness in your legs. Also, if you're not improving in 2-3 weeks, please book another appointment."

WPBA Learning Opportunities

Case-Based Discussion (CBD)

  • β€’ Complex polyarthritis case
  • β€’ DMARD monitoring decisions
  • β€’ Chronic pain management
  • β€’ Safeguarding in MSK (domestic violence)
  • β€’ Capacity assessment (dementia + fracture)

Consultation Observation Tool (COT)

  • β€’ New patient with joint pain
  • β€’ Breaking bad news (RA diagnosis)
  • β€’ Difficult consultation (chronic pain)
  • β€’ Shared decision-making (joint injection)
  • β€’ Health promotion (osteoporosis prevention)

Reflection Points for Portfolio

Clinical Governance

  • β€’ Delayed diagnosis of inflammatory arthritis
  • β€’ DMARD monitoring failure
  • β€’ Missed cauda equina syndrome
  • β€’ Inappropriate opioid prescribing

Quality Improvement

  • β€’ Audit of RA referral times
  • β€’ Osteoporosis screening in at-risk patients
  • β€’ NSAID prescribing safety
  • β€’ Patient satisfaction with MSK consultations

⚑ Key Reminders - Don't Forget!

ALWAYS Use GALS

Gait, Arms, Legs, Spine screening takes 2 minutes and identifies 96% of MSK problems. Don't skip it - it's your safety net and AKT gold standard.

Think Inflammatory

Morning stiffness >30 minutes, symmetrical small joints, systemic symptoms. Early referral saves joints - window of opportunity is narrow (3 weeks for RA).

Safety-Net Everything

"If pain worsens, you develop fever, or new neurological symptoms, contact us immediately." Document your safety-netting advice - medico-legal essential.

Remember: You don't need to be a rheumatologist to provide excellent MSK care. You just need to know when to worry, when to treat, and when to refer.

β˜• Now go reward yourself with that well-deserved coffee

Congratulations! You've mastered the MSK curriculum

From red flags to DMARD monitoring, from GALS to MRCGP - you're now equipped to provide excellent MSK care in primary care. Remember: you don't need to be a rheumatologist, you just need to know when to worry, when to treat, and when to refer.

βœ… Complete Curriculum Coverage 🩺 MRCGP Ready β˜• Coffee Time!

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How IT ALL STARTED
WHAT WE'RE ABOUT
WHO ARE WE FOR?

Bradford VTS was created by Dr. Ramesh Mehay, a Programme Director for Bradford GP Training Scheme back in 2001. Over the years, it has seen many permutations.Β  At the time, there were very few resources for GP trainees and their trainers so Bradford decided to create one FOR EVERYONE.Β 

So, we see Bradford VTS asΒ  the INDEPENDENTΒ vocational training scheme website providing a wealth of free medical resources for GP trainees, their trainers and TPDs everywhere and anywhere.Β  We also welcome other health professionals – as we know the site is used by both those qualified and in training – such as Associate Physicians, ANPs, Medical & Nursing Students.Β 

Our fundamental belief is to openly and freely share knowledge to help learn and developΒ withΒ each other.Β  Feel free to use the information – as long as it is not for a commercial purpose.Β  Β 

We have a wealth of downloadable resources and we also welcome copyright-free educational material from all our users to help build our rich resource (send to bradfordvts@gmail.com).

Our sections on (medical) COMMUNICATION SKILLS and (medical) TEACHING & LEARNING are perhaps the best and most comprehensive on the world wide web (see white-on-black menu header section on the homepage).

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