The role of the GP in the care of people with musculoskeletal problems
Musculoskeletal problems constitute a significant proportion of GP consultations. As a GP, your role is to:
- advise appropriately to support the self-care and prevention of problems
- intervene urgently when patients present with emergencies or ‘red flag’ symptoms
- coordinate care with other health professionals, leading to effective and appropriate acute and chronic management. Care of patients with musculoskeletal problems will often involve GPs working closely with specialists in orthopaedics, rheumatology and pain medicine as well as with allied health disciplines such as physiotherapy
- coordinate the holistic care of complex patients presenting with symptoms affecting the musculoskeletal system
- communicate effectively, taking into account the psychosocial impact of musculoskeletal problems on the patient, their family, friends, dependants and employers. People who experience chronic pain often have comorbid psychological diagnoses and may require a multidisciplinary approach.
Emerging issues in the care of people with musculoskeletal problems
- People are living longer and remaining active for longer, therefore musculoskeletal problems are presenting to general practice more frequently. More people than before are having their joints injected, replaced or resurfaced, often in advanced years, due to improvements in medical technology and surgical expertise. At the same time, younger patients experiencing musculoskeletal problems as a result of multisystem disorders (such as rheumatoid arthritis) have more medical and surgical options available than in the past and many have shared care with GPs.
- Musculoskeletal conditions are a common cause of severe long-term pain and physical disability and are major causes for work limitation and early retirement.
- In cases of suspected inflammatory arthritis, urgent referral to a rheumatologist can significantly improve outcomes for patients in both the short and long term.
- The longer waiting lists for musculoskeletal surgery exacerbated by Covid-19, and the move to remote consultations for some services such as physiotherapy, mean GPs have an increasing role in managing the biopsychosocial impacts, which may include inequity of access and preventable symptomatic decline.
- There is an increasing place for managing patients with a lifestyle management approach, including discussion about nutrition and physical activity.
Knowledge and skills guide
For the care of people with musculoskeletal problems, consider the following areas within the general context of primary care:
- the natural history of the condition, including whether acute or chronic
- the incidence and prevalence, including in different demographic groups
- typical and atypical presentations
- recognition of normal variations throughout life
- fracture prevention and use of tools to assess fracture risk
- risk factors, including lifestyle, socio-economic and genetic factors
- diagnostic features and differential diagnosis
- recognition of ‘alarm’ or ‘red flag’ features
- appropriate and relevant investigations
- interpretation of test results
- management, including initial and continuing care, chronic disease monitoring and emergency care
- patient and carer information and education, including self-care
- prognosis.
Symptoms and signs
- Extra-articular symptoms associated with musculoskeletal disease (such as skin, eye and gastrointestinal manifestations)
- Falls and trauma
- Joint pain, stiffness, swelling, deformity, redness (including individual joints such as back and neck, jaw, hip, knee, ankle, foot, shoulder, elbow, wrist or hand, or generalised)
- Lumps and deformities of bone, joint or soft tissue
- Muscle pain and weakness
Common and important conditions
- Avascular necrosis
- Bone cancers, including metastatic disease
- Chronic pain
- Congenital or inherited diseases such as osteogenesis imperfecta, Marfan syndrome, Ehlers-Danlos syndrome, Gaucher disease, hypermobility syndromes
- Crystal arthropathies
- Foot disorders such as plantar fasciitis, digital neuroma
- Fractures, dislocations and significant soft tissue trauma
- Hand disorders such as trigger finger, Dupuytren’s contracture, carpal tunnel syndrome, ulnar nerve compression
- Infection such as septic arthritis and osteomyelitis
- Inflammatory arthropathies (sero-positive and sero-negative)
- Lymphoedema
- Muscle disorders such as polymyalgia rheumatica and muscular dystrophies
- Osteoarthritis
- Osteoporosis
- Skeletal problems including disorders of calcium homeostasis such as osteomalacia, rickets and Paget’s disease (see also the Metabolic problems and endocrinology topic guide)
- Soft tissue disorders such as bursitis, epicondylitis and Achilles tendon problems
- Spinal disorders, including mechanical back pain, disc lesions, malignancy (primary or metastatic) and cervical spinal disorders
- Wounds and lacerations
Examinations and procedures
- Examinations: functional assessment, examination of back and spine, joint examinations, systemic manifestation of musculoskeletal problems, exclusion of red flags, screening examinations
- Procedures: knowledge of the appropriate use of steroid injections and joint aspiration (although the ability to perform these is not essential)
Investigations
- Investigations: blood tests, X-rays, joint aspirate analysis, computed tomography (CT) and magnetic resonance imaging (MRI) scans, dual energy X-ray absorptiometry (DEXA) scans, bone scans, ultrasound, biochemical and immunological indicators of musculoskeletal problems, nerve conduction studies, tissue biopsy, scoring systems such as FRAX (fracture risk assessment tool)
Service issues
- Variability of local service provision for musculoskeletal problems
- Service provision for veterans
- Practice policies for supporting staff and patients with musculoskeletal problems, including creating a healthy workplace
Case discussion
Jasmine Cruz, a 32-year-old care assistant in a local residential home, presents with worsening lower back pain over the past month. The pain is confined to her back and does not radiate down her leg. She dates the pain to an episode where she had to lift a patient off the floor unassisted. She offers the information that staff absence rates in her workplace have been high recently – there are not enough people around to help with manual handling.
On questioning, Jasmine says her appetite and weight have been steady, but she has started to feel a bit low and gets increasingly tired towards the end of the day. She has had episodes of back pain in the past, but it has never lasted this long. She lives in a shared house and her family are in the Philippines and rely on the money she sends home to them each month. She is concerned she might be developing a long-term problem that will make her work difficult.
On examination, she looks generally well and is moderately overweight. There is some curvature in the lower spine that disappears when she bends down to touch her toes – she can almost reach her toes but slowly and with some difficulty.
You advise her about work and physical activity and provide an advice leaflet explaining the simple messages around back pain and how to protect the back when lifting and doing heavy work. You suggest that she tries to lose some weight with the objective of reducing the strain on her back. You recommend simple but regular analgesics, especially at night, and provide ‘safety-netting’ advice.
Questions
These questions are provided to prompt you to consider the key points of the case. They can form the basis for a case-based discussion with your educational supervisor and will assist you in writing reflective entries in your ePortfolio. The questions are examples to trigger reflection and are not intended to be comprehensive.
| Core capabilities | Questions |
|---|---|
Fitness to practise This is about professionalism and the actions expected to protect people from harm. This includes the awareness of when an individual’s performance, conduct or health, or that of others, might put patients, themselves or their colleagues at risk. | General practice can be quite a sedentary profession. How do I look after my own musculoskeletal health? What is my own attitude towards people who I believe are falsifying or exaggerating their musculoskeletal symptoms? |
An ethical approach This is about practising ethically with integrity and a respect for equality and diversity. | What further information would prompt me to raise concerns about the local residential home? Who would I raise any concerns with? How would I express my concerns? |
Communicating and consulting This is about communication with patients, the use of recognised consultation techniques, establishing and maintaining patient partnerships, managing challenging consultations, third-party consulting, the use of interpreters and consulting modalities across the range of in-person and remote methods. | How might I negotiate any conflict over time off work (for example, if Jasmine requests ‘a sick note for a few weeks until I feel better’)? What questions would I ask to explore Jasmine's agenda, health beliefs and preferences? How might I help Jasmine to develop her own motivation to lose weight? |
Data gathering and interpretation This is about the gathering, interpretation and use of data for clinical judgement, including information gathered from the history, clinical records, examination and investigations. | What aspects of Jasmine’s case cause me concern? What is the likely prognosis? Would investigations be useful? If so, which ones? |
Clinical examination and procedural skills This is about clinical examination and procedural skills. By the end of training, the GP registrar must have demonstrated competence in general and systemic examinations of all the clinical curriculum areas, including the five mandatory examinations and a range of skills relevant to general practice. | What clinical signs might identify back pain with serious pathology? How might I distinguish mechanical lower back pain from nerve root pain? |
Decision-making and diagnosis This is about having a conscious, organised approach to making diagnosis and decisions that are tailored to the particular circumstances in which they are required. | What are the differential diagnoses for Jasmine’s symptoms? What is the diagnosis likely to be? What tools (such as scoring systems) are available to assess potential chronicity in back pain? How might I use time as a diagnostic tool? |
Clinical management This is about the recognition and a generalist’s management of patients’ problems. | What options do I have in treating this problem? What follow-up arrangements would I make? |
Medical complexity This is about aspects of care beyond the acute problem, including the management of comorbidity, uncertainty, risk and health promotion. | How would I communicate risk, and involve Jasmine in its management to an appropriate degree? What do I know about methods for helping patients to improve lifestyle factors? |
Team working This is about working effectively with others to ensure good patient care and includes sharing information with colleagues and using the skills of a multiprofessional team. | Who else might be involved in the management of Jasmine’s back pain (for example, physiotherapy, a chiropractor)? Do I know how to get advice from colleagues outside the primary health care team before referral? What sources of advice do I have within the practice? |
Performance, learning and teaching This is about maintaining the performance and effective CPD of oneself and others. The evidence for these activities should be shared in a timely manner within the portfolio. | What barriers might I face in providing the ‘best’ care for my patients as defined by national guidelines? What tools are available to stratify those at risk of developing chronic low back pain? What online resources are available that would help me to understand more about Jasmine’s condition? |
Organisation, management and leadership This is about understanding how primary care is organised within the NHS, how teams are managed and the development of clinical leadership skills. | What would be the key points of this consultation that should go in the patient’s record? Which clinical code would I use for this consultation? Are there any online resources that I could share with Jasmine? |
Holistic practice, health promotion and safeguarding This is about the ability of the doctor to operate in physical, psychological, socio-economic and cultural dimensions. The doctor is able to take into account the patient’s feelings and opinions. The doctor encourages health improvement, self-management, preventative medicine and shared care planning with patients and their carers. The doctor has the skills and knowledge to consider and take appropriate safeguarding actions. | What would help Jasmine to stay at work? What are the implications (personal and societal) for sickness absence due to problems like chronic low back pain? What self-care and health promotion advice might I provide to Jasmine on this occasion? What steps could I take to facilitate continuity of care for Jasmine? How might cultural beliefs be relevant in this case? |
Community health and environmental sustainability This is about the management of the health and social care of the practice population and local community. It incorporates an understanding of the interconnectedness of health of populations and the planet. | What are the advantages of a local back pain service? What other options are there for managing musculoskeletal disease in the community? What provision might my practice make for patients and staff with musculoskeletal disorders? |
How to learn this area of practice
Work-based learning
You will have no shortage of clinical exposure to musculoskeletal problems during your time as a GP registrar. You will see a wide range of conditions and it is worth keeping a log of these cases to demonstrate that, with experience, you are becoming confident in managing the conditions.
Musculoskeletal problems offer the opportunity for you to develop clinical skills and reflect on the use of investigations in managing uncertainty and complexity. There are national guidelines and standards of care that can be used to improve outcomes for musculoskeletal patients. Take the opportunity to reflect on the care that you deliver, using tools such as audits, quality improvement projects and reviews of referral activity and use of investigations.
The first contact with a patient is crucial and one of the great things about general practice is the ability to use time as a diagnostic tool. Following up your patients can provide a very useful insight into the natural course of musculoskeletal problems and give valuable clues in the clinical conundrums we all face.
Few GP registrars will get significant exposure to a core musculoskeletal speciality during their time in hospital attachments but many of the patients you will see during your training, especially older adults, will have significant musculoskeletal problems. Take time for a focused examination of a painful joint, and ask about mobility issues, work problems and function around the home, to get a feel for the impact that musculoskeletal conditions can have on the individual. Remember to consider the psychosocial impact of musculoskeletal problems too.
Try to spend some time with specialist nurses and pharmacists engaged in shared care prescribing of disease-modifying anti-rheumatic drugs (DMARDs). Can you think of some of the benefits and potential pitfalls of shared care prescribing? What issues do the nursing team have? How are problems communicated to all involved? Think how you would, as a GP, ensure a safe service for your patients in the community.
Consider attending an orthopaedic clinic and explore the decision to undertake a joint replacement for osteoarthritis. What factors influenced the decision? Were they the same factors for each patient you saw? Were patient decision aids being used?
Many areas have ‘interface’ or ‘tier 2’ musculoskeletal services in the community or hospital setting. GPs with an Extended Role (GPwER) or first contact physiotherapists who work in these services will be able to help you improve your clinical skills, and the patients are a rich resource of common musculoskeletal problems.
Time spent in a local chronic pain service can give a valuable insight into the multidisciplinary approach to managing patients with chronic musculoskeletal and other pain. Pause to reflect on the barriers that patients face to getting back to normal functional levels and also the factors that may have contributed to the development of chronic problems. Were there missed opportunities to address their problems earlier – perhaps preventing progression to a more chronic problem?
Self-directed learning
It is highly unlikely that you will go through the duration of your specialist training and not experience musculoskeletal aches and pains of one sort or other, from the minor through to the more significant. Perhaps you are involved in sport and have noticed some new ache or pain when you are training. How does it make you feel? Are you worried that the pain would get worse? What if you can’t do the things you enjoy? What about work? How would you cope if your pain and disability prevented you following your chosen career path?
Reflecting on such issues provides a valuable insight into how your patients may be feeling when they come to see you. Asking about such worries forms part of the thorough assessment of a patient. If you do not address these concerns, you are less likely to help that person and may miss acting on cues that could prevent the patient from developing a chronic problem.
Learning with other healthcare professionals
Patients may seek advice and treatment from a wide range of other professionals and therapists. As a GP, it is important to gain an understanding of what these practitioners do, and whether the treatment they provide is supported by an evidence base, to advise your patients appropriately.
It is important to understand the role of other registered healthcare professionals involved in musculoskeletal care, to see how their methods differ from yours. These healthcare professionals offer a wide range of interventions and treatments. In particular, time spent with physiotherapists can help improve your assessment and examination skills and enhance your understanding of what patients should expect when they see these professionals.
Other members of the practice team, including nurses and healthcare assistants, spend a lot of time with patients with chronic diseases. They have valuable insights into how patients are getting along. Find out if their assessment includes asking patients about pain and level of function and which validated tools can be used to measure this.
Carers, both professional and informal, may be the best-placed individuals to inform you how a person is coping at home and in the community. You often get a very limited view of the stoical patient within the confines of the surgery.
All GPs have a role in advising patients about fitness for work. How this advice is communicated has a significant effect on the future of that individual’s working life. Discussion with occupational health physicians involved in Department for Work and Pensions Work Capability Assessments can help you understand how decisions regarding work fitness are made and how you as a GP can facilitate patients to stay in work, for example by delivering a consistent message around back pain.
Structured learning
There are many eLearning resources available and RCGP eLearning has a module on musculoskeletal care.
Look out for core musculoskeletal skills courses aimed at GPs that offer the opportunity to develop your consultation and examination skills, as well as keeping you up to date with the latest evidence and opinion on best practice. You may also consider attending courses offering joint injection training.
Examples of how this area of practice may be tested in the MRCGP
Applied Knowledge Test (AKT)
- Risk factors for osteoporosis
- Differential diagnosis of musculoskeletal pain
- Recognition of acute inflammatory arthritis
Simulated Consultation Assessment (SCA)
- A sight-impaired man is training for a charity marathon and has developed pain in his outer thigh
- An elderly man has had persistent low back pain for six weeks, which is keeping him awake
- A teenage boy has had intermittent groin and knee pain for two months and, after a fall playing football yesterday, is limping when trying to walk
Workplace-based Assessment (WPBA)
- Consultation Observation Tool (COT) about the diagnosis of fibromyalgia in a woman with persistent, widespread joint pains with normal investigation
- Clinical examination and procedural skills (CEPS) – musculoskeletal, such as on a swollen joint
- Case-based Discussion (CbD) discussing a patent who has been started on methotrexate by a specialist for rheumatoid arthritis and the need for blood test monitoring in primary care