Musculoskeletal health

This Topic Guide explores part of the RCGP curriculum, Being a General Practitioner. It will help you understand important issues relating to musculoskeletal health by illustrating the key learning points with a case scenario and questions. It also contains tips and advice for learning, assessment and continuing professional development, including guidance on the knowledge relevant to this area of general practice.

Each Topic Guide is intended to illustrate important aspects of everyday general practice, rather than provide a comprehensive overview of each clinical topic. It should therefore be considered in conjunction with other Topic Guides and educational resources.

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 orthopaedic, rheumatology and pain medicine as well as with allied health disciplines such as physiotherapy, occupational therapy, osteopathy and rehabilitation medicine 
  • 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, dependents and employers. People who experience chronic pain often have comorbid psychological diagnoses, and their care may include counselling support

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 ever before have their joints injected, replaced or resurfaced, often in advanced years, due to advances in medical technology and surgical expertise. At the same time, younger patients experiencing musculoskeletal problems as a result of multisystem disorders (for example, 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 have a significant impact on patients' disease in both the short and long term. 

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 untreated condition including whether acute or chronic 
  • The prevalence and incidence across all ages and any changes over time  
  • 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 cultural factors 
  • Diagnostic features and differential diagnosis 
  • Recognition of 'alarm' or 'red flag' features 
  • Appropriate and relevant investigations 
  • Interpretation of test results 
  • Management including self-care, initial, emergency and continuing care and chronic disease monitoring 
  • Patient information and education including self-care 
  • Prognosis 

Symptoms and signs 

  • Extra-articular symptoms associated with musculoskeletal disease (for example, skin, eye, gastrointestinal manifestations) 
  • Falls 
  • Joint pain, stiffness, swelling, deformity, redness (including individual joints such as back and neck, jaw, hip, knee, ankle, foot, shoulder, elbow, wrist, 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, Ewing's and soft-tissue sarcoma 
  • Cervical spinal disorders including cervical spondylosis, torticollis and 'whiplash' injuries, vertebral fracture and long-term consequences 
  • Congenital/inherited diseases such as osteogenesis imperfecta, Marfan's syndrome, Ehlers-Danlos syndrome, Gaucher's disease, hypermobility syndromes 
  • Crystal arthropathies such as gout, pyrophosphate arthropathy 
  • Fractures, dislocations, haematoma, sprains, strains and other significant soft-tissue trauma: recognition and principles of management  
  • Hand disorders such as trigger finger, Dupuytren's contracture, carpal tunnel syndrome, ulnar nerve compression. Foot disorders such as plantar fasciitis, digital neuroma  
  • Infection such as septic arthritis and osteomyelitis  
  • Inflammatory arthritis and connective tissue diseases such as: rheumatoid arthritis, sero-negative arthritis such as psoriatic arthropathy and axial spondyloarthritis 
  • Lymphoedema  
  • Muscle disorders such as polymyalgia rheumatica and giant cell arteritis, polymyositis and dermatomyositis, fibromyalgia, muscular dystrophies and myasthenia gravis 
  • Osteoarthritis including joint replacement surgery risks and complications 
  • Osteoporosis: primary and secondary 
  • Reactive arthritis, viral arthropathy; connective tissue disorders such as systemic lupus erythematosus, scleroderma, systemic sclerosis 
  • Skeletal problems including disorders of calcium homeostasis such as osteomalacia, rickets, Paget's disease (see also RCGP Topic Guide Endocrinology and Metabolic Problems)
  • Soft tissue disorders such as bursitis, epicondylitis, Achilles tendon problems 
  • Spinal disorders including mechanical back pain, disc lesions, malignancy (primary or metastatic), infection (including osteomyelitis, osteoarthritis, spinal stenosis, osteochondritis), developmental disorders (such as scoliosis and kyphosis), trauma including vertebral fracture and long-term consequences, acute neurological emergencies (such as cauda equina) 
  • Chronic pain (such as complex regional pain syndrome) 
  • Trauma including fractures and primary care management of injuries/ first-aid  
  • Wounds (including surgical) and lacerations: management and principles of care

Examinations and procedures 

  • Examinations: functional assessment, examination of back and spine, joint examinations, systemic manifestation of musculoskeletal problems, exclusion of red flags, screening examinations (for example, GALS) 
  • Procedures: knowledge of the appropriate use of steroid injections (although the ability to administer them is not essential)

Investigations 

  • Investigations: blood tests, X-rays, CT and MRI scans, DEXA scans, bone scans, ultrasound, biochemical and immunological indicators of musculoskeletal problems, nerve conduction studies, tissue biopsy 

  • 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, 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 she 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 which will make her work difficult.  

On examination, she looks generally well and is moderately overweight; there is some curvature in the lower spine which disappears when she bends down to touch her toes – she can almost reach her toes but slowly and with some difficulty.  

You advise Jasmine 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 net" 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 Competence     
                        Questions                

Fitness to practise
This concerns the development of professional values, behaviours and personal resilience and preparation for career-long development and revalidation. It includes having insight into when your own performance, conduct or health might put patients at risk, as well as taking action to protect patients. 

 

 

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? 

Maintaining an ethical approach 
This addresses the importance of practising ethically, with integrity and a respect for 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? 

Communication and consultation 
This is about communication with patients, the use of recognised consultation techniques, establishing patient partnerships, managing challenging consultations, third-party consulting and the use of interpreters. 

 

 

 

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 interpreting the patient's narrative, clinical record and biographical data. It also concerns the use of 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 the adoption of an appropriate and proficient approach to clinical examination and procedural skills. 

 

 

What clinical signs might identify back pain with serious pathology? 

How might I distinguish mechanical lower back pain from nerve root pain? 

Making decisions 
This is about having a conscious, structured approach to decision-making; within the consultation and in wider areas of practice. 

 

 

 

What are the differential diagnoses for Jasmine's symptoms? What is the diagnosis likely to be? 

What tools (for example, scoring systems) are available to assess potential chronicity in back pain? 

How might I use time as a diagnostic tool?  
Clinical management 
This concerns the recognition and management of common medical conditions encountered in generalist medical care. It includes safe prescribing and medicines management approaches. 
What options do I have in treating this problem? 

What follow-up arrangements would I make? 

Managing medical complexity
This is about aspects of care beyond managing straightforward problems. It includes multi-professional management of co-morbidity and poly-pharmacy, as well as uncertainty and risk. It also covers appropriate referral, planning and organising complex care, promoting recovery and rehabilitation. 

 

How would I communicate risk, and involve Jasmine in the management to an appropriate degree? 

What do I know about methods for helping patients to improve lifestyle factors? 

Working with colleagues and in teams 
This is about working effectively with other professionals to ensure good patient care. It includes sharing information with colleagues, effective service navigation, use of team skill mix, applying leadership, management and team-working skills in real-life practice, and demonstrating flexibility with regard to career development. 

 

 

Who else might be involved in the management of Jasmine's back pain for example, physiotherapy, chiropractor? 

Do I know how to get advice from colleagues outside of the primary health care team, before referral? 

What sources of advice do I have within the practice?  

Improving performance, learning and teaching
This is about maintaining performance and effective CPD for oneself and others. This includes self-directed adult learning, leading clinical care and service development, quality improvement and research activity. 

 

 

 

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 which would help me to understand more about her condition?  

Organisational management and leadership
This is about the understanding of organisations and systems, the appropriate use of administration systems, effective record keeping and utilisation of IT for the benefit of patient care. It also includes structured care planning, using new technologies to access and deliver care and developing relevant business and financial management skills. 

 

 

What would be the key points of this consultation that should go in the patient's record? 

How would I read code this consultation?  

Are there any online resources that I could share with Jasmine? 

Practising holistically, safeguarding and promoting health
This is about the physical, psychological, socioeconomic and cultural dimensions of health. It includes considering feelings as well as thoughts, encouraging health improvement, preventative medicine, self-management and care planning with patients and carers. 

 

 

 

What would help Jasmine to stay at work?  

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 orientation
This is about involvement in the health of the local population. It includes understanding the need to build community engagement and resilience, family and community-based interventions, as well as the global and multi-cultural aspects of delivering evidence-based, sustainable healthcare. 

 

 

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 trainee. You will see a wide range of conditions and it is worth keeping a log of the 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 upon the utility of investigations in managing uncertainty and complexity. 

There is no shortage of 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 your patients up can provide a very useful insight into the natural course of musculoskeletal problems and give valuable clues in the clinical conundrums we all face. 

Listen to the language your patients use to describe how their 'brittle bones', 'crumbly spines', 'grinding', 'worn-out' joints are affecting them; how they feel their bodies have let them down. And see how positive language can influence the perception of their pain and improve both how you feel about your ability to help, and the outcome for the patient. When a patient states that, 'all I need is a new pair of knees', ask yourself whether you have done what you can to help alleviate pain and improve function, using pharmacological and non-pharmacological interventions.  

Few GPs in training 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 the elderly, 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, in order 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.  

During placements in A&E you will see plenty of common musculoskeletal problems, including acute back pain. Think about whether you would be confident in managing these patients in the GP surgery setting and whether these patients might be more effectively managed in primary care. 

Try to spend some time with speciality 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 a Special Interest (GPwSI) or Extended Scope 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's 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 will 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 in order to advise your patients appropriately.  

It is important to understand the role of other registered healthcare professionals involved in musculoskeletal care, including physiotherapists, occupational therapists, chiropractors, osteopaths and podiatrists, 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 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 of 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 e-Learning resources available and the RCGP online learning environment has a module on musculoskeletal care.  

Look out for core musculoskeletal skills courses, aimed at GPs, which 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 muscle pain 
  • Recognition of acute, inflammatory arthritis  

Clinical Skills Assessment (CSA) 

  • A profoundly deaf man is training for a charity marathon and has developed pain in his outer thigh. Examination expected 
  • An elderly man has had persistent low back pain for six weeks which is keeping him awake. Examination expected 
  • 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) on a swollen knee joint 
  • COT about a patent who has been started on methotrexate by a specialist for rheumatoid arthritis and the need for blood test monitoring in primary care
     

Next: Neurodevelopmental disorders, intellectual and social disability >

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