Conditions of the Musculoskeletal System

This document has been endorsed by the American Academy of Family Physicians and was developed in cooperation with the Association of Departments of Family Medicine, the Association of Family Practice Residency Directors and the Society of Teachers of Family Medicine.

The goal of these guidelines is to provide a framework within which the family practice resident can gain a working knowledge of the many aspects of musculoskeletal disease and gain the skills necessary to provide care for his/her patients. The specialty of family practice is vitally interested in all aspects of musculoskeletal problems. Family physicians must have knowledge of even the most intricate problems so that appropriate judgments are made regarding the ultimate care of the patient.

Appropriate history-taking and competency in physical examination and diagnosis of musculoskeletal problems are essential parts of family practice training. Family physicians should be able to competently diagnose and treat those musculoskeletal problems that are within the scope of family practice. The family physician may not provide definitive care in all instances, depending on training and experience, but must have the knowledge to refer appropriately and educate the patient’s family. The ultimate goal of this curriculum is optimal patient care by the family physician, either with or without a consultant.

Knowledge

Normal anatomy and physiology
Normal growth and development
Musculoskeletal history taking
Principles of musculoskeletal physical examination
Laboratory data including indications, contraindications and interpretation (e.g. joint fluid)
Testing
1. Interpretation of common musculoskeletal radiographs
2. Appropriate use of magnetic resonance imaging, computed tomographic scanning and bone scanning
3. Procedures: indications and understanding of techniques
  1. Arthrogram
  2. Myelogram
  3. Arthroscopy
Pathogenesis/pathophysiology/recognition
1. Joint pain, swelling and erythema
2. Muscular pain, swelling and injury
3. Musculoskeletal trauma
4. Fractures
5. Dislocations
6. Tendon injuries
7. Nerve injuries
8. Bone and joint deformities
9. Bone and joint infections
10. Metabolic bone diseases
11. Musculoskeletal congenital anomalies
12. Musculoskeletal birth injuries
13. Compartment syndrome
14. Avascular necrosis
15. Osteoporosis
16. Overuse syndromes
Pediatric problems
1. Hip dislocation
2. Congenital hip dysplasia
3. Legg Calvé-Perthes disease
4. Osgood-Schlatters disease
5. Slipped capitofemoral epiphysis
6. “Clubfoot” (talipes)
7. Intoeing (metatarsus adductus, tibal torsion, femoral anteversion)
8. “Bow leg” (genu varum) and “knock knee” (genu valgum)
9. Epiphyseal injuries in children according to the Salter-Harris classification
10. Transient synovitis
11. Child abuse
Management and therapy
1. Outline expected course with and without therapy
2. Patient education for acute and chronic problems
3. Pharmacologic treatment
  1. Salicylates
  2. Nonsteroidal anti-inflammatory agents, including cox-2 inhibitors
  3. Steroids, oral and injectable
  4. Muscle relaxants
  5. Antibiotics
4. Supportive and corrective devices
  1. Braces (thoracolumbar, knee)
  2. Casts
  3. Splints
  4. Orthotics
5. Rehabilitation
  1. Physical therapy
    1. Cold, heat
    2. Ultrasound
    3. Exercises
    4. Iontophoresis
  2. Occupational therapy
  3. Alternative modalities
  4. Psychosocial aspects of trauma
6. Surgery
  1. Internal and external fixation devices
  2. Artificial joint replacement
Prevention
1. Pre-participation screening
2. Conditioning and training
3. Injury prevention
4. Physical fitness/Exercise Prescription
5. Bone loss
  1. Nutrition
  2. Exercise
  3. Pharmacology

Skills

Basic Care
1. Fractures (simple, stable, closed and nondisplaced)
  1. Metacarpal, metatarsal, phalangeal
  2. Forearm, single bone midshaft
  3. Humerus, midshaft
  4. Clavicle
  5. Ribs
  6. Vertebrae, lumbar or thoracic compression-type
  7. Pelvis, excluding interruption of the pelvic ring
  8. Patella
  9. Lower leg, single bone midshaft
  10. Unimalleolar ankle
  11. Calcaneus
2. Sprains and strains
  1. Finger
  2. Toe
  3. Ankle
  4. Knee
  5. Vertebral column
  6. Wrist
  7. Elbow
  8. Shoulder
  9. Neck
  10. Muscular strains (e.g. hamstring, trapezius)
3. Other problems
  1. Costochondritis
  2. Bursitis/tendinitis/tenosynovitis
  3. Elbow: “tennis,” “nursemaid,” “little-league”
  4. Entrapment syndrome
  5. Baker’s cyst
  6. Chondromalacia patellae
  7. Osgood-Schlatter disease
  8. Osteochondroses/aseptic necrosis
  9. Osteoarthritis/crystaline-induced arthritis (e.g. gout/pseudo-gout)
  10. Metabolic bone disease (osteoporosis, Paget’s disease)
  11. Acute and chronic low back pain
  12. Foot conditions
    1. Halux Valgus (bunions)
    2. Plantar Fasciitis
    3. Mortons Neuroma
  13. Osteomyelitis
  14. Overuse syndromes
    1. Shoulder impingement
    2. Patellofemoral syndrome
  15. Rheumatologic Disorders
4. Procedures (indications, contraindications and competency)
  1. Joint aspiration (arthrocentesis)
  2. Joint and musculoskeletal injection (local anesthesia, steroid)
  3. Wrapping and taping
    1. Elasticized bandage
    2. Ankle taping
    3. Clavicular figure-of-eight bandage
    4. Soft cervical collar
  4. Splints (upper and lower extremity)
  5. Plaster and fiberglass casts
    1. Short and long leg, with and without walker
    2. Short and long arm
    3. Thumb Spica
    4. Cast wedging
    5. Cast problems
  6. Dislocation reduction
    1. Simple anterior shoulder
    2. Radial head
    3. Simple posterior elbow
    4. Phalanges
    5. Patella
    6. Mandible
  7. Traction application (Buck’s, cervical)
Advanced care
1. Fractures
  1. Closed tarsal and carpal bones, particularly navicular
  2. Colles’ fracture
  3. Nondisplaced medial or lateral epicondyle of humerus
  4. Nondisplaced type I or type II epiphyseal injuries in children
  5. Jones Fracture (proximal 5th metatarsal)
2. Meniscal tears
3. Recurrent dislocations (e.g. shoulder, patella)
Orthopedic Emergency Recognition and Stabilization
1. Compartment Syndrome
2. Hip Dislocation
3. Knee Dislocation
4. Pelvis Fracture
5. Cervical Spine Fracture
6. Cord Injury
Surgical Assisting

Implementation

Learning and experience in the area of musculoskeletal problems will be acquired longitudinally throughout the three years of residency training. The principle site for training in ambulatory musculoskeletal care is the continuing patient care experience in the family practice center. There should be at least minimal experience in inpatient orthopedics. Competently trained enthusiastic preceptors must be available to work individually with residents to teach and assess performance of the desired skills. The teaching of musculoskeletal care lends itself well to hands-on training in core conferences and workshops, using films, patient demonstrations and models. Practice can be provided in bone, muscle and joint examination, splinting, taping, casting, arthrocentesis and rehabilitative measures. Additional training sites that have proved useful include private orthopedic offices, emergency departments, sports medicine and rehabilitation centers and specialized clinics, including adult back, scoliosis and foot clinics. Electives can serve to consolidate orthopedic training, to expose the resident to a greater concentration of common problems or to provide experience with unusual problems (for example e.g. acute ski injury clinics, military bases, training paratroopers, gait and balance clinics for the elderly.)

Resources

Green, MD ed., Essentials of Musculoskeletal Care. 2d ed. AAOS, 2001.
DeLee & Drez’s Orthopaedic Sports Medicine: Principles and Practice. 2d ed. 2-volume, Saunders, 2002.
Bucholz, MD & Heckman, MD. Rockwood, Green and Wilkins’ Fractures, Hardbound/Two-Volume Set Plus CD-Rom. Lippincott, 2001.
Simon, Md & Koenigsknecht, Md, Emergency Orthopedics. 4th ed. McGraw-Hill Publishing, CO., 2001.
Hoppenfeld S. Physical examination of the spine and extremities. New York, NY: Appleton-Century-Crofts, 1976.
Steinberg GG, Atkins CM, Baran DT, Ramamurti CP.eds. Ramamurti’s Orthopedics in primary care. 2d ed. Baltimore, MD: Williams & Wilkins, 1992.
Lillegard WA, Butcher JD, Rucker KS. Handbook of Sports Medicine. 2nd ed. Butterworth, Heinemann, Woburn, MA, 1999.

Web Sites

http://www.acsm.org American College of Sports Medicine
http://www.amssm.org American Medical Society for Sports Medicine
http://www.physsportsmed.com The Physician and Sports Medicine

Published 7/95
Revised 12/01