THE AUSTRALIAN MUSCULOSKELETAL
CORE COMPETENCY PROJECT
(2005 - 2010)
A PROJECT DIRECTED THROUGH THE
AUSTRALIAN ORTHOPAEDIC ASSOCIATION RESEARCH FOUNDATION
Project Director: A/Prof Mellick J Chehade
Development of National Core Competencies in
Musculoskeletal Basic and Clinical Science
DETAILED COMPETENCY CONCENSUS DOCUMENT
DEC 2010
THE AUSTRALIAN MUSCULOSKELETAL EDUCATION COLLABORATION
A project to improve the health of the nation through better medical education delivery, supported by
funding from the Australian Government
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AMSEC Core Competency Framework
(a more-detailed AMSEC Core Competency Framework available as a separate document/interactive pdf through the AMSEC website: www.amsec.org.au )
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Table of Contents
Goals and Objectives of the AMSEC Project - 2005 ............................................................ 9
Background ...................................................................................................................... 10
Development of the AMSEC Framework and Musculoskeletal Core Competencies ......... 12
The AMSEC Framework .................................................................................................... 14
The contents of this document have been cross-referenced with the AMSEC Core Competency Framework (shown in
blue font). Sections of the AMSEC Core Competency Framework are included to illustrate where and how the
competencies to the framework. A more complete AMSEC Core Competency Framework is shown on the preceding
page with a more-detailed AMSEC Core Competency Framework avaialble as a separate document/interactive pdf
through the AMSEC website: www.amsec.org.au
Basic Science and Supporting Knowledge > Fundamental Basis of Medicine >
Biomedical Sciences
Anatomy Principles .......................................................................................................... 16
Biology of Cells ................................................................................................................. 26
Biochemistry and Molecular Biology ................................................................................ 27
Human Development and Genetics .................................................................................. 29
Biology of Tissue Response to Disease ............................................................................. 30
Multisystem Processes ..................................................................................................... 32
Pharmacodynamic and Pharmacokinetic Processes ......................................................... 34
Microbial Biology and Infection........................................................................................ 35
Immune Responses .......................................................................................................... 36
Research Methods ........................................................................................................... 38
Basic Science and Supporting Knowledge > Fundamental Basis of Medicine
Behavioural and Social Science ........................................................................................ 39
Basic Science and Supporting Knowledge > Fundamental Basis of Medicine
Professionalism ................................................................................................................ 40
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Basic Science and Supporting Knowledge > Specialised >
Scientific Basis of Musculoskeletal Practice > Normal Processes
Biomechanics ................................................................................................................... 44
Calcium and Phosphate Metabolism ................................................................................ 46
Skeletal System and Bones ............................................................................................... 48
Articular System and Joints .............................................................................................. 50
Muscular System and Muscles ......................................................................................... 54
Nervous System and Nerves............................................................................................. 57
Scientific Basis of Musculoskeletal Practice > Abnormal Processes
General Pathological Processes in Musculoskeletal Conditions........................................ 59
Specific Reactions of Musculoskeletal Tissues to Disorders and Injuries .......................... 61
Musculoskeletal Deformities ............................................................................................ 65
Scientific Basis of Radiology and Imaging > Normal Processes
Fundamentals of Image Production ................................................................................. 66
Radiological Anatomy ...................................................................................................... 70
Radiographic Views and Landmarks to Identify ................................................................ 70
Scientific Basis of Radiology and Imaging > Abnormal Processes
Injury and Pathological Conditions ................................................................................... 84
Reactions of Specific Tissues ............................................................................................ 85
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Clinical Sciences and Skills > General Principles of Assessment and Management in
Medicine > General Assessment
General Principles of Clinical Imaging............................................................................... 86
Medicine > Interpretation and Decision Making
Critical Reasoning and Biostatistics .................................................................................. 88
Diagnostic Formulation .................................................................................................... 90
Medicine > Management of Conditions Common Across Health
Wound Management ....................................................................................................... 92
Medicine > General Procedural/Equipment Usage Skills
General Principles of Procedures and Equipment Usage .................................................. 95
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Clinical Sciences and Skills > Principles of Musculoskeletal Practice >
Musculoskeletal Assessment
History ............................................................................................................................. 97
Musculoskeletal Assessment > Examination
General Principles of Musculoskeletal Examination ....................................................... 100
GALS (Gait, Arms, Legs, Spine) ....................................................................................... 103
Spine .............................................................................................................................. 106
Hip and Pelvis ................................................................................................................. 109
Knee ............................................................................................................................... 112
Ankle & Foot.. ................................................................................................................ 116
Shoulder......................................................................................................................... 120
Elbow ............................................................................................................................. 124
Wrist and Hand .............................................................................................................. 127
Trauma Examination ...................................................................................................... 131
Neurological Examination .............................................................................................. 133
Gait Examination ............................................................................................................ 135
Paediatric Examination .................................................................................................. 136
Musculoskeletal Assessment > Investigations
Laboratory...................................................................................................................... 140
MSK imaging .................................................................................................................. 142
Ancillary Investigations .................................................................................................. 148
Clinical Sciences and Skills > Principles of Musculoskeletal Practice
Musculoskeletal Diagnostic Formulation........................................................................ 150
Musculoskeletal Management Modalities > Therapeutic > Non-Operative
Pharmacological ............................................................................................................. 152
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Exercise and Rest ........................................................................................................... 154
Supports and Aids .......................................................................................................... 156
Nutrition ........................................................................................................................ 158
Psycho-Social Management ........................................................................................... 159
Musculoskeletal Management Modalities > Therapeutic
Operative ....................................................................................................................... 160
Musculoskeletal Management Modalities
Rehabilitation................................................................................................................. 163
Patient Education and Self Management ....................................................................... 165
Shared Care and Referral ............................................................................................... 167
Prevention ..................................................................................................................... 168
Complementary and Alternative Medicine .................................................................... 170
Clinical Sciences and Skills > Principles of Musculoskeletal Practice
Musculoskeletal Conditions ........................................................................................... 172
Musculoskeletal Procedural Skills > General
Limb Realignment .......................................................................................................... 173
Splinting Procedures ...................................................................................................... 175
Injection Procedures ...................................................................................................... 178
Priorities of Musculoskeletal Practice > MSK Emergencies
Open Fractures .............................................................................................................. 180
Musculoskeletal Injuries with Neurological, Vascular and/or Visceral Involvement ....... 182
Compartment Syndrome ................................................................................................ 184
Cauda Equina Syndrome ................................................................................................ 187
Bone and Joint Infections ............................................................................................... 189
Temporal Arteritis .......................................................................................................... 194
Musculoskeletal Mimickers ............................................................................................ 195
Priorities of Musculoskeletal Practice > National Priority and High Burden MSK
Conditions
Back Pain and Sciatica .................................................................................................... 197
Osteoporosis .................................................................................................................. 201
Osteoarthritis ................................................................................................................. 204
Rheumatoid Arthritis...................................................................................................... 208
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Juvenile Idiopathic Arthritis............................................................................................ 211
Priorities of Musculoskeletal Practice
Priority Ambulatory Conditions ...................................................................................... 215
Publications...................................................................................................................... 220
Acknowledgements ........................................................................................................ 220
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Goals and Objectives of the AMSEC
Project - 2005
The mission of the AMSEC Project is to advance national health care standards by ensuring the
delivery of world-leading musculoskeletal education to the country’s trainee medical professionals.
The vision is to have the defined musculoskeletal core competencies developed for
implementation into the curricula of all Australian Medical Schools by 2010
AMSEC Goals
Goal 1: National Consensus: To achieve a consensus amongst all stakeholders involved in the
practice or education of Musculoskeletal Science on the need for national core competencies and
to develop a plan of action to address this need.
Goal 2: Core Competency Definition: To define and achieve agreement on the Musculoskeletal Core
Competencies with respect to Red Flag Emergencies, a standardised National Physical
Examination and Core Basic and Clinical Musculoskeletal Science.
Goal 3: Core Competency Assessment: To ensure that the defined “core” knowledge and skills are
being appropriately assessed by developing strategic assessment philosophies and assisting in the
development of both formative and summative assessment tools and strategies.
Goal 4: Chronic Disease Self-Management: To improve the quality of life of patients with chronic
musculoskeletal conditions by ensuring that heath care professionals are appropriately educated
and trained to effectively empower patients with necessary skills, confidence and resources to be
actively involved at the centre of their own health care
AMSEC Objectives

To improve the delivery of musculoskeletal care in Australia by establishing a minimum
national baseline in musculoskeletal education. This is to be achieved through the
development, provision and maintenance of national multi-disciplinary core competencies
targeted at medical students, doctors, allied health practitioners and patients.

To ensure that graduating Australian health care professionals are suitably equipped in the
areas of musculoskeletal basic and clinical sciences to address the increasing impact of
chronic musculoskeletal conditions such as osteoarthritis, rheumatoid arthritis and
osteoporosis.

To ensure that graduating Australian health care professionals are suitably versed in the
concept of “Chronic Disease Self-Management” (CDSM) as an integral part of patient
management.
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Background
The AMSEC Project is funded through the Department of Health and Ageing and stems from
original work done as part of the International Bone and Joint Decade (BJD) which identified that
there are significant gaps in the level of knowledge and education of medical students in regard to
musculoskeletal (MSK) medicine globally. This was also unanimously acknowledged in meetings
between the Project Director and representatives from all Australian medical schools at the outset
of this project in 2005, and has been reinforced with recent research in the Australian context.
Over the past four and half years the AMSEC Project Team has been working with representatives
of Australian universities, key professional colleges and bodies, national and international experts
in MSK medicine, medical educators, students and consumer organisations to develop the MSK
competencies and to ensure their relevance and applicability to the Australian context. They have
also been developed in line with the AMC-defined standards. A series of national expert Working
Groups were established to review draft competencies (developed by the AMSEC Project Team) in
the areas of Physical Examination, Musculoskeletal Emergency Conditions, Patient Education and
Self Management, Procedural Skills and Rehabilitation.
Basic and Clinical Science Working Groups were also established as it became clear when
development of the AMSEC competencies began, that without a basic knowledge framework
providing the context for the competencies, they would have little meaning for medical curricula.
Basic and Clinical Science core knowledge was always envisaged as forming the core component
for the AMSEC competencies, and a simple, lucid and evidence-based structure or framework for
presenting this core knowledge has been developed.
A key factor in the success of the AMSEC Project has been the involvement of the various
professional colleges (e.g. medical, nursing, physiotherapy) which has ensured that standards for
undergraduate education are agreed upon and provide the necessary base for further
specialisation. It has also fostered links between the professional, clinical and education sectors,
thus serving to promote greater clinical engagement in education during placements, because
clear learning objectives are provided through the Framework, and clinicians have played a key
role in the development of the competencies.
As implementation of the AMSEC Framework and competencies into Australian medical curricula
progresses, it is evident that this evidence-based curriculum tool is setting the standards by which
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medical programs are benchmarking their MSK content and teaching. Thus a national standard for
the level of required knowledge and skills for the effective management of MSK conditions has
been set.
The AMSEC Project therefore provides an excellent template to inform the development of a
highly-collaborative interdisciplinary approach to health education at a national level, ensuring
accuracy, relevance and comprehensiveness and which offers an effective springboard for national
collaboration across a variety of professions and educational organisations, thus providing a
mechanism for breaking down barriers and facilitating assessment between professional and
educational silos.
In summary therefore, the AMSEC Model offers:

a process for engaging educators, professionals and clinicians across sectors at a local,
national and international level in the development of specific competencies

a process for developing a practical and useful framework and competencies which can be
adopted into existing curricula with a minimum of disruption

a system for developing evidence-based, consensus educational standards for the
management of specific health conditions by defining them in terms of competencies, with the
supporting core knowledge, skills and attitudes defined and detailed to be consistent with the
required competency level.

a process for developing key evidence-based resources to support and complement the
competencies. Provision of resources is a key strategy to support the uptake of a competencybased educational intervention.

It incorporates both formative and summative assessments based specifically on the
knowledge base and competencies articulated in the Framework and linked to resources
developed by musculoskeletal care and management experts from across Australia.

AMSEC is efficient / effective/ collegiate

The AMSEC Framework can be adapted to any curriculum
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Development of the AMSEC Framework
and Musculoskeletal Core Competencies
The AMSEC Framework
Throughout 2008 and into 2009, the AMSEC Project concentrated on developing core
competencies in the nominated areas of:

Physical Examination

Red Flags

Procedural Skills

Musculoskeletal Emergencies (Red Flags)

Patient Education and Self-Management
However, as development of competencies in the areas of Basic and Clinical Science progressed,
and planning for implementation was undertaken, it rapidly became evident that the competencies
could not be practically implemented into medical curricula unless an overarching context was
provided which encompassed the basic and clinical science core knowledge base. This core
knowledge base is not exclusive to MSK medicine, however it is core for understanding the
competencies. It was therefore decided to develop a generalised framework for health education to
facilitate the implementation of the core competencies.
In order to understand and effectively practice MSK medicine, a fundamental knowledge of the
basic sciences (such as biochemistry and biology) is assumed, however the scope and detail of
that knowledge has not been clarified to date. This is particularly so in the areas of anatomy and
the pathophysiology of MSK conditions, whilst the key elements of a standardised physical
examination have also not been agreed upon nor specified. The AMSEC Framework provides a
detailed outline of the basic knowledge required for effective MSK practice, and details specific
competencies in key skill areas. It has two broad sections:
1.
An outline of the basic and clinical science components common across medical
disciplines and health professions, which are then related to MSK-specific basic and
clinical science
2.
Competencies specifically related to MSK practice.
Building on the basic science principles and objectives, the clinical science competencies identified
in the AMSEC Framework define general principles and encompass not only the directly practical
aspects of assessment and management of MSK conditions, but also other important related
management modalities and issues. These include patient education and self-management,
prevention, evidence appraisal and critical reasoning, safety and quality care, professionalism and
other areas required for the provision of quality patient-focussed holistic care. For this reason many
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of the clinical competencies that are fundamental or common across disciplines have been
separated from those that would be considered more specifically MSK.
Each element of the Framework has defined learning outcomes which become more specific and
detailed as the framework “unfolds”. Each outcome has the facility for linkage to a range of
resources such as NHMRC and other national evidence-based consensus guidelines, multimedia
presentations, podcasts and formative assessment tools. A “Level of Practice” based on
knowledge and procedural skills has also been assigned to each competency based on the
expected clinical role or domain of practice. These are a central strategy for ensuring vertical
integration within a curriculum and the assigned levels of practice can be adopted and refined
across disciplines providing a foundation for interdisciplinary collaboration but also maintaining
discipline-specific identify and speciality. The development of related education resources can be
shared whilst simultaneously promoting a "common language" that will enhance inter-professional
collaboration in both education and practice.
The AMSEC Framework is not a curriculum. It was designed to define the standard of MSK
education appropriate for Australian universities and to provide suitable learning outcomes. The
standards are defined in terms of competencies, with the supporting core knowledge, skills and
attitudes defined and detailed to be consistent with the required competency level. It was
envisaged that these competencies could be mapped into existing curricula enabling the
identification of important gaps that need to be addressed, thus ensuring that an appropriate
minimum national standard is achieved.
The content addresses current expected practice levels whilst allowing for important expected and
emerging changes to practice. The Framework can be used as a curriculum mapping tool, as the
elements detailed in each section can act as a checklist for identifying what is already included in a
particular curriculum, and where any gaps may exist.
The AMSEC competencies are broadly based on the BJD (Bone and Joint Decade) Global core
recommendations for a musculoskeletal undergraduate curriculum and articulate with the
Australian Medical Council (AMC) standards and procedures for medical school accreditation. The
BJD competencies were originally designed to allow local adaptation. Accordingly, the AMSEC
competencies incorporate all of the BJD competencies and have been expanded in detail to
facilitate those additional competencies which best suit the requirements of our local curricula.
The AMSEC Framework is underpinned by a sound educational philosophy of ‘spiralling
knowledge’ which is principles-based and contextually related to clinical competencies. These are
horizontally and vertically integrated in a “road map” of clearly defined learning outcomes which are
assigned to each element of the Framework and link to post graduate and specialist training
competencies.
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The AMSEC Framework
The AMSEC Framework provides a detailed outline of the basic science knowledge required for
effective MSK practice, and details specific competencies in key skill areas.
The AMSEC
competencies are broadly based on the BJD (Bone and Joint Decade) Global core
recommendations for a musculoskeletal undergraduate curriculum and articulate with the
Australian Medical Council (AMC) standards and procedures for medical school accreditation. The
BJD competencies were originally designed to allow local adaptation. Accordingly, the AMSEC
competencies incorporate all of the BJD competencies and have been expanded in detail to
facilitate those additional competencies which best suit the requirements of our local curricula.
The basic science knowledge base articulated in the AMSEC Framework encompasses key
principles, beginning at the cellular/molecular level which is then related to knowledge of the more
specialised structural details including the normal form and function of MSK tissues (including
anatomy and physiology) and the processes resulting in abnormal reactions. A particular focus on
anatomy has been identified as vital to the broader understanding required in MSK medicine and
this is reflected in the detail provided.
Building on the basic science principles and objectives, the clinical science competencies identified
in the AMSEC Framework define general principles and encompass not only the directly practical
aspects of assessment and management of MSK conditions, but also other important related
management modalities and issues.
The AMSEC Framework is not a curriculum. It was designed to define the standard of MSK
education appropriate for Australian universities and to provide suitable learning outcomes. The
standards are defined in terms of competencies, with the supporting core knowledge, skills and
attitudes defined and detailed to be consistent with the required competency level. It is envisaged
that with this framework these competencies can be mapped into existing curricula enabling the
identification of important gaps that need to be addressed, thus ensuring that an appropriate
minimum national standard is achieved.
The AMSEC Framework and competencies are divided into two major sections:
1.
2.
Basic Science and Supporting Knowledge:

Fundamental Basis of Medicine (Health Science)

Specialised (Scientific Basis of Musculoskeletal Practice and Radiology and Imaging)
Clinical Science and Skills:

General Principles of Assessment and Management in Medicine (Health Science)

Principles of Musculoskeletal Practice
The framework supports a spiralling of knowledge, with the “Clinical Science and Skills” building
directly on the “Basic Science and Supporting Knowledge”. Each element of the framework has
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defined learning outcomes which become more specific and detailed as the framework “unfolds”
thereby facilitating a spiralling of knowledge and identification of future specialities, facilitating
longer-term professional objectives for medical students. Each outcome has the capability to link to
a range of resources such as NHMRC and other national evidence based consensus guidelines,
multimedia presentations, podcasts and formative assessment tools.
Levels of Knowledge
A “Level of Knowledge” has been assigned to each competency, and these are a central strategy
for ensuring vertical integration. The levels have been defined as:
Core is not only that which is essential, but at an expected level commonly
considered necessary for efficient and effective practice at the designated
level
Core
Important information in the context of general MSK and related practice, but
not essential for safe, competent practice at intern level
Advanced
+
Specialised
Information that is in general in the domain of specialisation in MSK practice.
++
Levels of Practice
The AMSEC Framework also identifies specific levels of practice relating to practical skills for
medical graduates / interns undertaking MSK procedures. These are defined as:
Level 0
(Not aware)
Level 1
(knows of)
Level 2
(knows how)
Level 3
(shows how)
Level 4
(does)
Highly-specialised uncommonly performed procedures
Outlines very general indications for a procedure - not expected to have seen
the procedure performed - exhibits a general awareness
Outlines at a basic level the performance of a procedure and its indications,
common and important complications and general limitations and has seen the
procedure performed either on patients or in a presentation.
Outlines the indications, complications and limitations of the procedures, and
has had training using cadavers, models, or patients in performing these
procedures though they will not be expected to be able to perform these
procedures without supervision
Performs clinical procedures independently and correctly, knows their
associated indications, complications and limitations and recognises when
further consultation or assistance is required
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Anatomy Principles
General Objective
Identifies and interprets the normal structure of the human body throughout life span (appreciating
the range of normality of the living human body) correlating structure with function as a part of
recognising the structure alterations in disease processes and their clinical manifestations; eliciting
and interpreting physical signs; interpreting imaging studies; and performing practical (including
emergency) diagnostic and treatment procedures that may be required of a ‘first-port-of-call’
doctor. The goals do not include the knowledge of a large quantity of the information contained in a
detailed systematic study of anatomy or the anatomical knowledge and skills required for the
successful practice of the various specialties and sub- specialties.
Specific Outcomes
Demonstrates knowledge and understanding of the general principles of anatomy and their
common applications as detailed in "An@tomedia - General Principles"
The Human Body
Background
The developmental history of an individual reflects the evolutionary history of its species
The potentials (and limitations) of cells, tissues and organs are determined by the germ
layers from which they are derived
Only mesoderm derived structures are vascular
Human Anatomical Terms
When describing the relationship between one structure and another, the body is
considered to be in the anatomical position
Where multiple movements occur at joints in close proximity, the preferred term is
movement ‘of the part’, rather than ‘at the joints’
Human Form and Structure
Branchial arch derivatives retain their nerve supply despite migration
The nerve supply to a muscle is retained even if the muscle migrates during development
Each limb develops with a principal bone proximally, a pair of long bones distal to it, then
short bones and five digits
The most distinctive human characteristic is the habitual adoption of upright stance and
locomotion based solely on the two lower (hind) limbs
Body Systems and Structure
Background
All organs, whether somatic or visceral, require neurovascular supply (although supply of
somatic organs is by a separate set of nerves and vessels to that of viscera)
Skeletal System and Bones
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Bony trabeculae are oriented along lines of stress (both compressive and tensile)
Articular surfaces are the only external surfaces of a bone not surrounded by periosteum
Bony elevations are produced at sites of traction
Hyaline cartilage is avascular and aneural
Unlike cartilage, bone requires a blood supply, as the calcified matrix does not allow
diffusion
Almost all secondary centres appear after birth (females generally at an earlier age than
males)
Growth in length occurs at the metaphyseal surface of an epiphyseal plate
Epiphyseal fusion occurs after puberty (females generally at an earlier age than males)
The earlier an epiphysis appears the later it fuses
Epiphyses for larger long bones tend to appear before (and fuse after) those for smaller
long bones
Damage to an epiphyseal plate will impair subsequent growth
Adults tend to have stronger bones than ligaments, while children have the reverse
Healing, including of fractures, is more rapid in children than in adults
Weight-bearing bones heal slower than non-weight bearing bones
Articular System and Joints
The shape of the articular surfaces determines the particular movements permitted
Bony articular surfaces do not come in direct contact with each other unless the overlying
articular cartilage has worn away
Synovial membrane lines the internal surface of the capsule and all non-articular
structures on the interior of a synovial joint
Ligaments within a joint (or between two joints acting as a functional unit) are positioned
along the axis of movement
Collateral ligaments are important contributors to stability by preventing unwanted side-toside movement
Children are more likely to fracture a bone before tearing a ligament
The weakest points of a ligament are at or near their attachments, rather than between
them
A ligament that is arranged in discrete parts (rather than a continuous band) allows more
joint mobility but is weaker and therefore more vulnerable
Discs or menisci create compartments, allowing different movements to occur
simultaneously on each side of the partition
Bursae are more numerous at joints with greater mobility
The contribution to joint stability from bones is dependent on the congruence of their
articular surfaces
Active muscles are the most important stabilising factor for mobile joints, providing the
first line of defence against dislocation
Nerves supplying muscles that produce movements at a joint also typically supply the
joint
Muscular System and Muscles
Tendinous attachments to bone, in contrast to those of fleshy muscle fibres, produce
bony markings
17
A large tendon attaching to a developing bone is likely to be associated with a traction
epiphysis (to allow for growth of the bone at the site of attachment)
In contrast to a ligament, a muscle tends to rupture at other sites in addition to its
attachments
Muscles crossing more than one joint are particularly prone to injury from over-stretching
Fleshy muscle fibres tend to be replaced by tendons at sites of pressure or friction
Deep fascia is not found as a continuous sheet around parts of the body that expand
significantly
Deep fascia is not found over the subcutaneous surface of a bone
Muscles with a common action are generally located in the same fascial compartment
Where nerves and vessels have a common course they tend to be enclosed within a
common fascial sheath (as a neurovascular bundle)
The active range of movement at a joint is proportional to the length of muscle belly
Strength is proportional to the cross-sectional area of the muscle
Muscles crossing more than one joint can generate extra force but are also prone to
overstretch
Prime movers tend to be located superficially and fixators deep
Skeletal muscles with a common action often share a common nerve supply and occupy
a common compartment
A muscle located on the border between two compartments may receive a dual nerve
supply (and have dual prime mover actions)
The nerve supply to a muscle reflects its developmental origin (nerves remain ‘faithful’ to
their muscles)
The segmental pattern of nerve supply in the trunk is in a simple cranial to caudal
sequence
An individual limb muscle typically receives its supply from two consecutive spinal cord
segments
Proximal flexor muscle groups are supplied from more cranial (pairs of) segments than
those for distal flexor muscles
The most caudal segment distributed via the limb plexus supplies the most distal muscle
group for the upper limb and for the lower limb (intrinsic muscles of palm and of sole,
respectively).
Where there is a major source artery (and principal vein) it enters as part of the
neurovascular bundle at the hilum, on the deep surface of the muscle
The majority of anastomoses in the body are via skeletal muscles
Integumentary System and Skin
The dermis on extensor surfaces tends to be thicker and tougher increasing protection
from injury
Connective tissue in living skin is oriented along the relaxed skin tension lines
In burns, fluid loss is proportional to the surface area affected
Territories supplied by peripheral nerves derived from consecutive spinal segments
overlap extensively (and their branches intermingle)
Overlap for pain and temperature is more extensive than that for touch
Nerve branches do not cross the midline of the body
18
Adjacent dermatomes that are consecutive overlap extensively
The middle segment of a limb plexus is distributed to the most distal skin
Adjacent dermatomes that are not consecutive do not overlap
Cutaneous nerve branches do not cross axial lines
Pain from a deep source is referred to the same neurosome
Unpaired viscera receive a bilateral nerve supply
Pain from an unpaired viscus is referred to the midline
Pain from a paired viscus is referred to the same side
Vessels, being derived from mesoderm, develop only in mesoderm-derived tissues
Continuous arteries supply continuous organs
Arteries travel with connective tissue via fascial planes particularly associated with
muscles
Vessels do not cross mobile planes
Vessels cross planes at sites (of least mobility) where connective tissue is anchored
Arteries course from fixed (concave) areas to mobile (convex) areas
Veins converge on fixed areas from mobile areas
The vast majority of muscles are part of more than one angiosome
Lymph capillaries are not present in epithelia (including epidermis) but are abundant
directly under an epithelial surface
Lymph vessels tend to accompany veins
Lymph from the skin normally passes through at least one set of lymph nodes before
reaching the venous system
The skin of almost the entire body drains first to a superficial lymph node group before
draining to a deep group
Visceral Systems and Viscera
Normal constrictions of the lumen tend to occur at the beginning and end of a tubular
viscus
Structures directly related to an organ tend to produce grooves or impressions on it
A duct opening into the lumen of a hollow viscus tends to narrow as it traverses the wall
Endocrine glands have a very rich blood supply
A paired viscus receives a unilateral neurovascular supply and refers pain to the same
side
Midline unpaired viscera receive nerve and vascular supply lines from both sides
Non-midline unpaired viscera have an arterial supply from unpaired branches of the aorta
(arteries of the foregut, midgut and hindgut) and venous drainage into an unpaired
system of veins (‘portal’ system)
Unpaired viscera receive a bilateral nerve supply
Pain from an unpaired viscus is felt over the midline of the body as impulses are
simultaneously received by the left and by the right side of the spinal cord
Sphincters are often located near an external orifice (particularly on the perineum)
The direction of the orifice is at right angles to the direction of apposition of the walls of
the tubular viscus (or duct) immediately proximal to it
The epithelial lining of viscera is avascular (as is the epithelium of skin)
19
The underlying connective tissue of the lamina propria in viscera is highly vascular (as is
the dermis of skin)
Arterial anastomoses, venous communications, watershed areas of lymph drainage and
internervous lines (of sensory nerve supply) occur at mucocutaneous junctions
Visceral nerves supply smooth muscle sphincters, and somatic nerves supply skeletal
muscle sphincters
Transmucosal junctions tend to be located where territories of different developmental
origin meet
Internervous lines for reflexes particularly occur where mucosa overlies skeletal muscle
There tends to be no arterial anastomoses across vascular segments although there may
be some venous communication
Visceral nerves supply smooth muscle and glands, while somatic nerves supply skeletal
muscle
The body wall and the (parietal) layer of serous membrane lining it are supplied by
somatic nerves, while the gut and the (visceral) layer of serous membrane around it is
supplied by visceral nerves
Nervous System and Nerves
Although some peripheral nerves are purely motor or purely sensory, the vast majority
are mixed
In contrast to a receptor, an effector is not in direct continuity with a neuron
The functional fibre type of a sensory nerve fibre corresponds to the type of organ
associated with the receptor
The functional fibre type of a motor nerve fibre corresponds to the type of effector
Sympathetic nerves primarily control smooth muscle tone of arterioles
The white matter in a spinal cord segment includes the long descending and ascending
fibres of all segments caudal to it
Most long pathways in the CNS cross the midline
Awareness of functional fibre types, key paths and decussation sites enables the precise
localisation of a lesion within the CNS
Posterior nerve roots are purely sensory while anterior nerve roots are purely motor
Each branchial arch is supplied by a mixed cranial nerve
A specific reflex is triggered by stimulation of its associated sensory nerve territory
Awareness and testing of the functional fibre types within cranial nerves enables accurate
diagnosis of a cranial nerve lesion
A ganglion, created by the collection of cell bodies of sensory neurons, is found on the
posterior root of every spinal nerve
Each posterior root ganglion resides in an intervertebral foramen, regardless of the length
of the associated nerve root
The sensory ganglia of cranial nerves are located in or near the associated foramina of
the skull
Each spinal nerve from T1-L2 is connected to the sympathetic trunk by a white ramus
communicans
Every spinal nerve is connected to a sympathetic trunk by a grey ramus communicans
Only anterior rami of spinal nerves take part in the formation of major plexuses
20
Peripheral nerves derived from anterior divisions of a plexus are distributed to flexor
compartments while those derived from posterior divisions are distributed to extensor
compartments
A nerve which supplies a muscle producing movement at a joint also supplies sensation
to the joint and skin overlying (the insertion of) the muscle
The CNS receives blood supply from its periphery
There are no lymph vessels in the CNS
Large nerve fibres within a peripheral nerve are the most susceptible to pressure
A neuron influences the vitality of its connections
Arterial System and Arteries
The greatest drop in blood pressure occurs across arterioles
Where arteries divide into terminal branches, the larger branch tends to be more directly
in line with the main trunk, with the smaller at a greater angle
The cardiovascular system is not only a closed system but also a double system with two
distinct blood circulations
Systemic arteries transport oxygenated blood
Adjacent (branches of) arteries tend to anastomose with each other
Skeletal muscles receive the most arterial branches and contain the majority of
anastomoses
Anastomoses occur around joints but are only significant within muscle bellies that cross
a joint
End organs are particularly vulnerable to having their arterial supply cut off
End tissues within end organs are most vulnerable to having their arterial supply
interrupted
An embolus within an artery tends to lodge immediately distal to a branch point, where
the main artery narrows
Venous System and Veins
A portal system of veins links two capillary beds at low pressure
A valve is typically located at the termination of a vein
The veins of the vena caval systems traversing body cavities of the trunk, together with
the entire vertebral and azygos systems of veins, are valveless
Lymphatic System and Lymph Vessels
Lymph capillaries are most numerous beneath surface epithelia
Lymph capillaries are present only in tissues derived from mesoderm
All lymph is normally returned to the venous system
The termination of lymph ducts occurs where the venous pressure is about zero, whether
upright or supine
Lymph drains from superficial nodes to deep nodes
After puberty, the thymus in particular (together with lymphoid tissue in general) involutes
with age
21
Body Regions and Position
Background
The first step in a clinical diagnosis is to determine the (anatomical) site of a lesion.
Arrangement of Body Regions
The branching patterns of vessels tend to be asymmetrical, resembling the branching of a
tree
Flexor muscles with a rich nerve supply (for fine control of movements) tend to occupy
compartments on the ventral aspect of the body and are covered by delicate skin with a
correspondingly rich nerve supply (for fine sensory discrimination)
Course antigravity extensor muscles tend to occupy compartments on the dorsal aspect
covered by hairy skin and a tough dermis
Posterior rami of spinal nerves directly supply the dorsal aspect of the trunk (and neck)
with their associated extensor regions containing skin, joints and (deeply located) intrinsic
muscles
A limb plexus divides into anterior and posterior divisions, with their nerve fibres
distributed (via associated peripheral nerves) to flexor regions and extensor regions,
respectively
Body Compartments and Fascial Planes
Compartments tend to be in layers
While major vessels and nerves may course along them, few cross mobile fascial planes
as they would overstretch or have their own mobility restricted
Vessels tend to cross planes at sites of fusion, where connective tissue is anchored
Arteries and nerves course from fixed to mobile areas
Fluids (including blood and pus) tend to track along mobile fascial planes as they provide
paths of least resistance
Body Walls and Cavities
Body walls and parietal layer of the serous membrane lining a body cavity are supplied by
somatic nerves (and parietal vessels)
Viscera and visceral layer of the serous membrane lining a body cavity are supplied by
visceral nerves (and vessels)
Neurovascular Pathways
Nerves and vessels tend to accompany each other as components of a neurovascular
bundle
Within a neurovascular bundle, the vein and lymph vessels are located more peripherally
The major limb arteries tend to run through flexor regions and are generally located on
the flexor aspect of joints
The major superficial veins of limbs follow the pre-axial and post-axial borders
The nerve supply to a structure remains constant even if the structure has migrated
during development
Arterial pulsation is best detected by palpation at a site where an artery is closely related
to both skin and bone
22
Development and Variation
Background
Anomalies found on physical examination or by imaging may be of clinical significance
per se or when misdiagnosed as being pathological
Encountering anomalies, particularly when not anticipated, can pose problems during
invasive procedures or surgical operations
It is vital for a clinician to distinguish typical from atypical, normal from abnormal, and
health from disease
Growth and Development
During the early embryonic phase, features appear from more primitive ancestors
Normal Variation
Lymphoid organs are the first to involute
The part of the skeleton that best distinguishes males from females is the bony pelvis
The most mobile viscera are those suspended by a mesentery
The surface markings and vertebral levels for organs, based on anatomical descriptions
of a recumbent cadaver, may be vastly different to those in a living person standing
upright
It is important to be aware that a female of reproductive age could be pregnant
Anatomical Variation in Structure
Multiple branches arising close to each other can have a common stem
Variations in venous patterns are extremely common as veins develop from numerous
endothelial channels
An arterial trunk arising from a main artery and subsequently dividing can be absent, with
its branches arising independently
A large anastomosing branch of a neighbouring artery may replace an artery and take
over its territory
Abnormal fusion of vertebral elements tends to occur at transitional regions
Accessory bones are created by failure of a centre of ossification to fuse with the rest of
the bone
Anomalies of bony fusion and non-fusion may create a domino effect along the spine
Anatomical Variation in Position
During development, migration may occasionally fall short of the normal site
During development, migration may occasionally overshoot the normal site or deviate to
an abnormal site
Abnormal communications may occur from endothelial channels failing to close during
development
Vessels develop from networks that have the potential for change, where preferred
channels remain while others regress (providing scope for variation)
23
Pathological Changes
In contrast to anatomical variation (with abnormal structure or position but no functional
impairment) pathological changes have impaired function, even if not immediately evident
Malformations occur when organ systems are forming (between the third to eighth weeks)
and most major malformations spontaneously abort
Multiple minor malformations generally signify an underlying major malformation
The cause of one disorder may be the consequence of another
Practical Perspectives
Background
Examining, investigating or treating a patient is a privilege and even if non-invasive, all
require informed consent
Radiographic Anatomy and Imaging
The intensity of blackness on a radiograph is directly proportional to the intensity of
radiation which reaches the film
The greater the tissue radiodensity, the greater the attenuation of X-rays
A radiological interface is created when tissues of different radiodensity lie adjacent to
each other
Lines (or edges) may be seen on a radiograph when radiological interfaces are parallel to
the path of the X-rays
An object should be radiographed in at least two projections at right angles to each other
Structures of most interest should be placed centrally within the X-ray beam
The X-ray film should be placed perpendicular to the centre of the X-ray beam
The organ or body part of most interest is positioned as close as possible to the recording
medium to minimise magnification and loss of sharpness
Compact bone (densely packed bone tissue infiltrated with calcium) appears more
opaque than cancellous bone (containing many little compartments)
Only fat has sufficient radiographic contrast compared to all other types of soft tissues
(and body fluids) to form visible interfaces on a plain film
When an organ or a tissue of soft tissue density is adjacent to air or gas, the difference in
radiodensity will form a clean and sharp edge, provided the interface is parallel to the Xray beam
Sectional Anatomy, CT and MRI
Radiographs display the entire body part or an organ that is imaged, whereas CT images
display slices of body parts or organs
MRI (unlike radiography and CT) avoids using ionising radiation
Implanted electronic devices and potentially mobile ferromagnetic material are
contraindications to MRI
On T1 weighted images, tissues with a high fat content appear bright
On T2 weighted images, tissues with high water content appear bright
The most important advantage of MRI over other imaging modalities is the ability to
distinguish types of soft tissues from each other
24
Ultrasound Imaging
Ultrasound allows real time cross-sectional imaging without any ionising radiation
An acoustic interface exists at the junction of two tissues of different acoustic impedance
The larger the difference in density of adjacent tissues, the larger the reflection, resulting
in a brighter signal from their acoustic interface
Thin subjects tend to be more suitable for ultrasound, while obese subjects tend to be
more suitable for CT
Clinical Procedures
Skin incisions made parallel to lines of tension heal with a minimal scar, while those
crossing lines of tension tend to produce a wider scar
Incisions should ideally be placed along prominent skin creases (particularly in the trunk,
neck and face) to disguise the scar
Incisions crossing joint lines should be avoided due to subsequent restriction of
movement even from normal scar contraction
Incisions should be planned with an awareness of underlying structures (particularly
nerves and vessels) and special care must be taken to avoid damaging them
Wounds should be closed layer by layer to prevent dead space and maximise wound
strength
Aspirating before injecting avoids inadvertent intravenous injection
Within a peripheral nerve, small fibres (mainly pain fibres) are most affected by local
anaesthetic agents
Larger fibres are affected to a lesser degree (hence touch sensation may remain)
The area anaesthetised by a nerve block corresponds to the sensory distribution of the
nerve (distal to the site of infiltration) minus the area of overlap from adjacent nerves
Adrenaline should not be injected into terminal parts (particularly digits or penis) because
they are (collectively) supplied by end-arteries
Ideal sites for cannulation of veins are at an inverted 'V' junction point or where a vein
pierces deep fascia
References
"An@tomedia - General Principles"
25
Biology of Cells
General Objective
Demonstrates knowledge and understanding of concepts and general principles of cellular biology
as the basis for understanding cell morphology, organisation and function; how alterations may
lead to disease states; and the rationale for diagnostic and research techniques as well as
therapeutic and/or other interventions.
Specific Outcomes
Explains the concepts and terminology in cell biology and describes their application in normal and
abnormal cell function.
Structure and function of cell components
e.g. endoplasmic reticulum, Golgi complex, mitochondria, lysosome, peroxidase, endosome,
centriole, microtubule, ribosome, polysome, plasma membrane, cytosol, cilia, nucleus, cytoskeleton
Signal transduction
including basic principles, receptors and channels, second messengers, signal transduction
pathways
Cell-cell and cell-matrix adhesion
Cell motility
Intracellular sorting
e.g. trafficking, endocytosis
Cellular homeostasis
e.g. turnover, pH maintenance, proteasome, ions, soluble proteins
Cell cycle
e.g. mitosis, meiosis, structure of spindle apparatus, cell cycle regulation
Structure and function of basic tissue components
including epithelial cells, connective tissue cells, muscle cells, nerve cells, and extracellular matrix
Adaptive cell response to injury
Intracellular accumulations
e.g. pigments, fats, proteins, carbohydrates, minerals, inclusions, vacuoles
Mechanisms of injury and necrosis
Apoptosis
26
Biochemistry and Molecular Biology
General Objective
Demonstrates knowledge and understanding of concepts and general principles of biochemistry
and molecular biology as the basis for understanding mechanisms by which genetic information
stored in DNA in the nucleus regulates protein synthesis and cell function; how alterations may
lead to disease states; and the rationale for diagnostic and research techniques as well as
therapeutic and/or other interventions.
Specific Outcomes
Explains the concepts and terminology in biochemistry and molecular biology and describes their
application in key conditions and research.
Gene expression: DNA structure, replication, and exchange
DNA structure: single- and double-stranded DNA, stabilising forces, supercoiling
Analysis of DNA: sequencing, restriction analysis, PCR amplification, hybridisation
DNA replication, mutation, repair and degradation
e.g. xeroderma pigmentosum
Gene structure and organization; chromosomes in prokaryotes and eukaryotes
Recombination, insertion sequences, transposons
Mechanisms of genetic exchange (transformation, transduction, conjugation)
Plasmids and bacteriophages
Gene expression: transcription
Transcription of DNA into RNA; enzymatic reactions, RNA; RNA degradation
Regulation: cis-regulatory elements, transcription factors, enhancers, promoters
Defects in transcription and RNA processing
e.g. thalassemias
Gene expression: translation
The genetic code
Structure and function of tRNA
Structure and function of ribosomes
Protein synthesis
e.g. haemoglobinopathies, cystic fibrosis
regulation of translation
post-translational modifications
protein degradation
defects in translation and protein structure
Structure and function of proteins
Principles of protein structure and folding
Enzymes; kinetics, thermodynamics, reaction mechanisms
Structural and regulatory proteins; ligand binding, self-assembly
27
Mutations that alter proteins
e.g. haemoglobinopathies, familial hypercholesterolemia
Energy metabolism; metabolic sequences and regulation
Generation of energy from carbohydrates, fatty acids, and nonessential amino acids
glycolysis
glycogenolysis
pentose phosphate (phosphogluconate) pathway
tricarboxylic acid cycle
electron transport and oxidative phosphorylation
Storage of energy: gluconeogenesis, fatty acid and triglyceride synthesis
Thermodynamics: free energy, chemical equilibria and group transfer potential; the
energetics of ATP and other high-energy compounds
Altered energy metabolism
e.g. cyanide poisoning, mitochondrial myopathies, diabetic ketoacidosis
Metabolic pathway of small molecules and associated diseases
Biosynthesis and degradation of amino acids
e.g. phenylketonuria, maple syrup urine disease
Biosynthesis and degradation of purine and pyrimidine nucleotides
e.g. gout, Lesch-Nyhan syndrome
Biosynthesis and degradation of lipids and cholesterol, steroid hormones, prostaglandins,
and thromboxanes
e.g. adrenogenital syndrome
Biosynthesis and degradation of other macromolecules and associated
abnormalities
complex carbohydrates
e.g. lysosomal storage disease
glycoproteins
proteoglycans
Tools and techniques of molecular biology
restriction enzymes
agarose gel electrophoresis
DNA ligation
plasmid vectors
genomic library
DNA sequencing
transgenic animals
southern and northern hybridization
PCR - polymerase chain reaction amplification
28
Human Development and Genetics
General Objective
Demonstrates knowledge and understanding of concepts and general principles of human
development and genetics, as the basis for understanding mechanisms by which genetic
information stored in DNA in the nucleus regulates protein synthesis and cell function; how
alterations may lead to disease states; and the rationale for diagnostic and research techniques as
well as therapeutic and/or other interventions.
Specific Outcomes
Explains the concepts, principles and terminology relating to human development and genetics and
describes their application with respect to normal and abnormal development, assessment and
treatment.
Embryogenesis
programmed gene expression
tissue differentiation and morphogenesis
homeotic genes
developmental regulation of gene expression
Congenital abnormalities
principles
patterns of anomalies
dysmorphogenesis
Principles of pedigree analysis
inheritance patterns
occurrence and recurrence risk determination
Population genetics
Hardy-Weinberg law
founder effects
mutation-selection equilibrium
Genetic mechanisms
chromosomal abnormalities
Mendelian inheritance
multifactorial diseases
Clinical genetics
genetic testing
prenatal diagnosis
newborn screening
genetic counselling/ethics
gene therapy
29
Biology of Tissue Response to Disease
General Objective
Demonstrates knowledge and understanding of concepts and general principles of inflammation,
tissue repair and neoplasia as the basis for understanding tissue responses in health and disease,
their clinical manifestations and the rationale for diagnostic techniques as well as therapeutic
and/or other interventions.
Specific Outcomes
Explains the concepts, principles and terminology of inflammation, tissue repair and neoplasia and
describes their application in relation to normal and abnormal reactions.
Inflammation, including cells and mediators
acute inflammation and mediator systems
vascular response to injury, including mediators
inflammatory cell recruitment
adherence and cell migration
phagocytosis
bactericidal mechanisms and tissue injury
clinical manifestations
e.g. pain, fever, leukocytosis, leukemoid reaction, chills
chronic inflammation
Reparative processes
wound healing, haemostasis, and repair
fibrosis
scar/keloid formation
thrombosis
granulation tissue
angiogenesis
regenerative processes
bone healing
direct/primary vs. secondary healing
stages
inflammation
soft callus
hard callus/mineralisation
remodelling
30
Neoplasia
classification, histologic diagnosis
grading and staging
cell biology, biochemistry, and molecular biology of neoplastic cells
transformation
oncogenes
altered cell differentiation
proliferation
hereditary neoplastic disorders
invasion and metastasis
tumour immunology
paraneoplastic manifestations of cancer
cancer epidemiology and prevention
31
Multisystem Processes
General Objective
Demonstrates knowledge and understanding of concepts and general principles of nutrition,
temperature regulation, adaptation to extreme conditions and fluid/electrolyte homeostasis as the
basis for understanding how alterations may lead to disease states; and the rationale for diagnostic
techniques as well as therapeutic and/or other interventions.
Specific Outcomes
Explains the following concepts and principles and describes their application with respect to
normal and abnormal physiological functioning.
Nutrition
generation, expenditure, and storage of energy at the whole-body level
assessment of nutritional status across the life span
calories
protein
essential nutrients
hypoalimentation
functions of nutrients
essential
trans-fatty acids
cholesterol
protein-calorie malnutrition
vitamin deficiencies and/or toxicities
mineral deficiencies and toxicities
eating disorders
obesity
anorexia
bulimia
nutritional supplements
Alternative diets
low carbohydrate (Atkins diet)
low Glycaemic Index diets
Temperature regulation
Adaptation to environmental extremes, including occupational exposures
physical and associated disorders
e.g. temperature, radiation, burns, decreased atmospheric pressure, high-altitude sickness,
increased water pressure
chemical
e.g. gases, vapours, smoke inhalation, agricultural hazards, volatile organic solvents, heavy metals,
principles of poisoning and therapy
32
Fluid, electrolyte, and acid-base balance and disorders
dehydration
acidosis
alkalosis
33
Pharmacodynamic and Pharmacokinetic
Processes
General Objective
Demonstrates knowledge and understanding of concepts and general principles of
pharmacodynamic and pharmacokinetic processes as the basis for understanding the action of
drugs, dosing, side effects, patient selection and the monitoring of response in clinical practice.
Specific Outcomes
Explains the following concepts and principles and relates to the use of pharmacological agents in
clinical practice.
General principles
pharmacokinetics
absorption, distribution, metabolism, excretion, dosage intervals
mechanisms of drug action, structure-activity relationships
concentration- and dose-effect relationships (e.g. efficacy, potency), types of agonists
and antagonists and their actions
individual factors altering pharmacokinetics and pharmacodynamics
e.g. age, gender,
pharmacogenetics
disease,
tolerance,
compliance,
body
weight,
metabolic
proficiency,
drug side effects, overdosage, toxicology
drug interactions
regulatory issues
e.g. drug development, approval, scheduling
General properties of autacoids
peptides and analogs, biogenic amines, prostanoids and their inhibitors, and smooth
muscle/endothelial autacoids
General principles of autonomic pharmacology
General properties of antimicrobials, including mechanisms of action and
resistance
General properties of antineoplastic agents and immunosuppressants,
including drug effects on rapidly dividing mammalian cells
34
Microbial Biology and Infection
General Objective
Demonstrates knowledge and understanding of concepts and general principles of microbial
biology and infection as the basis for understanding the clinical manifestations of infection,
diagnosis and management in clinical practice.
Specific Outcomes
Explains the concepts, general principles and key terminology relating to microbial biology and
infection and their general application to clinical practice.
Microbial classification and its basis
Bacteria and bacterial diseases
structure and composition
metabolism, physiology, and regulation
genetics
nature and mechanisms of action of virulence factors
pathophysiology of infection
epidemiology and ecology
principles of cultivation, assay, and laboratory diagnosis
Viruses and viral diseases
physical and chemical properties
replication
genetics
molecular basis of pathogenesis
pathophysiology of infection
latent and persistent infections
epidemiology
oncogenic viruses
principles of cultivation, assay, and laboratory diagnosis
Fungi and fungal infections
structure, physiology, cultivation, and laboratory diagnosis
pathogenesis and epidemiology
Parasites and parasitic diseases
structure, physiology, and laboratory diagnosis
pathogenesis and epidemiology
Principles of sterilisation and pure culture technique
35
Immune Responses
General Objective
Demonstrates knowledge and understanding of concepts and general principles of cellular biology
as the basis for understanding cell immune function; alterations in disease states; and the rationale
for diagnostic and research techniques.
Specific Outcomes
Explains the concepts, terminology and processes related to the immune system in normal and
abnormal cell function.
Production, function and biological characteristics
Granulocytes
Natural Killer cells
Macrophages
T lymphocytes
T-lymphocyte receptors
B lymphocytes and plasma cells
Immunoglobulin and antibodies
Important terms
antigenicity and immunogenicity
antigen presentation
cell activation and regulation
tolerance
clonal deletion
Immunologic mediators
chemistry
function
molecular biology
classic and alternative complement pathways
cytokines
chemokines
Immunogenetics
MHC structure and function
class I, II molecules
erythrocyte antigens
Immunisations: vaccines, protective and immunity
Alteration in immunologic function
T- or B-lymphocyte deficiencies
e.g. DiGeorge syndrome
36
deficiencies of phagocytic cells
combined immunodeficiency disease
HIV infection/AIDS and other acquired disorders of immune responsiveness
drug-induced alterations in immune responses, immunopharmacology
Immunologically-mediated disorders
hypersensitivity (types I–IV)
transplant and transplant rejection
autoimmune disorders
risks of transplantation, transfusion
e.g. graft-versus-host disease
isoimmunisation, haemolytic disease of the newborn
immunopathogenesis
Immunologic principles underlying diagnostic laboratory tests
e.g. ELISA, complement fixation, RIA, agglutination
Innate immunity
37
Research Methods
General Objective
Demonstrates knowledge and understanding of basic concepts and principles of measurement,
study design and statistics as the basis for interpretation and critical appraisal of epidemiological
data, clinical assessment and research output.
Specific Outcomes
Explains (using basic formulas where applicable) key concepts and principles of measurement,
study design and statistics and understands the key differences between quantitative and
qualitative measures and their applications.
Fundamental concepts of measurement
scales of measurement
distribution, central tendency, variability, probability
disease prevalence and incidence
disease outcomes
e.g. fatality rates
associations
e.g. correlation and covariance
health impact
e.g. risk differences and ratios
sensitivity, specificity, predictive values
Fundamental concepts of study design
types of experimental studies
e.g. clinical trials, community intervention trials
types of observational studies
e.g. cohort, case-control, cross-sectional, case series, community surveys
sampling and sample size
subject selection and exposure allocation
e.g. randomization, stratification, self-selection, systematic assignment
outcome assessment
internal and external validity
Fundamental concepts of hypothesis testing and statistical inference
confidence intervals
statistical significance and Type I error
statistical power and Type II error
38
Behavioural and Social Science
General Objective
Understands key concepts and principles of psychosocial development throughout life, the
multitude of psychological and social factors influencing patient and professional behaviour and
interactions, and applies these to the multiple domains of "professionalism" and the effective care
of patients.
Specific Outcomes
Psychosocial development
Outlines and explains the key elements of psychosocial development in the progression through
the life cycle, from birth through senescence
Cognitive, language, motor skills, and social and interpersonal development
Sexual development
Influence of developmental stage on Physician-Patient interview
Influence
Outlines and explains the key psychological and social factors influencing patient behaviour
Personality traits or coping style, including coping mechanisms
Psychodynamic and behavioural factors, related past experience
Family and cultural factors, including socioeconomic status, ethnicity, and gender
Adaptive and maladaptive behavioural responses to stress and illness
Interactions between the patient and the physician or the health care system
Patient adherence, including general and adolescent
Interaction
Outlines and describes the key issues involved in optimising patient interviewing, consultation, and
interactions with the family
Establishing and maintaining rapport
Data gathering
Approaches to patient education
Enticing patients to make lifestyle changes
Communicating bad news
“Difficult” interviews
Multicultural ethnic characteristics
39
Professionalism
General Objective
Understands the core concepts and principles underlying the key non-technical "professional" roles
in health including communicator, advocate, scholar, manager, leader, educator, collaborator and
legal and ethical responsibilities and relates these to the lifelong advancement of professional
practice in health care.
Specific Outcomes
Personal and professional development
Explores and is open to a variety of career options
Participates in a variety of continuing education opportunities
Behaves in ways which acknowledge the professional responsibilities relevant to his/her
health care role
Maintains an appropriate standard of professional practice & works within personal
capabilities
Reflects on personal experiences, actions & decision-making
Acts as a role model of professional behaviour
Identifies and addresses personal learning objectives
Establishes and uses current evidence based resources to support own learning
Seeks opportunities to reflect on and learn from clinical practice
Seeks and responds to feedback on learning
Participates in research and quality improvement activities where possible
Is aware of and optimises personal health & well-being
Behaves in ways to mitigate the personal health risks of medical practice
e.g. fatigue, stress
Behaves in ways which mitigate the potential risk to others from your own health status
e.g. infection
Scholar
Definition: As ‘Scholars’, physicians demonstrate a lifelong commitment to reflective learning, as well as the
creation, dissemination, application and translation of medical knowledge.
Description: Physicians engage in a lifelong pursuit of mastering their domain of expertise. As learners, they
recognise the need to be continually learning and model this for others. Through their scholarly activities,
they contribute to the creation, dissemination, application and translation of medical knowledge. As teachers,
they facilitate the education of their students, patients, colleagues, and others. (CanMEDS Competencies)
Maintain and enhance professional activities through ongoing learning
Critically evaluate information and its sources, and apply this appropriately to practice
decisions
Facilitate the learning of patients, families, students, residents, other health professionals,
the public, and others, as appropriate
40
Contribute to the creation, dissemination, application, and translation of new medical
knowledge and practices
Communicator
Definition: As “Communicators’, physicians effectively facilitate the doctor-patient relationship and the
dynamic exchanges that occur before, during, and after the medical encounter.
Description: Physicians enable patient-centred therapeutic communication through shared decision-making
and effective dynamic interactions with patients, families, caregivers, other professionals, and important
other individuals. The competencies of this role are essential for establishing rapport and trust, formulating a
diagnosis, delivering information, striving for mutual understanding, and facilitating a shared plan of care.
Poor communication can lead to undesired outcomes, and effective communication is critical for optimal
patient outcomes. The application of these communication competencies and the nature of the doctor-patient
relationship vary for different specialties and forms of medical practice. (CanMEDS Competencies)
Develop rapport, trust and ethical therapeutic relationships with patients and families
Accurately elicit and synthesise relevant information and perspectives of patients and
families, colleagues and other professionals
Accurately convey relevant information and explanations to patients and families,
colleagues and other professionals
Develop a common understanding on issues, problems and plans with patients and
families, colleagues and other professionals to develop a shared plan of care
Convey effective oral and written information about a medical encounter
Manager
Definition: As ‘Managers’, physicians are integral participants in healthcare organisations, organising
sustainable practices, making decisions about allocating resources, and contributing to the effectiveness of
the healthcare system.
Description: Physicians interact with their work environment as individuals, as members of teams or groups,
and as participants in the health system locally, regionally or nationally. The balance in the emphasis among
these three levels varies depending on the nature of the specialty, but all specialties have explicitly identified
management responsibilities as a core requirement for the practice of medicine in their discipline. Physicians
function as managers in their everyday practice activities involving co-workers, resources and organisational
tasks, such as care processes, and policies as well as balancing their personal lives. Thus, physicians
require the ability to prioritise, effectively execute tasks collaboratively with colleagues, and make systematic
choices when allocating scarce healthcare resources. The CanMEDS Manager Role describes the active
engagement of all physicians as integral participants in decision-making in the operation of the healthcare
system. (CanMEDS Competencies)
Participate in activities that contribute to the effectiveness of their healthcare
organisations and systems
Manage their practice and career effectively
Allocate finite healthcare resources appropriately
Serve in administration and leadership roles, as appropriate
Health Advocate
Definition: As ‘Health Advocates’, physicians responsibly use their expertise and influence to advance the
health and well-being of individual patients, communities, and populations.
Description: Physicians recognise their duty and ability to improve the overall health of their patients and the
society they serve. Doctors identify advocacy activities as important for the individual patient, for populations
41
of patients and for communities. Individual patients need physicians to assist them in navigating the
healthcare system and accessing the appropriate health resources in a timely manner. Communities and
societies need physicians’ special expertise to identify and collaboratively address broad health issues and
the determinants of health. At this level, health advocacy involves efforts to change specific practices or
policies on behalf of those served. Framed in this multi-level way, health advocacy is an essential and
fundamental component of health promotion. Health advocacy is appropriately expressed both by individual
and collective actions of physicians in influencing public health and policy. (CanMEDS Competencies)
Respond to individual patient health needs and issues as part of patient care
Respond to the health needs of the communities that they serve
Identify the determinants of health of the populations that they serve
Promote the health of individual patients, communities and populations
Collaborator
Definition: As ‘Collaborators’, physicians effectively work within a healthcare team to achieve optimal patient
care.
Description: Physicians work in partnership with others who are appropriately involved in the care of
individuals or specific groups of patients. This is increasingly important in a modern multiprofessional
environment, where the goal of patient-centred care is widely shared. Modern healthcare teams not only
include a group of professionals working closely together at one site, such as a ward team, but also
extended teams with a variety of perspectives and skills, in multiple locations. It is therefore essential for
physicians to be able to collaborate effectively with patients, families, and an interprofessional team of expert
health professionals for the provision of optimal care, education and scholarship. (CanMEDS Competencies)
Participate effectively and appropriately in an inter-professional healthcare team
Effectively work with other health professionals to prevent, negotiate, and resolve interprofessional conflict
Educator *
Incorporates teaching into clinical work
Uses varied approaches to teaching small and large groups
Plans, develops and conducts teaching sessions for peers and juniors
Evaluates and responds to feedback on own teaching
Provides effective supervision
e.g. by being available, offering an orientation, learning opportunities, being a role model
Adapts level of supervision to the learner's competence and confidence
Provides constructive, timely and specific feedback based on observation of performance
Participates in feedback and assessment processes
Provides constructive guidance or refers to an appropriate support to address problems
(ADV)
Leader *
Shows an ability to work well with and lead others
Exhibits the qualities of a good leader and takes the leadership role when required (ADV)
Legal *
Complies with the legal requirements in patient care
42
e.g. Mental Health Act, death certification
Completes appropriate medico-legal documentation
Liaises with legal and statutory authorities, including mandatory reporting where
applicable (ADV)
Complies with the legal requirements of being a doctor
e.g. maintaining registration
Adheres to professional standards
Respects patient privacy & confidentiality
Ethical *
Behaves in ways which acknowledge the ethical complexity of practice and follows
professional and ethical codes
Consults colleagues about ethical concerns
Accepts responsibility for ethical decisions
Resources
Frank, JR. (Ed). 2005. The CanMEDS 2005 physician competency framework. Better
standards Better physicians. Better care. Ottawa: The Royal College of Physicians and
Surgeons of Canada
* Australia Curriculum Framework for Junior Doctors. 2010. Professionalism. [accessed
21/6/10] <http://curriculum.cpmec.org.au/index.cfm>
43
Biomechanics
General Objective
Understands the basic definition and principles of biomechanics as the basis for understanding the
physical nature and behaviour of tissues in response to rest and activity in health; to injury and
disease; and to commonly-used therapeutic physical interventions in rehabilitation.
Specific Outcomes
Explains in general terms the difference between material properties and structural properties of
MSK tissue.
Relates the following terms to biomechanical properties of musculoskeletal tissue
stress
strain
stiffness
strength
fatigue failure
elastic
plastic
viscosity
viscoelastic
+ creep
+ toughness
+ yield strength
+ ultimate strength
+ modulus of elasticity
+ hysteresis
+ isotropic
+ anisotropic
Describes the twelve degrees of freedom of movement of any joint in terms of translation and
rotation about the biomechanical axes
Relates the following terms to joint movement
force
vector
moment
+ instant centre of rotation
+ screw axis
Relates the following terms to forces on MSK tissues during normal function as well as during
injury and fracture
compression
torsion
44
bending
tension
shear
Relates "Wolff's Law" to trabecular orientation
+ Explains the concept of moment of inertia and its application to the study of joint kinetics
+ Explains the use of a "free-body diagram" in modelling forces on MSK structures
45
Calcium and Phosphate Metabolism
General Objective
Understands the key concepts and principles of calcium and phosphate metabolism and its control
mechanisms as the basis for understanding bone turnover in health, ageing and disease
(osteoporosis) and the effect of lifestyle, culture, gender, race, environment, pharmaceutical and
physical factors on MSK and general health.
Specific Outcomes
Explains the following with respect to calcium and phosphate metabolism
Key functions of calcium and phosphate in human biology
Maintenance of intracellular free calcium concentration
Free, complexed and protein bound fractions
Relationship of calcium and phosphate balance to dietary intake, gastrointestinal
absorption and renal excretion
Explains the key terms, concepts and principles in bone turnover
coupling of bone formation and resorption in a steady state
bone as a major and dynamic reservoir for calcium and phosphate
remodelling and the variation of bone mass with stages of life
the role of different cells, (osteoblasts, osteocytes and osteoclasts) as an osteon or bone
modelling unit
bone formation, canaliculi, collagen, osteiod, alkaline phosphatase, osteocalcin and
hydroxyapatite crystals
mineralisation and normal plasma calcium and phosphate levels
osteocytic osteolysis and the transfer of calcium from the interior of an osteon to the
extracellular fluid
main cells and mechanisms of tunnelling in bone resorption
extracellular fluid and urine markers of bone resorption including pyridinolines,
pyridiniums
N-telopeptides of collagen, hydroxyproline and hydroxylysine
Explains the key terms, concepts and principles of Vitamin D production, maintenance and actions
Dietary sources
Vitamin D synthesis in the skin
Vitamin D actions on gut
Vitamin D and immunomodulation
Activation and hydroxylations
Response to calcium or phosphorus levels
Vitamin D actions on skeletal muscle
Interaction with osteoblast receptors and sensitisation of bone to resorptive effects of
PTH
46
Modulation of gene expression
Explains the key terms, concepts and principles of PTH production, maintenance and actions
regulation by calcium levels
chief cells and their actions
intracellular effects on kidneys, bone an GIT
renal effects on calcium and phosphate resorption
hydroxylation of Vit D
mediation of PTH's osteoclast effect via osteoblasts
Explains the key terms, concepts and principles of calcitonin production, maintenance and actions
C cells and their actions
inhibition of osteocytic osteolysis
Explains the relationship of calcium homeostasis to the following important clinical applications
muscle weakness and falls prevention
neuromuscular irritability and carpopedal spasm
osteomalacia
osteoporosis
rickets
hypercalcaemia and hypercalciuria in granuloma-forming diseases (sarcoidosis or
tuberculosis)
hyperparathyroidism
Paget's disease
Resources
Osteoporosis Australia website: www.osteoporosis.org.au
ANZ Bone & Mineral Society website: www.anzbms.org.au
47
Skeletal System and Bones
General Objective
Explains the key terms, concepts and principles relating to the form and function of the skeletal
system and bone and relates to important clinical contexts.
Specific Outcomes
Bone
Form and structure of cortical (compact) and cancellous (spongy) bone
Mechanical and haemopoietic functions
Composition including cells and matrix
osteoblasts
osteoclasts
osteocytes
osteoid
collagen
Trabeculae and their orientation
Medullary cavity and contents
Anabolic and catabolic processes in bone turnover
Periosteum
Different layers
Role in bone formation
Role in blood supply
Role in nerve supply
Bone types and bony features
General classification of bone types
Bone surfaces (e.g. articular)
Bone markings and their significance
Ossification and primary growth centres
Ossification types
intra membranous
intra cartilaginous (endochondral)
Position in bone
Time of appearance
48
Secondary centres and epiphyses
Location
Time of appearance
Gender differences
Blood supply
Microstructure and zones
Relationship to growth
Timing of plate closure and gender differences
Epiphyses
pressure vs. traction epiphyses
epiphyseal lines
accessory bone formation
Long bone growth
Growing end
Nutrient artery direction
Neurovascular supply
Sensory supply
Vascular foramina
Nutrient and periosteal arteries
Metaphyseal and epiphyseal arteries
Vascular circle
Anastomoses in the end of a long bone (immature vs mature bone)
Clinical context
Stages of fracture repair
Avascular necrosis
Delayed and non union
Hypertrophic vs. atrophic non union
Osteopaenia
Osteoporosis
Osteomalacia and rickets
Osteopetrosis
Osteogenesis imperfecta
Growth plate injuries/ conditions and deformity
Salter Harris classification
Height prediction
49
Articular System and Joints
General Objective
Explains the key terms, concepts and principles relating to the form and function of the articular
system and joints and relates to important clinical contexts.
Specific Outcomes
Joints
Types of Joints
fibrous (syndesmosis)
sutures
syndesmoses
gomphosis
synostosis
primary and secondary (symphyses) cartilaginous
synovial
plane
uniaxial (hinge, pivot)
biaxial (condylar, ellipsoid, saddle)
multiaxial (ball and socket)
Key components/terms
fibrous capsule
synovial membrane
articular cartilage
ligaments
labrum/meniscus
Clinical context
haemarthrosis
lipohaemarthosis
dislocation
subluxation
joint instability
arthrosis
arthrocentesis
Articular Cartilage
hyaline cartilage
50
fibrocartilage (disc, meniscus, labrum)
elastic cartilage
structure and function of constituent cells and extracellular matrix
chondryocytes, chondroblasts, chondroid
calcified zone
collagen
deep zone
extracellular matrix (ECM)
superficial tangential zone
middle (transitional) zone
tidemark
proteoglycans
glycosaminoglycans
aggrecans
chondroitin sulphate
hyaluronate
blood supply and nutrition
Clinical context
avascular
cartilage nutrition
fibrocartilage vs. hyaline cartilage and resilience to load
healing of chondral defects
effects of joint motion and loading on articular cartilage maintenance
tidemark involvement in injury
osteoarthritis
osteochondral fractures
Synovial tissue
Synovium
Synoviocytes
Type A synoviocytes
Type B synoviocytes
Desmosomes
Synovial fluid
Clinical context
Pannus
Synovitis
Haemarthrosis
Rheumatoid Arthritis
+ Pigmented Villonodular Synovitis
51
+ Primary Synovial Chondromatosis
Ligaments
intrinsic vs. extrinsic ligaments
intracapsular vs. extracapsular ligaments
collateral ligaments
accessory ligaments
fibrillin
elastin
endoligament
epiligament
fascicles
orientation of fibres relative to function
crimp
anisotropic
Clinical context
sprains and grades
stages of healing
ligament injury and proprioception
healing in intra-articular vs. extra-articular ligaments
physiological loading and mobility vs. immobilisation on remodelling and healing
Ehlers-Danlos syndromes
Menisci
Fibrochondrocytes
Vascular anatomy and "red and white zones"
Sharpey’s fibres
Viscoelastic structure
Clinical context
bucket handle tear
red/white zones and healing
locked knee
ageing and degenerate tears
Intervertebral discs
nucleus pulposis
annulus fibrosis
52
Clinical context
discitis
disc rupture
disc herniation
nerve root impingement
canal stenosis
cauda equina syndrome
foraminal stenosis
Bursae
serous membrane
communicating vs. non communicating
with synovial joint
mobile surfaces and friction reduction
Clinical context
inflammatory and infective bursitis
joint pathology and herniation
Baker's cyst
Infra-patellar bursitis
Olecranon bursitis
Fat pads
intra capsular/extra articular
Clinical context
fat pad signs on X-rays (elbow effusion)
+ "pinched fat pad"
53
Muscular System and Muscles
General Objective
Explains the key terms, concepts and principles relating to the form and function of the muscular
system and relates to important clinical contexts.
Specific Outcomes
Skeletal muscle
Components/types/features
Types and influence on function
belly types - fusiform, digastric, circular
forms - pennate vs. parallel
aerobic vs. anaerobic metabolism, fibre types and relation to energy consumption rates
and contraction/twitch rates
'one' and 'two joint' muscles and range vs. power
Contractile unit and its constituents
Myofibres
Endomysium
Epimysium
Perimysium
Sarcomeres
Musculotendinous junction
Mechanism
action potential
sarcolemma
sarcoplasmic reticulum
fibre recruitment and strength
calcium mobilisation and the regulation of skeletal muscle contraction
myosin, ATP, ADP, creatine and cross bridging in the energy supply to muscle
'Motor Unit'
Motor end plate (neuromuscular junction)
Synapse
Schwann cell
Acetylcholine
Static and dynamic contractions/ movement
isokinetic
isometric
isotonic
dynamic strength
static strength
54
concentric contraction
eccentric contraction
synergistic and antagonistic actions
basic variables of force, length and time in muscle contraction and derived variables of
velocity and work
muscles, bones and joints forming lever systems
first, second and third order levers
range and speed vs. power
power, load and fulcrum
length tension relationship
agonists and antagonists
fixator muscles acting as dynamic ligaments (e.g. rotator cuff)
strength and cross sectional area
synergists as balancers
Clinical context
ageing and sarcopaenia
strains and grades
muscle stem cells and healing
heterotopic ossification
muscular dystrophy
Tendons
Tendon, aponeurosis and raphe
Deep fascia and retinacula
Fascial septa, sheets and sheaths
Fibrous and synovial tendon sheaths
Clinical context
tenosynovitis, tendinitis, tenovaginitis
mesotendons and significance of injury with respect to blood supply
hand injuries, flexor tendon zones
zone 2 injuries
tendon repairs and splinting
Neurological supply and myotomes
Sensory nerve fibres, proprioception and stretch reflexes
Reciprocal innervation and coordination of prime movers and antagonists
Skeletal muscle tone
Neurovascular hilum and motor point
55
Myotomes and typical innervation of a limb muscle from 2 consecutive spinal cord
segments
Dual nerve supply in some muscles (with example)
Motor unit
Clinical context
Peripheral nerve vs. nerve root deficiency
56
Nervous System and Nerves
General Objective
Explains the key terms, concepts and principles relating to the form and function of the nervous
system and relates to important clinical contexts.
Specific Outcomes
Cellular organisation
dendrites
cell body
synaptic cleft
Schwann cells
axons
myelin sheath
nodes of Ranvier
terminal boutons
synapse
organisation of central and peripheral nervous system
the environment of the neuron including the role of CSF and blood brain barrier
transmission of information
Sensory physiology
sensory transduction
receptive fields
specialised receptors
sensory coding
sensory pathways
peripheral and central nervous system mechanisms of nociception
referred pain and concepts of pathway convergence
Motor system and control
Spinal cord motor organisation and alpha motor neurons
Organisation of descending motor pathways
Brainstem control of posture and movement
Cortical control of voluntary movement
Cerebellar regulation of posture and movement
Basal Ganglia regulation of posture and movement
57
Autonomic nervous system and control
Ganglia
Pre- and post-ganglionic neurons
Organisation of the sympathetic, parasympathetic and enteric nervous systems
Autonomic neurotransmission and role of cholinergic, adrenergic and peptidergic
receptors
Clinical context
Acute and chronic pain
Complex Regional Pain Syndromes
Upper and lower motor neuron lesions
Spinal cord injuries
Cerebrovascular injuries/accidents
Cerebellar disorders
Compartment syndromes
58
General Pathological Processes in
Musculoskeletal Conditions
General Objective
Understands the pathophysiology of the various processes that may affect the MSK system and
the relevant specific conditions in which these processes are involved in order to explain the
general manifestations of these processes in terms of clinical symptoms and signs, and the typical
changes detected on relevant and commonly utilised investigations (laboratory, imaging and
special tests).
Specific Outcomes
Outlines and describes fundamental pathophysiological processes and relates these to general
and important specific MSK clinical manifestations.
Vascular/Ischaemic
Polyarteritis Nodosa
Bone infarcts
Temporal Arteritis
Inflammatory/Infection
Septic arthritis
Osteomyelitis
Cellulitis
Fibrositis
Tenosynovitis
Synovitis
+ Lyme disease
Traumatic/Mechanical
Fractures
Sprains
Strains
Dislocations
Repetitive motion injuries
Nerve compression
Autoimmune or Immune-mediated
Ankylosing Spondylitis
Polymyositis
Systemic Lupus Erythematosus
Dermatomyositis
Polymyalgia Rheumatica
59
Metabolic/Endocrine/Toxic/Drugs
Osteomalacia
Osteoporosis
Gout
Idiopathic
Dupuytren's contracture
Scoliosis
Paget's disease
Neoplastic
Osteosarcoma
Ewing's sarcoma
Myeloma
Metastatic
Congenital/Inherited/Developmental
Muscular Dystrophy
Osteogenesis Imperfecta
Developmental Dysplasia of Hip
Dwarfism
Degenerative
Osteoarthritis
Disc disease
Psychological
Conversion disorders
Overlay in other conditions
Chronic Pain Syndromes
Compensable patients
60
Specific Reactions of Musculoskeletal
Tissues to Disorders and Injuries
General Objective
Understands the pathogenesis of the main generalised and local reactions of MSK tissues to
abnormal conditions in order to explain and categorise their clinical manifestations and relate them
to specific clinical examples.
Specific Outcomes
Categorises and describes the principle local and generalised reactions of MSK tissues in
response to abnormal conditions including their clinical manifestations and relates to examples of
specific causes.
Bone
Bone deposition
Generalised Increases
Osteopetrosis
Acromegaly
Generalised Decreases
Osteoporosis
Rickets (children)
Osteomalacia (adults)
Localised increases
Work hypertrophy
Degenerative arthritis
Fractures
Infection
Osteosclerotic neoplasms
Localised decreases
Disuse atrophy/osteoporosis
Infection
Osteolytic neoplasms
Bone failure (fracture)
Trauma
Overuse/fatigue
Pathological conditions of bone
e.g. osteoporosis, Osteogenesis Imperfecta, neoplasia
61
Bone death (necrosis)
Trauma
Vascular conditions
Infection
Neoplasia
Epiphyseal Plates
Increased growth
Pituitary gigantism
Marfan's syndrome
Decreased growth
Achondroplasia
Pituitary dwarfism
Rickets
Articular cartilage
Destruction
Infections
Ankylosing Spondylitis
Prolonged immobilisation
Continuous compression
Intra articular injections of hydrocortisone
Degenerative
Premature ageing
Previous destruction
Joint incongruity or irregularity
Peripheral proliferation
Osteophyte formation
Synovial Membrane
Fluid production/Effusion
Serous
Inflammatory
Purulent
Haemorrhagic
Hypertrophy
Adhesion formation
62
Joint capsule and ligaments
Joint Laxity
Congenital generalised laxity
Injury
Infection
Contracture
Congenital joint contracture
Infection
Chronic arthritis
Muscle contracture
Skeletal Muscle
Disuse atrophy
Poliomyelitis
Polyneuritis
Myasthenia gravis
Muscular dystrophy
Prolonged immobilisation
Pain
Work hypertrophy
Isometric contraction/exercise
Muscle ischaemia
Vascular trauma
Thromboembolic disease
Compartment syndrome
Infection
Muscle contracture
Prolonged shortened state
Polymyositis
Muscular dystrophy
Cerebral palsy
Muscle regeneration following injury
Nerve tissue
NOTE: incomplete overlap with Neurology- ongoing consultation and horizontal integration required
Axonal reaction
Wallerian degeneration
63
Regeneration and limitations
Upper motor neuron lesions
Lower motor neuron lesions
64
Musculoskeletal Deformities
General Objective
Understands the main conditions affecting bones and joints that result in deformities and
understands their pathogenesis.
Specific Outcomes
Outlines and explains the principle types and causes of bone and joint deformities.
Bone Deformity
Types
Loss of Alignment
Abnormal Length
Bony Outgrowth
Causes
Congenital Abnormalities of Bony Development
Fractures
Disturbances of Epiphyseal Plate Growth
Bending of Abnormally Soft Bone
Overgrowth of Adult Bone
Joint Deformity
Types
Displacement of the Joint
Excessive Mobility (Hypermobility) of the Joint
Restricted Mobility of the Joint
Causes
Congenital Abnormalities of Joint Development
Acquired Dislocations
Mechanical Blocks
Joint Adhesions
Muscle Contractures
Muscle Imbalance
Fibrous Contractures of Fascia and Skin
External Pressures
Joint Deformities of Unknown Cause (Idiopathic)
65
Fundamentals of Image Production
General Objective
Explains the basic principles of and defines in basic terms key terminology and concepts relating to
the fundamentals of image production and interpretation with respect to the main imaging
modalities.
Specific Outcomes
Plain Radiography
Plain Radiographic Production
X-rays as part of a spectrum of electromagnetic waves
how X-rays are generated within an X-ray tube from a high voltage
how X-rays are recorded on film or digital media
image intensifier tubes for use in real-time procedural imaging
X-ray interaction with tissues
effects of X-rays on tissues
common types of radioaction used
common units of radiation
mSv equivalents
attenuation of X-ray beam
tissue radiodensities
radiodensity spectrum of 4 main groups (air, fat, soft tissues and bone)
degrees of lucency or opacity
radiological interfaces
lines on a radiograph and the "end-on effect"
Radiographic views
standard anteroposterior (AP) and lateral views
posterior-anterior (PA) views
oblique views
other specialised views
Properties and quality
film penetration
sharpness
geometric unsharpness
motion unsharpness
image resolution and noise
image magnification and distortion
superimposition and summation
Bone features
compact (cortical) and cancellous parts of long bone
66
trabeculae
short and irregular bone
primary and secondary ossification centres
epiphyseal (growth) plate
epiphyseal line
accessory bones
sesamoid bones
Joint features
radiological joint space
bony articular surfaces
joint soft tissues
Soft tissue interfaces
fat-soft tissue interfaces
air-soft tissue interfaces
Contrast radiography
contrast enhancement
positive and negative contrast media
oral and parenteral contrast administration
myelography
contrast arthrography
arteriography
venography
lymphography
digital subtraction angiography
CT Imaging
Sectional anatomy
conventional orientation
axial sections
sagittal sections
coronal sections
CT image production
the use of a gantry and bed
rotating X-ray tube
multiple axial slice acquisition
image reconstruction
the voxel
CT tissue properties
radiodensity and Hounsfield units (HU)
water attenuation as HU value of 0
values of air, fat, water, soft tissue and bone
CT image properties
arrangement in slices
67
matrix of pixels
pixels from voxels
CT windowing (soft tissue and bone)
spatial resolution
contrast resolution
Special CT techniques
oral contrast media
intravenous contrast media
high resolution (thin slice) CT
multi-slice CT
helical CT
MR Imaging
Image production
radiofrequency (RF) signal emission
body magnetisation
RF application and detection
magnet and coils
MR control processing and storage
contraindications to MR imaging
Basic knowledge of tissue properties that can be imaged by MR
T1 constant
T2 constant
proton density
STIR sequences
MR image properties
pixels representing voxels in MR
different magnetic properties representative of different chemical composition
Special MR imaging
MR arthrography
MR arteriography
contrast media e.g. gadolinium
Ultrasound Imaging
US image production
formation and detection with transducers
piezoelectric crystals
ultrasound reflection
US probes
acoustic coupling gel
Tissue properties in US
reflection, absorption and scatter
68
acoustic impedance
echogenicity
US image properties
US tissue scale - fluid, solid soft tissue and fat
real time sector scans
Doppler US images
Doppler effect
Colour effect
Duplex scanning
Pulsed Doppler
Nuclear Medicine
Nuclear scintigraphy image production
Phases of bone scan
Radionuclide labelling
Technetium
Gallium
++ Thallium
++ Indium
++ FDG (flurodeoxyglucose)
++ For PET-CT
Types / applications
bone scan - whole body and regional
white cell
parathyroid
thyroid
V/Q scan
SPECT-CT
++ PET-CT
DXA/Dual Energy X-ray Absorptiometry
Image production
Radiation dose/safety
Machine differences/comparative measurements
Application
BMD assessment
body fat assessment
Interpretation
T scores
Z scores
PBS eligibility
++ Racial and age differences
69
Radiological Anatomy
General Objective
Identifies and describes in anatomically correct and radiologically-relevant terminology the normal
appearances of key bony and soft tissue structures and landmarks in standard projectional and
cross-sectional imaging modalities in a manner that is clearly understandable by the target
audience.
Radiographic Views and Landmarks to Identify
Cervical Spine
Lateral view
Basion
Anterior Arch of C1
Dens
Anterior Atlantodental Interval (AADI)
Ring of C2
Prevertebral Soft Tissues
Vertebral Bodies
Intervertebral Disc Space
Superior Facet
Inferior Facet
Transverse Process
Posterior Arch of C1
Pars Interarticularis of C2
Spinolaminar Junction
Interfacetal Joint
Articular Mass
Lamina
Interlaminar Spaces
Pedicle
Spinous Processes
AP view
Mandible
Pedicle
Joint of Luschka
Uncinate Processes
First Rib
Intervertebral Disc Space
Lateral Column
70
Vertebral Body
Spinous Processes
Interspinous Space
Open-mouth view
Dens
C1 Transverse Process
Lateral Atlantoaxial Articular Space
Inferior Border of C1 Posterior Arch
C2 Spinous Process
Incisors
Skull Base
C1 Lateral Mass
Lateral Atlantodental Interval (LADI)
C2 Body
Oblique views
Laminae
Articular Masses
Interfacetal Joint
Spinous Processes
C2 Body
Pedicles
Intervertebral Disc Spaces
Neuroforamina
Additional views
Flexion-extension views
Swimmer's view
Thoracic Spine
AP view
Pedicle
Spinous Processes
Right Paraspinous Line
Right Diaphragm Dome
Clavicle
Transverse Process
Costovertebral Articulation
Costrotransverse Articulation
Left Paraspinous Line
Descending Aorta
Left Diaphragm Dome
71
Lateral view
Scapulae
Right Diaphragm Dome
Left Diaphragm Dome
Rib
Neuroforamina
Facet Joint
Lamina
Spinous Process
Additional views
Swimmer's view
Lumbar Spine
AP view
Facet Joint
Iliac Wing
Sacroiliac Joint
12th Rib
Spinous Process
Pedicle
Transverse Process
Sacral Wing
Lateral view
Osteophyte
Calcified Anterior Longitudinal Ligament
Iliac Crests
Transverse Process
Facet Joint
Posterior Vertebral Body Line
Pedicle
Spinous Process
Additional views
Oblique views
Lumbosacral lateral
Thoracolumbar AP & Lateral
72
Clavicle/ Scapula
AP view of the clavicle
Medial Third of Clavicle and Sternoclavicular joint
Superior Angle of Scapula
Middle Third of Clavicle
Lateral Third of Clavicle
Acromion
Humeral Head
Angled view of the clavicle
Medial Third of Clavicle and Sternoclavicular joint
Middle Third of Clavicle
Conoid Tubercle
Lateral Third of Clavicle
Acromion
Humeral Head
AP view of the scapula
Medial Margin of Scapula
Superior Angel of Scapula
Superior Margin of Scapula
Scapular Spine
Clavicle
Coracoid Process
Acromion
Humeral Head
Glenoid Fossa
Scapular Head
Scapular Body
Lateral Margin of Scapula
Inferior Angle of Scapula
Transscapular Y view
Clavicle
Coracoid Process
Acromion
Humeral Head
Superior Angle of Scapula
Glenoid Fossa
Scapular Body
Inferior Angle of Scapula
Additional views
73
Serendipity view
Stress views
AP view of the shoulder
Posterior Oblique view
Shoulder
AP view
External rotation
Ribs and Thorax
Scapular Spine
Coracoid Process
Distal Clavicle
Acromion
Greater Tuberosity
Bicipital Grove
Lesser Tuberosity
Surgical Neck of Humerus
Glenoid Fossa
Scapular Neck
Internal rotation
Scapular Y view
Greater Tuberosity
Coracoid Process
Clavicle
Superior Margin of Scapula
Acromion
Scapular spine
Humeral Head (centred over Glenoid Fossa - crux of Y)
Scapular Body
Axillary view
Glenoid Fossa
Coracoid Process
Humeral Head
Lesser Tuberosity
Acromion
Clavicle
Additional views
Posterior oblique view (Grashey view)
74
Elbow
AP view
Olecranon Fossa and Coracoid Fossa (superimposed)
Lateral Epicondyle
Capitellum
Radial Head
Radial Neck
Radial Shaft
Humeral Shaft
Humeral Metaphysis
Medial Epicondyle
Trochlear Articulate Surgace
Coronoid Process
Proximal Radioulnar Joint
Ulnar Shaft
Lateral view
Radial Tuberosity
Radial Neck
Supinator Fat Stripe
Radial Head
Coronoid Process
Anterior Fat Pad
Trochlear Sulcus
Olecranon
Medial Aspect of Trochlear Articular Surface
Trochlear Notch
Capitellum
Additional views
Lateral oblique view
Medial oblique view
Capitellum view
Olecranon view
Wrist
PA view
Hook of Hamate
Hamate
Triquetrum
75
Pisiform
Lunate
Ulnar Styloid
Ulnar Styloid
First Metacarpal
Trapezoid
Trapezium
Capitate
Scaphoid
Radial Styloid
Radius
Lateral view
Hamate
Capitate
Triquetrum
Ulnar Styloid
Ulna
First Metacarpal
Hook of Hamate
Trapezium
Scaphoid
Pisiform
Lunate
Pronator Quadratus Fat Stripe
Radius
Pronation Oblique view
Hook of Hamate
Hamate
Capitate
Pisiform
Triquetrum
Lunate
Ulnar Styloid
Ulna
First Metacarpal
Trapezium
Trapezoid
Scaphoid
Radial Styloid
Radius
Additional views
76
Scaphoid view
Supination Oblique
Carpal tunnel view
Hand
PA view
Trapezoid
Trapezium
Scaphoid
Radius
Distal Phalanges
Middle Phalanges
Proximal Phalanges
Metacarpals
Hamate
Capitate
Triquetrum
Lunate
Ulna
Lateral view
Thumb Metacarpal
Trapezium
Scaphoid
Radius
Metacarpals
Triquetrum
Lunate
Ulna
Pronation Oblique view
Sesamoid
Trapezium
Scaphoid
Metacarpals
Hamate
Triquetrum
Lunate
Additional views
Supination oblique (ball-catcher's) view
Brewerton view
77
Digits
Finger views
Thumb views
AP thumb (Robert view)
Pelvis
AP view
Anterior Superior Iliac Spine
Vascular Groves in Ilium
Superior Acetabular Rim
Femoral Neck
Greater Trochanter
Lesser Trochanter
Ischial Ramus
Ischial Tuberosity
Inferior Pubic Ramus
Pubic Symphysis
Superior Pubic Ramus
Obturator Foramen
Fovea of Femoral Head
Posterior Acetabular Rim
Iliac Wing
Iliac Crest
Sacroiliac Joint
L5 Vertebral Body
Sacral Neuroforamen
L5 Transverse Process
Sacral Wing
Arcuate Line
"Tear Drop" - Articular Surgace of Acetabulum, Ischiopubic Line, Iliopubic Line (Arcuate
Line), Radiographic "U" (inferior lip of anterior articular surface of acetabulum)
Coccyx
Ischial Spine
Anterior Judet view (internal oblique/obturator oblique)
Iliopubic Line (Arculate Line) (Anterior column of acetabulum)
Obturator Foramen
Iliac wing
Posterior Rim of Acetabulum
Posterior Judet view (External oblique/iliac oblique)
78
Ischiopubic Ramus (posterior column of acetabulum)
Ischial Spine
Obturator Foramen
Anterior Rim of Acetabulum
Iliac Wing
Additional views
Inlet view
Outlet view
Lateral sacral view
Hip
AP view
Sacroiliac Joint
Iliopubic Line (Arculate Line)
Acetabular Articular Surface
Centrum of Acetabulum
Fovea Capitus
Ilioischial Line
Superior Pubic Ramus
"U" - Anterior-Inferior Lip of Acetabulum
Obturator Foramen
Inferior Pubic Ramus
Ischial Tuberosity
Femoral Neck
Lesser Trochanter
Anterior Superior Iliac Spine
Posterior Acetabular Rim
Greater Trochanter
Cross-table lateral (groin lateral) view
Ischial Spine
Ilioischial Line
Greater Trochanter
Lesser Trochanter
Femoral Neck Cortex
Additional views
Frog-leg view
Posterior Oblique view
79
Anterior Oblique view
Knee
AP view
Patella
Medial Femoral Condyle
Medial Tibial Plateau
Medial Tibial Condyle
Intercondylar Eminence
Anterior Tibial Tubercle
Remnant of Growth Place
Lateral Femoral Condyle
Lateral Tibial Plateau
Lateral Tibial Condyle
Fibular Head
Lateral view
Root of Intercondylar Notch
Fibular Head
Quadriceps Tendon
Patella
Medial Tibial Condyle
Anterior Tibial Tubercle
External Oblique view
Medial Femoral Condyle
Patella (lateral margin)
Internal Oblique view
Patella (medial margin)
Proximal Tibiofibular Joint
Axial Patellar view (Sunrise/Skyline view)
Additional views
Cross-table lateral
80
Intercondylar notch view (Tunnel view)
Ankle and Leg
AP view
Talus
Medial Malleolus
Tibia
Fibula
Lateral Malleolus
Lateral view
Tibia
Talar Dome
Talar Neck
Navicular
Cuneiforms
5th Metatarsal Tuberosity
Cuboid
Anterior Process (Calcaneus)
Sustentaculum Tali
Posterior Tubercle of Talus
Posterior Malleolus (Posterior Lip of Tibia)
Lateral Malleolus (Fibula)
Mortise view
Talar Dome
Medial Clear Space
Distal Tibiofibular Joint (Lateral Clear Space)
Tibiofibular Overlap
Additional views
External Oblique view
Internal Oblique view
"Poor" lateral view
Foot
AP view
Sesamoids
1st Metatarsal
1st Cuneiform
2nd Cuneiform
Navicular
81
Tuberosity
Talar Neck
Calcaneus (anterior process)
Cuboid
Metatarsals - Head, Neck, Shaft, Base
Internal oblique view
Proximal Phalanx
Sesamoids
Navicular
Talar Neck
Tibia
Fibula
Calcaneus (posterior tuberosity)
Cuboid
Lateral view
Phalanges
Metatarsals Shafts
Metatarsal Bases
Cuneiforms
Navicular
Accessory Ossicle
Talar Neck
Talar Dome
Lateral Malleolus
Talus (posterior tubercle)
Calcaneus (posterior tuberosity)
Sustentaculum Tali
Cuboid
Calcaneus view
Sustentaculum Tali
Posterior Tuberosity of Calcaneus
Lateral Malleolus
Additional views
Talus view
Cuneiform views
Toes
82
Great Toe
83
Injury and Pathological Conditions
General Objective
Identifies and describes the common manifestations of basic pathological processes on imaging
modalities.
Specific Outcomes
Acronym: Vitamin CDP
Vascular/Ischaemic
Inflammatory/Infectious
Autoimmune or immune mediated
Metabolic/Endocrine/toxic/drugs
Idiopathic
Neoplastic
Degenerative
Psychological
84
Reactions of Specific Tissues
General Objective
Identifies and explains the significance of altered appearances of bone, joints and soft tissues.
Specific Outcomes
Bone
sclerosis
osteopaenia
lysis
expansion of cortex
periosteal reaction
destruction
abnormal mineralisation/calcification
failure (fracture)
Joint
effusion
degeneration
destruction
periarticular lysis/erosions/destruction
abnormal mineralisation/calcification
loss of joint space
peripheral proliferation/osteophytes
subchondral sclerosis
periarticular osteopaenia
joint collapse/failure
Soft tissue
swelling
fluid collections
ectopic mineralisation/ ossification
hypertrophy
atrophy
fatty infiltration
85
General Principles of Clinical Imaging
General Objective
Understands and applies the general principles of requesting, reporting and interpretation of
diagnostic imaging to the safe assessment and management of health conditions.
Specific Outcomes
Requesting
Accurately and succinctly provides relevant clinical information on request forms
Explains need for clinical correlation
Explains importance of relevant clinical information and "Pre-test Probability" with respect
to Interpretation of Imaging by Reporting Doctor
Selects imaging investigations that are most appropriate with respect to diagnostic role, use in
management decisions and cost-effectiveness
Explains value of sensitivity/specificity data and utilisation of evidence-based guidelines
for requesting diagnostic imaging
Explains need to restrict imaging (and other investigations) to those which can
appropriately interpret and that will potentially guide the referrer's management
Explains rationale for deferring requests for selected investigations to specialist
practitioners
Explains key reasons for overuse of diagnostic imaging
Explains indications and expectations (including obtaining documented consent) for proposed
imaging modalities including any associated special preparation, precautions and risks (including
radiation risk relative to background exposure)
Explains commonly-used evidence-based diagnostic imaging protocols where appropriate
Reporting/Interpreting
Applies a systematic approach (e.g. ABC's) to the description and
interpretation of diagnostic imaging
Verifies details of patient and timing of examination
Identifies key characteristics of image production required for interpretation
projectional view on plain radiographs
presence of contrast
density weighting on CT (e.g. soft tissue or bone)
T weighting or fat saturation on MRI
phase labelling in scintigraphy
Assesses adequacy of view
Identifies key anatomical features
Identifies key pathological features/ abnormalities
86
Comparison with previous imaging studies when available
normal variations at level prescribed for level of training
disruption of normal cortical outlines
abnormal soft tissue swellings
fluid collections
abnormal gas
Explains and applies a focused/targeted approach to the interpretation of diagnostic imaging in
selected cases
Constructs a report providing an appropriate diagnosis or limited differential diagnosis and
proposed further diagnostic steps if required for common and important urgent or red flag
conditions
Interprets and applies diagnostic imaging reports in appropriate patient assessment, management
and education
Accurately and succinctly communicates findings from imaging studies using terminology
appropriate to target audience (health professional and community/patients)
Safety
Explains and applies principles of radiation safety
87
Critical Reasoning and Biostatistics
General Objective
Understands and interprets core descriptive and interferential statistics and epidemiological
concepts and applies this to the critical evaluation of published literature and practical procedures
with respect to their reliability, validity, utility, and effectiveness.
Specific Outcomes
General principles of application and interpretation of Biostatistics
Explains with particular reference to health care
Descriptive Statistics
mean
standard deviation
standard error of the mean
median
interquartile range
confidence interval of a mean
confidence interval of a proportion
coefficient of variation
Inferential Statistics
tests of difference
t-test
rank tests
analysis of variance
power analysis
survival analysis
tests of association
chi-squared test
Fisher's exact test
tests of correlation
regression
Spearman’s coefficient
Pearson’s coefficient
tests of agreement
kappa
88
General principles of application and interpretation of epidemiological
concepts
Explains with respect to musculoskeletal diagnoses
sensitivity
specificity
predictive value
likelihood ratio
prevalence
pre-test probability
pre-test odds
post-test probability
post-test odds
reliability
validity
Describes
General principles of the critical evaluation of medical literature
Decision analysis trees
Principles of planning and interpreting trials of diagnostic tests
Principles of planning and interpreting trials of therapeutic interventions
Concept of placebo
Concepts of effect-size of a treatment and the "Number Needed to Treat"
Merits of different types of clinical trials and their relation to "levels of statistical evidence"
Role and limitations of Evidence-Based Medicine (EBM)
Difference between application of population based "evidence based medicine" and
patient centred "evidence-informed practice"
89
Diagnostic Formulation
General Objective
Understands the principles of diagnosis, evidence-based diagnostic formulation and contemporary
diagnostic taxonomy, with an appreciation of ideal diagnostic criteria, the limitations of diagnostic
methods and the statistical methods for quantifying them.
Specific Outcomes
Applies a "problem based" symptomatic diagnostic approach to the history, examination, limited
investigation, and assessment of a patient presenting with a complaint.
pain
injury
weight loss
lethargy
fever
failure to thrive (paediatric)
general symptoms relating to systems e.g. respiratory, cardiovascular etc
Relates problems to a "surgical sieve" or pathological axes
Acronym = "VITAMIN CDP"
Vascular/Ischaemic
Inflammatory/Infectious
Autoimmune or Immune mediated
Metabolic/Endocrine/Toxic/Drugs
Idiopathic
Neoplastic
Degenerative
Psychological
Explains the different approaches to diagnostic formulation and the advantages and disadvantages
the gestalt or “heuristic” approach (clinical impression)
the hypothetico-deductive approach
the exhaustive approach
the “decision-tree” or algorithm approach
Explains the principles of diagnosis as the process of determining the nature and circumstances of
a medical condition by following a rational strategy
the integration of structural and functional information during assessment to determine
which further steps are needed
90
the appraisal of positive and negative findings resulting from history-taking, clinical
examination and ancillary investigations
relating the findings to anatomical and pathological axes (refer below)
correlating postulated structural and functional impairments with known pathological
entities and possible psychosocial sequelae
Discusses features used to discriminate between specific common conditions and the evidence on
which they are based
Exhibits an appreciation of the limitations of contemporary diagnostic methods in satisfying ideal
diagnostic criteria of reliability and validity
Relates the elements of critical reasoning and clinical epidemiology and the evidence on which
they are based to the process of diagnosis
Communicates diagnoses in terms consistent with contemporary taxonomy, and with reference to
anatomical and pathological axes
Evaluates the accuracy and ambiguity of diagnostic terms and statements found in literature
pertaining to medical conditions
91
Wound Management
General Objective
Has knowledge and understanding of the key basic science concepts and principles of
inflammation and repair, relates these to normal and abnormal processes in wound healing, and
applies these principles to the assessment and management of wounds. This includes the ability
to: recognise normal from abnormal wound healing; describe healing and its progress using
appropriate current terminology (e.g. as per the "T.I.M.E." model); and outline a basic wound
management plan based on these principles.
Specific Outcomes
Background knowledge
Pathophysiology of wound healing and repair
phases of wound healing
cellular responses
molecular responses
Soft Tissue Injuries
Defines and describes the general characteristics and the main clinical concerns of the following
terms used in relation to soft tissue injuries
contusions
crush injuries
haematomas
abrasions
lacerations
tears/avulsions
proximally and distally based flaps
penetrating injuries/puncture wounds
de-gloving injuries
open (compound) fractures
Wound healing
Defines different types
Primary
Secondary
Tertiary
Wound Classifications
Outlines and explains
Wound terms based on bacterial burden
92
Contamination
Colonisation
Critical-colonisation
Infection
Surgical wound classification system
Class 1: clean
Class 2: clean-contaminated
Class 3: contaminated
Class 4: dirty/ infected
Wounds associated with fractures
+Gustilo-Anderson Classification
+Tscherne soft tissue wound classifications
Open fractures
Closed fractures
Explains relationship between wound classification systems and clinical outcomes
e.g. risk of operative infection depending of wound type/class
TIME Model
Outlines and describes the TIME model of wound assessment
Describes wounds with reference to TIME model
Applies TIME model to the formulation of a general wound management plan
Differentiates between acute and chronic ulcers/wounds
Explains the role of surgical debridement in the management of wounds with reference to
the TIME model
Explains the concept of wound bed preparation
Description of wound using appropriate contemporary taxonomy
Wound Management
Outlines in general terms the different types of wound dressings and their applications
Outlines appropriate plan for further assessment as required
Instructs management orders as appropriate
Rest
Elevation
Splintage
Dressings
Surgical intervention
incision and drainage
debridement/wound bed preparation
closure
coverage
93
+grafts
+flaps
Adjuvant therapy
antibiotics
nutrition
+hyperbaric oxygen
94
General Principles of Procedures
and Equipment Usage
General Objective
Understands the core general principles associated with the performance of procedures and the
use of medical and related equipment including informed consent, selection, patient and equipment
preparation, and the specifics of application.
Specific Outcomes
Outlines and discusses key principles and issues relating to
Consent
Indications
Contraindications
Likely benefits
Possible complications and their frequency
Predictors of success
The likely outcome of the procedure in a specified scenario
Preparation
Ensure correct patient and correct site and/or side
Ensure appropriate and safe location
Infection control and prophylaxis
IV access
Analgesia
Sedation
Anaesthesia
Airway control
Prior medical optimization
Prior consultation with relevant senior/specialist practitioner
Performance
Relevant anatomy including landmarks, structures directly involved and structures at risk
+ Variations in practice required in special circumstances
++ Alternative techniques if multiple methods are commonly used
++ The evaluation of the effectiveness of the procedure
++ Related contemporary issues/controversies
Equipment
Mechanism of action
Correct operation/utilisation
+ Features commonly available
95
++ Likely maintenance requirements and purchase procedures
96
History
General Objective
Constructs in consultation with a patient (or representative) accurate and organised MSK
screening and problem-focused histories that address presentations with acute or chronic pain,
traumatic injury and/or functional disability. This includes the ability to take a relevant history
applying understanding of the general pathological processes and specific reactions of MSK
tissues to disorders and injuries.
Specific Outcomes
Demonstrates ability to obtain and record from a patient with a musculoskeletal disorder a medical
history in the knowledge of the key defining and distinguishing characteristics
Full medical history
the patient's identification and social history
name, sex, age, laterality (handedness), address, domestic circumstances, dependants, present
occupation (with work description), previous occupations, employment status, employer, source of
income, sporting activities, hobbies, other leisure interests
the patient's presenting symptoms
pains, altered sensations, stiffness, instability, deformity, loss of function, with particular reference to
site, radiation, quality, periodicity, duration, mode of onset, aggravating and relieving factors, effects
on lifestyle (in terms of activities of daily living) and treatment to date
specific details of mechanism of injury where applicable
e.g. heights, velocities, twisting, bending forces
previous episodes of similar symptoms and the effects of management on them
other previous musculoskeletal problems
general medical history, including current and past medical problems
e.g. diabetes
substance intake
including tobacco, alcohol and all current medications, whether prescribed or otherwise
allergies
family medical history including inheritable disorders
biological and psychosocial lifestyle risk factors
Screening history
General
pain, displacement, dislocation, stiffness, swelling, and limitation of activities
Trauma
High-energy and low-energy trauma and injury and its sequelae
Pain
97
acute and chronic pain and associated severity, effects, and modulating factors
Functional
the impact on the individual of a chronic musculoskeletal condition due to impairment of
function, limitation of activities and restriction of participation (WHO ICF 22)
Structural/ Tissue-based history
General
Bone
Fracture
Malignancy
Infection
Osteoporosis
Joints
Osteoarthritis (degenerative joint disease)
Ankylosing arthritis
Pseudogout
Septic arthritis
Other inflammatory arthritides
Intra-articular injuries
Gout
Connective tissue
Bursitis
Tendonosis
Tenosynovitis
Nerves
Entrapment/ compression
Peripheral neuropathy
Radiculopathy
Injury
Muscles
Inflammatory
Congenital
Neurological
Spinal conditions
Mechanical neck/back pain
Spinal cord or root entrapment
Vertebral fracture of traumatic origin
Vertebral fracture of osteoporotic origin
Inflammatory back pain
Deformity
98
Infection
Neoplasia
99
General Principles of
Musculoskeletal Examination
General Objective
Understands and applies the general principles of a patient-centred examination to the assessment
of all patients presenting with a MSK condition.
Specific Outcomes
Explains principles of and correctly demonstrates the appropriate performance of key elements of
MSK examination and related issues.
Communication
conveys clear and relevant instructions including consent
conveys observations and findings to patient
documentation using clear and appropriate terminology
Introduction/Initial Patient Contact
appropriately introduce themselves including their name and title or level of training
care and respect at all times
Consent
what is going to be done in general terms that the patient can understand
why the examination is necessary or desirable
any potentially adverse effects of the examination
that the patient should provide any feedback during the examination regarding pain or
concerns
the rights of the patient to withdraw consent
Patient Exposure
adequacy
comfort and dignity
chaperone use
infection control
Patient Inspection
Acronym = "GUAMS +G"
"General features" of the patient
height
100
body habitus
colour
clothing
general hygiene/ personal care
general deformities/ syndromal features
obvious mannerisms
obvious pain/discomfort
other distinctive features
Use of aids
walking aids/ frames/ sticks/ crutches etc
orthotic devices
splints and braces
assistive devices
Alignment
general alignment
symmetry
other deformity
Muscle bulk
symmetry
muscle wasting
Skin
colour
wounds/ulcers
scars
sinuses
swellings/ masses/ lumps
erythema
discolorations
exanthema
Gait
limp
fluency
Patient Palpation
Be attentive of patients reaction to palpation at all times
Identify potentially painful or problematic sites by suitable enquiry prior to commencement
of palpation
Approach and palpate tender sites very carefully/softly initially - increasing local pressure
as tolerated by patient whilst both observing and communicating with patient
Consider avoiding palpation of pre-identified painful regions until later in examination.
101
Sites of abnormal tenderness including bone, muscle, ligaments, tendons, joint capsule
and synovium, bursae, nerves
Abnormalities or differences in local temperature
Abnormal lumps or swellings
Abnormalities of skin hydration
Assessment of Patient Movement
Range of motion
Normality / abnormality of power
Symmetry of movements
Fixed deformity
Grades of power -MRC
"Lag" between active and passive movements
Assessment of Joint Stability
signs of generalised ligamentous laxity
Normality from marked-moderate instability of any peripheral major or minor limb joints
++ Minor/ subtle instability of any peripheral major or minor limb joints
References
The Code of Practice and Guidelines for Taking Consent
The Code of Practice and Guidelines for use of Chaperone (e.g. Medical Board)
Guidelines for infection control
AMSEC Physical Examination (Multimedia)
102
GALS (Gait, Arms, Legs, Spine)
General Objective
Performs, interprets and records GALS screening history and examination using standardised
technique.
Specific Outcomes
General/Baseline
"General Examination Principles"
MSK Clinical Anatomy
History
Identifies pain or stiffness of any muscle, joint, spine
Determines ability to completely dress
Observes ability to walk up and down stairs
Examination
Gait
Instruction/action and observation: "walk up the corridor and then turn around and walk
back"
symmetry and smoothness of movement with respect to legs, arm swing and pelvic
tilting
stride length
heel strike
stance
toe off
swing through
ability to turn quickly
Arms
General observation
including front, back and side
normal bulk and symmetry of shoulder muscles
symmetry of shoulder height
Instruction/ action and observation
"put both hands behind the head with the elbows back"
normal movement of the glenohumeral, sternoclavicular and acromioclavicular joints
"place both hands in front, palms down, fingers straight"
103
presence or absence of wrist or finger swelling , normal wrist pronation and finger
extension
squeezing across metatarsals
tenderness of the MTP joints
"place both hands by the side with elbows straight"
normal elbow extension
"make a tight fist with each hand"
normal power grip
"place the tip of each finger onto the tip of your thumb in turn"
normal fine precision pinch/ dexterity
Legs
General observation
normal bulk and symmetry of gluteal muscles
symmetry of iliac crest height
normal bulk and symmetry of quadriceps
presence or absence of popliteal swelling
presence or absence of knee deformity or mal-alignment in terms of varus or valgus
deformity
presence or absence of knee swelling
presence of normal arches or deformity in terms of planus or cavus
presence or absence of hindfoot swelling or deformity
presence or absence of forefoot or midfoot deformity
presence or absence of callosities on soles
passive flexion of hip and knee whilst holding the knee
full knee flexion and presence or absence of knee crepitus determined by the direct
pressure of the patella
patello-femoral tenderness and/or an effusion
Spine
General observation
alignment of spine to distinguish between a straight spine and scoliosis
normal cervical lordosis
normal lumbar lordosis
normal (mild) thoracic kyphosis
normal and symmetrical paraspinal muscles
"touch toes"
normal lumbar and hip flexion
application of pressure over the mid supraspinatus muscles bilaterally
presence of absence of hyperalgaesia to suggest fibromyalgia
104
Documentation
"GALS" table
Resources
View a video of the GALS examination at
http://www.qub.ac.uk/cskills/video%20resource/gals_video_page.htm
105
Spine
General Objective
Explains principles of and correctly describes and/or demonstrates the appropriate performance of
key elements of the regional and related examination of the spine to determine normal from
abnormal.
Specific Outcomes
General/ Baseline
Scientific basis of MSK practice: MSK clinical anatomy
as outlined in
 General Examination Principles
 Examination of Gait
 Neurological Examination
 Gait and Spine sections of GALS Screening Examination
Observation
General appearance
as per general principles
Height
Body habitus
Syndromes (Marfan, Turner, Down, Achondroplasia)
Use of Aids
Walking aids
Other assistive devices
Splints/ Braces
Alignment
Shoulder height
Lordosis - cervical/lumbar
Kyphosis - thoracic
Torticollis
Scoliosis
+ Head balance
++ Gibbus
Muscle bulk
paraspinal musculature
wasting of upper limbs
wasting of lower limbs
106
Skin
Neck webbing
"Cafe au lait" spots
Hair line
Gait
as per "Gait examination"
Palpation
Bony landmarks
Upper spine
hyoid bone
thyroid bone
first cricoid ring
carotid tubercle
occiput
inion
superior nuchal line
spinous processes
facet joints
Lower spine
tops of posterior iliac crests
spinous processes
posterior aspect of coccyx
greater trochanter
ischial tuberosities
+ iliac tubercles
++ sacral promontory
Soft tissue
Upper spine
sternocleidomastoid muscle
lymph node chain
thyroid gland
carotid pulse
parotid gland
supraclavicular fossa
trapezius muscle
+ greater occipital nerves
+ superior nuchal ligament
Lower spine
paraspinal muscles
107
anterior abdominal muscles
sciatic nerve
inguinal area
+ supraspinous and interspinous ligaments
+ piriformis muscle
++ cluneal nerves
Movement
Active cervical motion
flexion
extension
lateral flexion
rotation
Active thoraco-lumbar motion
flexion
extension
lateral flexion
thoracic rotation
Special Tests
Neural stretch
Straight leg raise
+ Lasegue’s sign
+ Bowstring test
+ Femoral nerve stretch test
Other tests
+ Block test
+ Spurling’s manoeuvre
+ Shoulder abduction relief test
+ Hoffmann’s sign
108
Hip and Pelvis
General Objective
key elements of the regional and related examination of the hip and pelvis to determine normal
from abnormal.
Specific Outcomes
General/Baseline
As outlined in
 Gait and Leg sections of
o "GALS" Screening Examination
o Examination of Gait
o Neurological Examination
Observation
General appearance
As per general principles
Use of aids
Correct use of walking sticks
Correct use of crutches
Correct use of walking frames
Abnormal wear patterns of footwear
Footwear modifications
Correct use of external supports e.g. hip abduction brace
Alignment
Hip
Knee
Spine
Pelvis
Muscle bulk
Quadriceps
Hamstrings
Gluteus Maximus
109
Adductors
Skin
Gait
Trendelenburg
Antalgic
Short leg
Palpation
Bony landmarks
Greater Trochanter
Ischial Tuberosity
Pubic Tubercle
ASIS
PSIS
Muscle bellies
Gluteal muscles
Quadriceps
Hamstrings
Adductors
Gracilis
Sartorius
Piriformis
Tendons
Gluteus Medius
Adductor tendon
Gracilis
Joints/Synovia/Bursae
Trochanteric Bursa
Pubic Symphysis
Sacroiliac Joint
Fascia
Tensor Fascia Lata
Lymph nodes
Inguinal nodes
Femoral nodes
110
Movement
Range of Motion Hip Joint
Flexion
Extension
Abduction
Adduction
Internal rotation
External rotation
Power
Flexion
Extension
Abduction
Lateral leg raise
Adduction
Internal rotation
External rotation
Special Tests
Leg Length
True leg length
Apparent leg length test
Block test
Galleazzi test
+Bryant's triangle
Other hip tests
Trendelenburg test (from in front)
Thomas
Sacroiliac joint
FABER test
Hip Rotational
Thigh-foot angle
Tibial torsion
Gage test
Cerebral Palsy/Contractures
+Ober's test
+Phelps Gracilis test
+Modified Tardieu reflexes (prone)
+Duncan-Ely test
111
Knee
General Objective
key elements of the regional and related examination of the knee to determine normal from
abnormal.
Specific Outcomes
General/Baseline
As outlined in
 Gait and Leg sections of
o “GALS” Screening Examination
o Examination of Gait
o Neurological Examination
Observation
General appearance
Use of walking aids
Innersoles
AFO’s
Callipers
Braces
Prostheses
Alignment
Knee
Patellofemoral joint
Ankle
Hindfoot
Muscle bulk
Quadriceps
Hamstrings
Triceps Surae
Skin
Gait
112
Antalgic
Stiff knee
++ Varus thrust
++ Valgus thrust
Palpation
Bony landmarks
Medial tibial plateau
Medial joint line
Tibial tuberosity
Medial femoral condyle
Lateral tibial plateau
Lateral joint line
Lateral tubercle (Gerdy's)
Lateral femoral condyle
Lateral femoral epicondyle
Head of fibula
Trochlear groove
Patella
+ Osteophytes
++ Adductor tubercle
Joints/ Synovia/ Bursae
Patella Sweep Test
Patella tap test
Bulge test
Cross fluctuation test
Muscle Bellies
Quadriceps
Biceps Femoris
Combined medial hamstrings
+ Semimembranosus (isolated)
+ Semitendinosus (isolated)
+ Gracillis
+ Sartorius
Tendons
Quadriceps
Biceps Femoris
Tensor fascia lata
+ Medial gastrocnemius
+ Lateral gastrocnemius
+ Pes anserinus
113
++ Semitendinosus
++ Gracillis
++ Sartorius
++ Semimembranosus
Ligaments
Patella ligament
Medial collateral ligament
Lateral collateral ligament
Fascia
Iliotibial band (ITB)
+ Fascia lata
Lymph nodes
Inguinal
Femoral
Popliteal
Movement
Range of Motion (active and passive)
Flexion
Extension
++ Internal rotation
++ External rotation
Power
MRC grades
Flexion
Extension
Special Tests
Patellofemoral joint
Patella apprehension
+ Patella tracking
+ Q angle
+ Clarke's test
Knee stability
Varus / valgus stress test
Lachman test
Anterior drawer
Posterior drawer
+ Posterior sag & medial condyle step-off
114
+ Quadriceps active test
++ Pivot shift
++ Reverse pivot shift
++ Dial test
Meniscal pathology
Thessaly test
McMurray's test
++ Apley's compression and distraction tests
++ Bollen's test
115
Ankle & Foot
General Objective
key elements of the regional and related examination of the foot and ankle to determine normal
from abnormal.
Specific Outcomes
General/Baseline
As outlined in
 Gait and Leg sections of "GALS" Screening Examination
 Examination of Gait
Observation
General appearance (including footwear)
Inflammatory arthritis
Asymmetrical wear on the sole
++ Distortion pattern
++ Toe box (narrow or wide)
Use of aids
Innersoles
+ AFO’s
++ Callipers
Alignment
General
Knee
Ankle
Hindfoot
Midfoot
Forefoot
Toes
Specific deformities
Pes planus
Pes cavus
116
Hallux valgus
+ Mallet toes
+ Claw toes
+ ‘Too many toes’ sign
++ Metatarsus adductus
++ Skew foot
++ Rocker bottom sole
Muscle bulk
Triceps Surae
+Gastrocnemius
+Soleus
++Plantaris
Lateral Leg compartment
++Peroneus Brevis
++Peroneus Longus
Anterior Leg compartment
++Tibialis Anterior
++Extensor Hallucis Longus
++Extensor Digitorum Longus
++Peroneus Tertius
++ Extensor Digitorum Brevis
Skin
Discolorations
Ischaemic changes
Venous insufficiencies
Varicosities
Callosities - including hard and soft corns
Ingrown toenails
Gait
Antalgic
High-stepping
Foot drop
++ Short propulsive phase
++ Stiff ankle
++ Foot progression angle
++ Toe gait
++ Heel gait
117
Palpation
Bony landmarks
Ankle
Medial malleolus
Lateral malleolus
Hindfoot and midfoot
Calcaneus
Navicular tubercle
Cuboid
Styloid process of fifth metatarsal
+ Talar dome & neck
+ Cuneiforms
++ Sinus tarsi
++ Sustentaculum Tali
++ Peroneal tubercle
++ Medial tubercle of talus
Forefoot
Metatarsals
Phalanges
Joints / Synovia / Bursae
Ankle
+ Distal tibiofibular
+ Subtalar
+ Metatarsophalangeal
+ Interphalangeal
+ Tarsometatarsal (Lis Franc)
+ Mid tarsal (Chopart)
Muscle bellies
Triceps Surae
Lateral compartment
Anterior compartment
Extensor Digitorum Brevis
Tendons
Achilles Tendon
Tibialis Anterior Tendon
+ Tibialis Posterior Tendon
++ Peroneus Brevis Tendon
++ Peroneus Longus Tendon
Lymph nodes
+ Femoral
118
+ Popliteal
++ Inguinal
Movement
Range of motion
Ankle
Subtalar
1st MTPJ
+ Midtarsal (Chopart)
+ Tarsometatarsal (Lis Franc)
+ Lesser MTPJs
+ IPJs
Power
Plantar flexion (Triceps Surae)
Dorsiflexion
Eversion (Peronei muscles)
Inversion (Tibialis Anterior and Posterior)
Extensor Hallucis Longus
+ Tibialis Anterior
+ Tibialis Posterior
+ Flexor Hallucis Longus
+ Extensor Digitorum Brevis
+ Extensor Digitorum Longus
Special Tests
Ankle
Squeeze test
Thompson test
Ankle anterior drawer test
+ Talar tilt test
++ Silfverskiöld test
Hindfoot
++ Jack's test
++ Coleman block test
Forefoot
+ Mulder’s test
119
Shoulder
General Objective
key elements of the regional and related examination of the shoulder to determine normal from
abnormal.
Specific Outcomes
General/Baseline
As outlined in
 Arms sections of "GALS" Screening Examination
Observation
General appearance
Shoulder contour
+ Scapular position
+ clavicle including Acromioclavicular and Sternoclavicular joints
Use of aids
Alignment
+ Shoulder height
Muscle bulk
Deltoid
Supraspinatus
Infraspinatus
Trapezius
Pectoralis Major
Triceps
Biceps
Latissimus Dorsi
++ Levator Scapulae
++ Rhomboids
120
Skin
Gait
Where walking aids are required
Palpation
Bony landmarks
Clavicle
Coracoid process
Scapular spine
Lateral edge of acromion
Posterior edge of acromion
+ Lesser tuberosity
+ Greater tuberosity
Joints/synovia/bursae
Acromioclavicular joint
Sternoclavicular joint
Subacromial space
Glenohumeral joint
Muscle bellies
Deltoid
Supraspinatus
Infraspinatus
Latissimus Dorsi
Trapezius
Pectoralis Major
Biceps
Triceps
+ Rhomboids
++ Levator Scapulae
++ Teres Minor
++ Pectoralis Minor
Tendons
Pectoralis Major
Deltoid
Supraspinatus tendon
Long head of Biceps
++ Conjoint tendon
++ Infraspinatus tendon
121
++ Subscapularis tendon
Lymph nodes
Supraclavicular
Axillary
Movement
Range of motion
Forward flexion
Abduction
Adduction
Extension
External rotation (arm by side)
Internal rotation (arm by side)
External rotation (in abduction)
Internal rotation (in abduction)
Shoulder/scapular elevation/shrugs
Shoulder/scapular retraction
Shoulder/scapular protraction
Power
Composite actions
Abduction
Forward flexion
Extension
External rotation (arm by side)
Internal rotation (arm by side)
Isolated actions
Deltoid
Trapezius
+ Supraspinatus
+ Subscapularis
+ Serratus anterior
Special Tests
Impingement
Neer's test
+ Hawkin's test
++ Neer’s sign
Glenohumeral instability
Wynn-Davies signs
Sulcus sign
122
Anterior and Posterior Load and shift
+ Anterior and Posterior Drawer tests
+ Anterior apprehension test
+ Fowler's relocation test
+ Posterior apprehension test
Other dysfunction
++ O’Brien’s test SLAP lesion
++ Popeye sign
++ Biceps tendonitis
123
Elbow
General Objective
key elements of the regional and related examination of the elbow to determine normal from
abnormal.
Specific Outcomes
General/Baseline
Scientific basis of MSK practice: MSK clinical anatomy
As outlined in
 Arms sections of “GALS” Screening Examination
Observation
General appearance
Use of aids
Alignment
Carrying angle of elbow
Muscle bulk
Biceps Brachii
Triceps Brachii
Forearm extensors
Forearm flexors
+ Mobile wad of 3 (Brachioradialis, ECRL, ECRB)
Skin
Rheumatoid nodules
Olecranon bursae/bursitis
124
Palpation
Bony landmarks
Lateral epicondyle
Radial head
Olecranon
Medial epicondyle
Radiocapitellar joint
Humero-ulnar joint
Muscle bellies
Biceps Brachii
Triceps Brachii
Forearm flexors
Forearm extensors
+ Mobile wad of 3 (Brachioradialis, ECRL, ECRB)
Tendons
Biceps Brachii
Common extensor origin
Common flexor origin
Triceps Brachii
Lymph nodes
Supraclavicular
Axillary
Epitrochlear
Neurovascular
Brachial artery
Ulnar nerve
Median nerve
Movement
Range of motion
Active and passive
Flexion
Extension
Pronation
Supination
Power
Composite actions
125
Flexion
Extension
Pronation
Supination
Special Tests
Elbow instability
+ Posterior drawer
+ Varus/ valgus stability
++ Lateral pivot shift test
Medial & lateral epicondyalgia
+ Resisted middle-finger extension
+ Resisted wrist flexion & pronation
126
Wrist and Hand
General Objective
key elements of the regional and related examination of the wrist and hand to determine normal
from abnormal.
Specific Outcomes
General/Baseline
As outlined in General Examination Principles
Observation
General appearance
+ Eyes
+ Face
Use of Aids
Walking aids
Assistive devices
Alignment/ Deformity
Ulnar deviation
Contractures
IPJ nodes
+ Swan necking
+ Z-deformity thumb
+ Boutonniere deformity
Muscle bulk
Forearm flexor compartment
Forearm extensor compartment
Thenar eminence
Hypothenar eminence
Dorsal interossei
Skin
127
Garrod's pads
Nail changes
Skin changes
Palpation
Bony landmarks
Radial styloid
Ulna head
Ulna styloid
Scaphoid (anatomical snuff box)
Scaphoid tubercle
Pisiform
Lister's tubercle
Bases of metacarpals
+ Trapezium
+ Hook of Hamate
DRUJ
Radiocarpal joint
Midcarpal joint
Metacarpophalangeal joint
Interphalangeal joint
Muscle bellies
Forearm flexor compartment
Forearm extensor compartment
Dorsal interossei
Thenar eminence
Hypothenar eminence
Tendons
Finger extensors
Finger flexors
Thumb abductors
Thumb extensors
Wrist extensors
Wrist flexors
Fascia
Palmar Fascia
Lymph nodes
Cubital
Supraclavicular
128
Axillary
Epitrochlear
Movement
Range of Motion
Thumb
Flexion
Extension
Abduction
Adduction
Opposition
MCPJs
Flexion (digits II-V)
Extension (digits II-V)
Adduction (digits II-V)
PIPJs
DIPJs
Power
Composite actions
APL / APB
EDC / EDB
Isolated actions
FDP
FDS
Dorsal interossei
Palmar interossei
EI
EDM
AbDM
OP
EPB
FPL
+ AdP
+ FPB
+ Palmaris
+ Lumbricals
+ EPL
129
Special Tests
Thumb conditions
+ Finkelstein’s test
++ Grind test
++ Torque test
Rheumatoid deformities
++ Swan neck deformity assessment
++ Boutonniere deformity assessment
Dupuytren's disease
++ Table top test of Hueston
Neurological tests
Median nerve
Ulnar nerve
Radial nerve
Digital nerves
Tinel's sign
+ Froments's sign
++ Wartenburg's sign
Vascular tests
Allen’s test
Digital Allen’s test
Joint stiffness
++ Bunnel Littler test
++ Retinacular (Zancoli's) Test
++ Elson's Test
Functional grip assessment
Hook grip
Large grip
Small grip
Pen grip
Key grip
Pinch grip
130
Trauma Examination
General Objective
Outlines and explains principles of and correctly describes and/ or demonstrates the appropriate
performance of key elements of targeted examination in the setting of trauma to determine normal
from abnormal.
Specific Outcomes
Background Supporting Knowledge
General Examination Principles
"GALS" Screening Examination
Examination of Gait
Neurological Examination
Wound Management
ATLS (EMST) basic principles
Knowledge
Describes and explains significance of the key terms, concepts and principles in trauma
assessment
Soft tissue injuries
Contusions
Crush injuries
Haematomas
Abrasions
Lacerations
Proximally and distally based flaps
Penetrating injuries
De-gloving injuries
Open (compound) fractures
At - risk sites for neurovascular injury
The dangers of hypothermia and need to maintain core temperature
Vascular injury and assessment of extremity pulses and perfusion
Assessment of spinal injury
Functional spinal cord level relative to bony vertebral level and differences between
adults and children
Assessment of peripheral nerve injury
Assessment of blood loss associated with different fracture locations
Strategies to test for airway patency, causes of airway insufficiency and strategies to
obtain and maintain an adequate airway
Strategies to test breathing status, causes of breathing insufficiency and strategies to
assist in ventilation
Assessment of perfusion by skin colour, blanching and capillary return
131
Assessment of shock and factors that may influence presentation and manifestation of
shock including age, medication, spinal injury, cardiac function and sepsis
Skills
Identifies, describes appropriately and accurately records:
Temperature
Airway patency
Respiratory status
Circulatory status and degree of shock including pulse, blood pressure and pulse
oximetry
Perfusion/ Pallor and/or cyanosis
Obvious deformities and dislocations of extremities
Cervical spine status including need to continue protection
Spinal Injury with neurological loss (in cooperative conscious patient)
Glasgow Coma Scale
Resources
EMST students manual
132
Neurological Examination
General Objective
performance of key elements of neurological examination to determine normal from abnormal.
Specific Outcomes
General/Baseline Knowledge
General competency in physical examination as outlined in "General Examination
Principles"
Tests of sensation
Pin prick
Deep pressure
Proprioception
Vibration
+ Temperature
+ 2 point discrimination
++ Monofilament testing (Semmes-Weinstein 10-g monofilament)
Tests of motor function
Muscle power using the MRC grading
Clonus
Anal sphincter tone
Tests of deep tendon reflexes
Biceps jerk
Triceps jerk
Brachioradialis
Knee jerk
Ankle jerk
Other specific tests of neurological function
Plantar (Babinski)
Tinel's test
Abdominal reflex
Cremasteric reflex
Anal Wink reflex
Bulbocavernous reflex
Occular signs of Horner's syndrome
++ Lhermitte's sign
++ Hoffmann's reflex
++ Palmomental
133
++ Lhermitte's sign
++ Gonda-Allen sign
++ Allen-Cleckley sign
++ Inverted Supinator sign
Nerves dysfunction of the upper limb
Axillary nerve
Musculocutaneous nerve
Radial nerve
Median nerve
Ulna nerve
Subscapular nerve
Pectoral nerves (combined)
Nerve to Supraspinatus
Long thoracic nerve
+ Thoracodorsal nerve
+ Dorsal scapular nerve
++ Lateral pectoral nerve
++ Medial pectoral nerve
Nerves dysfunction of the lower limb
Nerve to Psoas
Superior gluteal nerve
Inferior gluteal nerve
Sciatic nerve
Obturator nerve
Femoral nerve
Common peroneal nerve
Superficial peroneal nerve
Deep peroneal nerve
Tibial nerve
Plantar nerve
Lateral cutaneous nerve of thigh
Spinal cord/nerve root dysfunction
Dermatomes
Myotomes
Neurological dysfunction based on specific aetiologies
Neurological loss due to major peripheral nerve abnormalities
Neurological loss due to spinal nerve root pathology
Neurological loss due to "upper motor neuron" causes
+ Neurological loss due to specific spinal tract disorders
+ Neurological loss due to brachial plexus injury/pathology
++ Neurological loss due to lumbosacral plexus injury/pathology
134
Gait Examination
General Objective
performance of key elements of Gait examination to determine normal from abnormal.
Specific Outcomes
General/Baseline
As outlined in General Examination Principles
Functional anatomy of main muscle groups involved in ambulation
Normal gait cycle kinematics
Knowledge
Stages of gait cycle
General classification of abnormal gait causes (ICD9)
NB- There is generally very poor agreement about classification of gait disorders and this
area needs to be further explored in the development of teaching resources –should be in
conjunction with neurologists
Abnormal Gait patterns
Identifies and describes abnormal gait patterns
Antalgic Gait
Trendelenburg gait
Abductor lurch gait
Short leg gait
Steppage gait
Broad based gait
Scissor gait
Pigeon gait
Toe walking gait
Stomping gait
Hip extension gait
Propulsive/Parkinsonian gait
Festinating/Parkinsonian gait
135
Paediatric Examination
General Objective
performance of key elements of Paediatric Examination to determine normal from abnormal.
Specific Outcomes
General/Baseline
As outlined in
 Extremity/regional examination
 "GALS" Screening Examination
 Gait Examination
Observation
Actively looks for
Mobility aids
Wheelchair
Walking Aids
AFOs
Customised shoe wear
Height and Weight
Spinal deformity
Scoliosis
Kyphosis
Lordosis
Lower limb alignment
Genu Valgus
Genu Varus
Foot posture
+ Patellar squinting
Muscle wasting
Quadriceps
Hamstrings
Anterior leg compartment
Triceps Surae
Foot intrinsics
Skin appearance
Pigmented lesions
136
Hair tuft at base of spine
Asymmetrical skin fold
++ Cervical hair line
Gait
Antalgic
Trendelenburg
Short-leg
Steppage
+Broad-based
+Crouch or jump gait of cerebral palsy
+Foot progression angle
+Scissoring
+Thrusting
Palpation
Warm swollen joints
Muscle bellies
Tendons
Lymph nodes
Masses around limbs
Bony landmarks
Movement
Spine
Cervical
Flexion
Extension
Lateral flexion
Rotation
Thoracolumbar
Flexion
Extension
Lateral flexion
Thoracic rotation
Hip
Flexion
Extension
Abduction
Adduction
Internal rotation
External rotation
137
Knee
Extension
Flexion
+Internal rotation
+External rotation
Foot and ankle
+Ankle
+Subtalar
+Tarsometatarsal (Lis Franc)
+1st MTPJ
++IPJs
++Lesser MTPJs
++Midtarsal (Chopart)
Special Tests
Developmental Dysplasia of the Hip (DDH)
Ortolani manoeuvre
Barlow manoeuvre
Lower limb rotational profile
Thigh-foot angle
+Gage test
++ Heel bisector
Spondylopathies (neural stretch)
Straight leg raise
+Lasegue’s sign
+Bowstring test
Cerebral palsy
Thomas test
++Ober's test
++Phelps gracilis test
++Modified Tardieu reflexes (prone)
++Duncan-Ely test
++Silfverskiöld test
Spine related lower limb neurology
Sensory (dermatomes)- crude touch (L1 - 5; S1 - 2)
Motor (myotomes)- (L 2/3; L3/4; L4; L5; S 1/2.)
Reflexes (absent/ present/ brisk)- (Babinski; Clonus; L1/2; L3/4; T6-9; T9-11; T11-12; S1/2;
S3/4)
+ Cremasteric
138
Leg length discrepancy
True leg length
Apparent leg length
Block test
Galleazzi test
++ Bryant's triangle
139
Laboratory
General Objective
Demonstrates the appropriate use and interpretation of laboratory investigations for diagnosis and
assessment of musculoskeletal and associated conditions.
Specific Outcomes
Blood
Full blood count
Haemoglobin
White cells
Platelets
Acute phase response
Erythrocyte Sedimentation Rate (ESR)
C Reactive Protein (CRP)
Immunological investigations
Rheumatoid factor
ANA
Serum biochemistry
Calcium
Creatinine
Phosphorus
Urate
Alkaline phosphatase
Creatine kinase
Albumin
Homocysteine
TSH
PTH
Protein electrophoresis
Serum 25-hydroxy-vitamin D
Magnesium
Zinc
Osteocalcin
Cross-links/telopeptides (NTX)
Microbiology
MC&S
Gram Stain
140
Synovial fluid analysis
White cells
Glucose
Culture
Crystals
Urine
Urinalysis
Blood
Protein
Leukocytes
Ketones
Glucose
pH
Markers
Hydroxyproline
Bence Jones protein
Microbiology
MC&S
141
MSK imaging
General Objective
Uses imaging modalities for the assessment and management of musculoskeletal conditions in
evidence-based efficient and cost-effective manner: X-ray, CT scan, MRI, bone densitometry
(DEXA), bone scintigraphy, musculoskeletal ultrasound.
Specific Outcomes
Background
Scientific basis of radiology and imaging
General principles of clinical imaging
Lists appropriate imaging studies including common "specialised projection" and "weight-bearing"
views for the assessment and management of common and important MSK injuries and conditions
Explains the application and general interpretation of important evidence based imaging protocols
for the assessment of general MSK trauma
"Trauma Series"
Cervical spine AP/lat +/- peg
Chest AP
Pelvis AP
Cervical spine trauma X-ray protocol
Ottawa ankle rules
Identifies from imaging views important normal bony and soft tissue structures/landmarks and
anatomical sites that are prone to injury
Defines and identifies criteria of normal range of alignment and position of bone and soft tissues by
reference to common lines or other established signs of normality on imaging modalities
Wrist
Carpal C's
Radial inclination
Volar tilt
Ulnar variance
Scapholunate angle
Scaphocapitate angle
Elbow
Radio-capitellum alignment
Shoulder
Acromiohumeral interval
142
Spine
Curves of spinal alignment
BDI (basion dental interval)
BAI (basion axial interval - children)
Anterior ADI (atlantodental interval)
Lateral ADI (atlantodental interval)
Cobb's angle
Hip and Pelvis
Shenton's line
Iliopectineal line
Ilioischial line
Centre edge angle
Tear drop of acetabulum
Sacral foramina symmetry
Knee
Insall's ratio (patella - patella ligament)
Patella tilt
Patella lateral translation
Foot and Ankle
Ankle medial gutter width
Distal tibiofibular overlap
Tarsometatarsal alignment
Hallux angle
Applies a systematic approach to the description and interpretation/reporting of MSK injuries on
standard radiographs
Extremity fractures/injuries
Site
Fracture pattern (transverse, oblique, spiral etc)
Alignment
Angulation/tilt
Rotation
Displacement/translation/shortening
Comminution
Intra-articular involvement
Soft tissue involvement
Swelling
Evidence of open injury (e.g. Gas)
Vertebral fractures/injuries
Site (vertebral level/s)
Fracture pattern (compression, wedge, burst, shear etc)
143
Column involvement (e.g. Anterior, middle, posterior)
Alignment
Angulation/tilt
Rotation
Displacement/translation/shortening
Comminution
Spinal canal involvement
Soft tissue involvement
Swelling
Evidence of open injury (e.g. Gas)
ABC's systematic approach in spine
A(i): appropriateness
Correct indication
Right patient
A(ii): adequacy
Extent (occiput to T1 upper border)
Penetration
Rotation/projection
A(iii): Alignment
Anterior aspect of vertebral bodies
Posterior aspect of vertebral bodies
Posterior pillar line
Spinolaminar line
Craniocervical and other lines and relationships
B: Bones
C: Connective tissues
Pre-vertebral soft tissue
Pre-dental space
Intervertebral disc spaces
Interspinous gaps
Identifies and explains key general manifestations of abnormality of bone and soft tissues from
MSK diagnostic imaging
Bone
Osteopaenia (generalised)
Lysis
Sclerosis
Cortical destruction
Infiltration
Cortical expansion
Soft tissue
Localised increased swelling
Gas in soft tissues
144
Joint effusion
Joint subluxation/dislocation
Identifies and interprets key signs used to assess "MSK/red flag emergencies" from appropriately
selected diagnostic imaging modalities
Identifies and interprets key diagnostic features of common and important MSK conditions and
injuries
General musculoskeletal conditions
Osteoarthritis
Osteoporosis
Inflammatory arthritis
Bone and joint infection
Tumours/ bone metastasis
Gout
Paget's disease
Paediatric
Non Accidental Injury in infants/toddlers
Perthes
SCFE
Bone and joint infection
JIA
Osteomalacia/ rickets
Spine
Scoliosis
Spondyloarthopathy
Discitis
Spondylolysis/spondylolisthesis
Spinal stenosis
Disc disease/prolapse
Common fractures/dislocations
Vertebral wedge and compression fractures (fragility)
Distal radial fractures (Colles')
Hip and pelvis
Intracapsular hip fractures
Femoral trochanteric fractures
Pelvic ring fractures (fragility)
Posterior hip dislocations
Rib fractures
Ankle fractures/dislocations
Clavicle fractures
Proximal humerus fractures
Anterior shoulder dislocations
145
Paediatric fractures
Greenstick forearm
Torus/buckle fractures
Supracondylar fractures
Growth plate injuries
Important indirect and soft tissue signs of injury
Spine
Craniocervical prevertebral soft tissue swelling
Asymmetrical peg view
Shoulder/arm
GHJ subluxation
ACJ disruption
Elbow/forearm
Posterior elbow fat pad
Anterior elbow "sail" sign
Wrist/hand
Pronator quadratus fat stripe
S-L separation
Pelvis
Sacroiliac joint widening
Pubic symphysis separation
Knee
Knee lipohaemarthrosis
Segond sign
Ankle
Diastasis
Irregular joint spacing
Commonly missed fractures/dislocations
Demonstrate basic knowledge of the following common easily missed injuries and appreciate the
role of a "targeted approach" to supplement a systematic approach in interpreting their imaging:
posterior dislocations or fracture dislocations of the shoulder
distal clavicle fractures or AC Joint separations
radial head fractures (adult)
supracondylar and medial or lateral epicondylar fractures in children
Monteggia and Galeazzi fracture-dislocations
non displaced distal radial fractures
carpal fractures (scaphoid, triquetrum)
dislocations/instability: perilunate, scapholunate dissociation
phalangeal avulsion fracture
acetabular fractures
pubic ramus fracture
iliac wing fractures
146
avulsion fractures ASIS, ischial tuberosity
femoral neck and trochanteric fractures
tibial plateau fracture
patellar fracture
ankle syndesmosis tear - Maisonneuve fracture
fifth metatarsal tuberosity fracture
calcaneus and talus fractures
tarsometatarsal fracture dislocations (Lis Franc)
growth plate fractures
torus fractures
acute plastic bowing
missed fractures in multi-trauma victim
soft tissue injuries
soft tissue foreign bodies
147
Ancillary Investigations
General Objective
Understands the indications for ancillary investigations of the musculoskeletal system, the
principles of their performance and the diagnostic significance of their results.
Specific Outcomes
Fluid and Tissue sampling
Describes the principles of the techniques of joint aspiration and bone and muscle biopsy, and
discusses the indications, diagnostic significance and morbidity of these procedures.
Electrodiagnostic Studies
Describes the physiological basis of electrodiagnostic techniques, outlines the information that can
be obtained using these techniques, and explains the clinical application of the findings
nerve conduction studies
surface and needle electromyography
+ somatosensory evoked potentials
+ sensory nerve action potentials.
Image-guided techniques
Explains the rationale, indications, efficacy and complications of fluoroscopically and other imaging
guided diagnostic injection techniques
Spinal injections
Transforaminal
Disc stimulation (“provocation discography”)
Intrathecal
+ Extraarticular: medial branch and dorsal ramus blocks
+ Intraarticular: atlantooccipital, atlantoaxial, sacroiliac
Ganglion blocks
Sympathetic
+ Dorsal root
+ Sphenopalatine
+ Trigeminal
Peripheral Joint Injections
Shoulder
Hip
+ Other peripheral joints
Nerve blocks
+ Superior hypogastric plexus
+ Obturator
+ Suprascapular
+ Intercostal
148
+ Glossopharangeal
Musculotendinous
+ Piriformis
Other
149
Musculoskeletal Diagnostic Formulation
General Objective
Is able to relate MSK problem-based assessment findings to anatomical and pathological
aetiologies; recognise features used to discriminate between specific MSK conditions; and apply
the principles of critical reasoning and diagnostic formulation in the construction of an appropriate
differential diagnosis.
Specific Outcomes
Demonstrates ability to formulate and express musculoskeletal diagnoses in terms consistent with
contemporary taxonomy, and with reference to anatomical and pathological axes, and the precepts
of impairment, disability and handicap
Problem-based
Applies a "problem-based" symptomatic diagnostic approach to the assessment of MSK conditions
utilising appropriately targeted history, examination and investigation strategies.
Musculoskeletal injury
Joint pain
Poly-, mono-, and peri-articular pain
Back pain
Regional pain or stiffness
Generalised pain or stiffness
Decrease or loss of motion or weakness
Altered sensation
Deformity
Mass
Pathology-based
Relates the assessment of MSK symptoms, signs and investigation findings to specific pathological
processes or aetiologies by way of a "surgical sieve" or pathological axes.
Vascular/Ischaemic
e.g. compression or disruption of a vessel
Inflammatory/ Infectious
e.g. bone or joint
e.g. low energy as in osteoporosis, occupational injuries, sports injuries, nerve compression
Autoimmune or immune mediated
e.g. Rheumatoid Arthritis
Metabolic/ Endocrine/ Toxic/ Drugs
e.g. osteoporosis, gout
Idiopathic
Neoplastic
150
e.g. myeloma
Degenerative
e.g. joint or spine
Psychological
e.g. conversion disorders, overlay onto chronic disease states etc
Anatomically-based
Relates the assessment of MSK symptoms, signs and investigation findings to specific anatomical
sources or locations
151
Pharmacological
General Objective
Describes the major indications, adverse effects, drug interactions, and contraindications of drugs
commonly used in the management of musculoskeletal conditions including access to the key
current Australian evidence-based guidelines.
Specific Outcomes
Baseline/Supporting knowledge
Pharmacodynamic and pharmacokinetic processes
Analgesics/anti-inflammatories
Paracetamol
Cox 2 inhibitors
Other Non-Steroidal Anti-Inflammatory Drugs (NSAIDS)
Opiates
Anti-rheumatoid agents
Disease-modifying anti-rheumatic drugs (DMARDS)
Corticosteroids
Methotrexate
Other immunosuppressants
Anti-gout agents
Hypouricaemic drugs (Allopurinol)
Colchicine
Other anti-arthritis medications
Hyaluronic acid
Osteoporosis medications (anti-resorptive and anabolic)
Calcium and Vitamin D
Bisphosphonates
PTH
Strontium
Hormone Replacement Therapy (HRT) for osteoporosis
+ Denosumab - RANKL inhibitors
+ Sclerostin inhibitors
+ Cathepsin K inhibitors
Antibiotics
Antidepressant drugs (in pain management)
Skeletal muscle relaxants
152
CAM medications
Fish oil
Glucosamine
Chondroitin sulphate
+ Neutriceuticals
+ Rubefacients
+ Counterirritants
+ Botox in spastic disorders
+ Cytotoxic drugs
153
Exercise and Rest
General Objective
Understands the key terminology, physiological effects and prescription of exercise and rest in
MSK practice.
Specific Outcomes
Describes the effects of exercise on the physiological and biomechanical functions of the tissues
involved
Describes the effects of rest on the physiological and biomechanical functions of musculoskeletal
tissues
Describes the effects of exercise on pathological processes
Describes the effects rest and pathological processes
Describes the limitations including risks and side effects (local and distant) of "non weight bearing"
(NWB) instructions in MSK practice
Outlines the principle functional objectives of therapeutic exercise (stretch, relax, strengthen,
mobilise, retrain and co-ordinate muscles and joints)
Outlines the basic indications for general rest (including bed rest) in treatment regimens including
their contraindications
Explains key terms relating to physical therapies and their application to the prescription of
exercise
active exercise
active-assisted exercise
active-resisted exercise
passive exercise (including continuous passive motion)
isometric
isotonic
isokinetic
open chain
closed chain
inner range quads
VMO exercises
static quadriceps
Explains in basic terms the principles of and gives examples of the general role of various types of
therapeutic exercise
stretching exercises
mobilisation exercises
strengthening exercises
endurance exercises
154
coordination exercises
balance exercises
proprioception exercises
relaxation exercises
posture training
+ neuromuscular re-education (including EMG biofeedback and movement awareness
training)
Explains the principles of "Pilates exercises" and discusses their application in management of
MSK conditions
Explains the role of exercise in regimes for the treatment and prophylaxis of musculoskeletal
disorders including
OA
osteoporosis
low back pain
inflammatory arthritis
disuse atrophy
soft tissue injuries (muscle and ligamentous)
rotator cuff injuries
neck pain
Outlines the principles of prescription of routine exercise and rest strategies in the management
plan of common MSK conditions
Discusses the importance of routine consideration of exercise and rest in the treatment and
prevention of MSK disorders and injury
Discusses the need to tailor exercise needs to patient and use evidence based medicine to
facilitate choice of exercise for both safety and efficacy
++ Describes the various schools of thought on the uses of exercises in musculoskeletal
management
++ Discusses the detailed specific scientific knowledge of physiology and measurement of
outcomes of exercise
Resources
Waddell G. The Back Pain Revolution. Churchill Livingstone, Edinburgh, 1998, pp 241261.
Simon SR (ed). Orthopaedic Basic Science. American Academy of Orthopaedic
Surgeons, Park Ridge, Illinois, 1994, pp 27-28 (articular cartilage), 53-54 (tendon), 70-72
(ligament), 108-110, 117 (muscle), 303 (bone)
155
Supports and Aids
General Objective
Describes the biomechanical effects of supports and aids on musculoskeletal tissues, their correct
usage and the principles of prescription of such devices in MSK practice.
Specific Outcomes
Explains the general principles underlying the use of supports and their biomechanical effects on
musculoskeletal tissues
biomechanical support
facilitation of function
alteration of alignment and redistribution of forces
"stress shielding" and potential negative effects such as disuse atrophy
proprioception
Discusses in general terms
the role of the orthotist/prosthetist and basic principles for use of orthotic and prosthetic
devices
basic differences between energy/cardiac output requirements with below and above
knee amputations and implications in successful use of prostheses
principal differences in problems between upper and lower limb amputations
general problems/complications that may occur at the amputation stump and principles
for management
the impact of prolonged hospital stay on a patient’s level of ability to perform ADL’s in
relation to fatigue, or endurance.
the functional impact of post op precautions or restrictions on a person’s ability to
perform ADL's
techniques of energy conservation
influence of physical and medical impairments on the selection of equipment and aids.
+ specific types of prosthetic devices
Identifies and explains in general terms the rationale for the use of orthotic devices
medial arch support
ankle support orthosis
heel cup
metatarsal head cushion
rocker bottom sole
ankle-foot orthosis
corn pads
wrist support
radial nerve cock up splint
shoulder abduction pillow
156
Abduction (Charnley) pillow
hip abduction braces
knee braces
thumb spica
elbow support for "tennis elbow"
Explains the roles of the occupational therapist
functional assessment of patients with MSK injury/disorders
clinical equipment / assistive technologies
home modifications
"efficiency strategies" to facilitate functioning
Identifies and discusses application of common "assistive technology" equipment
Mobility
Personal Care
Toileting
Dressing
Showering
Meal Preparation
Describes principles for selection of size and adjustment of common walking aids and outlines
specific patient instructions/education
walking stick/cane
axillary crutches
arm gutter crutches
walking frame/with and without wheels
gutter frames
157
Nutrition
General Objective
Applies knowledge and understanding of the general principles of nutrition to the management of
patients with MSK conditions and trauma.
Specific Outcomes
Explains the role and prescription of nutrition (dietary and supplements) in important clinical
scenarios
Vitamin D
Discusses Vit D in low sun exposure circumstances
Describes requirements for Vit D supplementation
Calcium
Outlines calcium requirements in high metabolic states
Outlines dietary sources of calcium and requirements for supplementation
Nutritional requirements in trauma patients
Describes the general changes with respect to:
total calories
protein
vitamins
minerals
Effects of malnutrition
Describes the effects of malnutrition on wound healing
Explains the effect of malnutrition states and physiological function (e.g. renal and
hepatic)
Outlines and explains the effects of alcohol abuse on nutritional status
Effects of extended preoperative fasting and strategies to minimize prolonged nutritional
deprivation
Identifies evidence based sources on the safety and efficacy of nutritional supplements in the
management of MSK conditions
158
Psycho-Social Management
General Objective
Recognises the significance of psychological and social factors in musculoskeletal impairment and
understands the principles of their management.
Specific Outcomes
Describes the roles of psychosocial risk factors in the course of impairment, disability and handicap
with particular reference to musculoskeletal conditions
Describes the effects of impairment, disability and handicap on lifestyle, including working capacity,
leisure activities, household tasks, sexual activities and personal care
Describes the processes of litigation in relation to musculoskeletal disorders, and the effects of
such legal processes on the patient's psyche and lifestyle
Identifies the circumstances in which referral to specialised psychosocial services is required
Lists possible suitable psychological and social support resources and explains process of referral
+ Describes counselling strategies useful for the modification of the psychological and social
effects of musculoskeletal disorders and their sequelae
+ Describes the behavioural techniques involved in the psychosocial management of patients with
chronic pain and disability arising from musculoskeletal impairment
159
Operative
General Objective
Explains the basic principles underlying the use of main surgical options in musculoskeletal
practice; outlines their general indications and expected outcomes; and discusses the general
risks, complications and peri-operative management principles.
Specific Outcomes
General role of surgery
Fractures
Arthritis
Deformity
Compression neural/vascular
Infection/necrosis
Fracture procedures
Open reduction
Closed reduction
Internal fixation
External fixation
Extremity procedures
Rotator cuff decompression and repair
Arthroscopy of the knee and shoulder
ACL reconstruction
Arthroplasty of hip and/or knee
Amputation
Synovectomy
Osteotomy
Arthrodesis
Carpal tunnel decompression
Spinal procedures
Spinal fusion
Discectomy and spinal decompression
Intervertebral disc arthroplasty
Vertebroplasty and kyphoplasty
Types of fixation devices and techniques
Plates and screws
IM nails and cross locking screws
K wires
160
External fixation pins and rods
+ Dynamic compression of plates
+ Locking plate fixation
+ Sliding hip screw
+ Minimally Invasive Percutaneous Osteosynthesis (MIPO)
Benefits and expected outcome of common procedures
Hip arthroplasty
Knee arthoplasty
Discectomy for sciatica
Spinal fusion for back pain
Shoulder arthroplasty
Surgical risks and potential complications
Wound healing/infection
Nerve injury
Vascular injury
Fracture
Haemorrhage
Failure of device
Mal union
Non union
Unresolved symptoms
Ongoing or new pain
Medical risks and potential complications
Respiratory infection
Urinary complications with IDC
Thrombosis and embolism
Myocardial ischaemia
Cerebrovascular accident
Death
Post-operative musculoskeletal management
Observation
Analgaesia
Antibiotics
Thromboprophylaxis
Drainage management
Wound/dressing management
Limb movement
Weight bearing status
Rehabilitation
Shared care and referral
Use of aids
161
Patient instructions/education
162
Rehabilitation
General Objective
Understands the principles of rehabilitation in terms of the realisation of optimal function despite
residual disability or the development of a person to the fullest physical, psychological, social,
vocational and educational potential consistent with his or her physiological or anatomical
impairment and environmental limitations.
Specific Outcomes
MSK disability in Australia
Demonstrates knowledge of
current prevalence and impact
the projected relative changes in prevalence of and the implications for the provision of
health services
Tracking functional progression in rehabilitation
Explains the rationale for
Range of motion
Flexibility
Strength
Balance
Rehabilitation services and options available to patients with
musculoskeletal disorders
Outlines and describes basic principles of
education
medical
physiotherapy
occupational therapy
other physical modalities
pain management units
hospital based inpatient and outpatients rehabilitation facilities
ADLs and quality of life assessment.
supports and aids
exercises and reconditioning
psychological counselling
pharmacological medications
surgical options
impairment evaluation
ergonomic assessment
+ functional reactivation
+ therapeutic blocks
163
Referral to appropriate services
Outlines the steps of referral
identifying the appropriate service for the particular need
initiating the referral and requesting the required service
liaison with the service provider
follow up
Occupational rehabilitation in cases of work-related injury
Outlines the general principles of musculoskeletal management in the broader context of
occupational rehabilitation
job site assessment and re-injury risk evaluation
ergonomic assessment
functional capacity evaluation
return to work program and re-evaluation
vocational assessment and work placement
liaison with the employer, rehab provider, insurer and case manager
Specific rehabilitation plans
Explains the general principles with examples of specific rehabilitation options to outline a basic
management plan for patients, including children, with musculoskeletal conditions
amputations
spinal cord injury
trauma
fractures
osteoporosis
osteoarthritis
rheumatoid arthritis
mechanical soft tissue lesions
neck and back pain
disuse atrophy
deconditioning due to prolonged immobilisation
Identifies suitable evidence based guidelines for rehabilitation of MSK
conditions
164
Patient Education and Self Management
General Objective
Understands the key principles of patient education and self management, their role in the
management of chronic conditions and discusses in general terms fundamental strategies outlined
in current evidence based national consensus guidelines.
Specific Outcomes
Patient Education, Reassurance and Motivation
Describes the biological, psychological and social factors that may influence the course of a
musculoskeletal condition
biological and therapeutic influences
the fear-avoidance model of behaviour
psychosocial factors (“yellow flags”)
Explains the nature of the musculoskeletal condition, its prognosis and factors that may influence
its course
the nature of the impairment
pathophysiological processes involved
biological influences on the course of the condition
treatment options and relative benefits
a pathway and timeline for return to work/function
Explains the role of explanation, reassurance and motivation in encouraging the patient to take an
active role in self-management
+ Discusses techniques used in the reassurance and motivation of a patient to be active in selfmanagement
Patient Self-Management
Explains the general principles of self-management and discusses their role in the routine
management of MSK conditions and identifies key issues applicable to self management strategies
as part of management of all patients.
Problem definition
Describes strategies used to define the problems that need to be addressed and the goals of self
management based on an assessment of patient needs and their capacity to achieve their goals
Goal setting
Outlines and explains the principles of goal planning/setting e.g. the "SMART" model
Specific
Measurable
Attainable
Realistic
165
Timely
Motivation
Outlines the principles of patient motivation
+ Describes the eight interaction technique strategies (Crompton et al 1999) used to motivate
patients to change or adopt healthy lifestyles
Management
Explains the principles for effective self-management
+ Outlines and describes the six interactive components associated with the "patient-centred
approach" and how this differs from a "disease-centred" approach
Monitoring
+ Discusses the types and timing of measures to monitor progress and outcomes of selfmanagement strategies
Resources
Describes the processes and resources that may be used to facilitate the implementation of selfmanagement strategies in medical practice
Resources
King W, Watt J. Notes on Patient Education, Reassurance and Motivation. Australasian
Faculty of Musculoskeletal Medicine, 2001.
RACGP's Chronic condition self management guidelines
http://www.racgp.org.au/Content/NavigationMenu/ClinicalResources/RACGPGuidelines/S
haringHealthCare/20020703gp.pdf
http://www.racgp.org.au/Content/NavigationMenu/ClinicalResources/RACGPGuidelines/S
haringHealthCare/20020703laminategp.pdf
166
Shared Care and Referral
General Objective
Understands the principles of, benefits and suitable use of shared care and referral for MSK
conditions in the contexts of both hospital and general practice.
Specific Outcomes
Principles
Outlines the principles of good referral
Explains the complexity of effective referral
Explains the concept of shared care
Outlines and discusses the value and challenges of shared care in hospital and general practice
Outlines factors required to establish and maintain shared care arrangements
Examples of shared care options for MSK conditions in the Australian context
167
Prevention
General Objective
Understands and applies the principles of primary, secondary and tertiary prevention (such as
lifestyle, falls prevention, workplace safety, road safety, Calcium and Vitamin D) in the context of
MSK conditions.
Specific Outcomes
Demonstrates knowledge of anatomy, physiology, bio mechanics, and pathology to understand the
relationships between habits, postures, activities of daily living, diet, lifestyle, recreational and work
activities and the genesis of musculoskeletal disorders and complaints.
Rationale
Provides a rationale through appropriate use of evidence for the anatomical, biomechanical and
pathophysiological basis for use of the following prevention strategies in the management of
priority musculoskeletal conditions
diet
smoking
alcohol
medication/drugs (prescribed or otherwise)
stress management
physical activity
rest
risk avoidance
posture
education
meditation
Principles
Outlines general principles and specific strategies of prevention (evidence-based)
falls
osteoporosis
"secondary fracture" prevention
osteoarthritis
osteoarticular infection
mechanical pressure soft tissue lesions (e.g. pressure sores, callosities)
work hazard injuries
work physical activity related injuries
road trauma prevention
sports injuries
child injuries
neck or back pain
168
Resources
Fitness to Drive guidelines :http://www.racgp.org.au/afp/200809/28828
169
Complementary and Alternative Medicine
General Objective
Has knowledge of the range of common complementary and alternative medicine (CAM) therapies
in MSK practice; sources of evidence regarding their safety and efficacy and the barriers to
obtaining evidence; the historical origin and relationship to traditional/western medicine; the
potential for interactions and contraindications of common CAM herbal and drug therapies with
traditional treatments; and the importance of maintaining an open mind and dialogue with patients
regarding the use of CAM therapies as part of an overall health plan.
Specific Outcomes
Explains the general background theory/scientific rationale underlying the practice of commonly
used complementary and alternative practices including the commonly-held beliefs of indications
and benefits and the known risks/adverse reactions associated with their practice.
Practices
Outlines basic principles of:
Medical practices
acupuncture
chiropractic therapy
homeopathy
naturopathy
aromatherapy
herbalism
traditional Chinese medicine
Ayurvedic medicine
reflexology
Patient-directed interventions
meditation (including transcendental)
yoga
Tai Chi
Qigong
Devices
magnets - unipolar and bipolar
copper
Complications
Describes:
Common potential interactions and contraindications of alternative medicine herb/drug
therapies with traditional treatments (e.g. garlic and anticoagulants)
170
Effect of publication bias on the analysis of alternative medicine
Explains:
Importance of maintaining an open dialogue with patients regarding their decision to use
CAM therapies as part of an overall health plan
Historical origin and relationship of traditional/western medicine to complementary and
alternative medicine
Importance of knowing or accessing accurate information, where available, on safety and
efficacy of common alternative and complementary medicine therapies so as to provide
unbiased and informed advice to patients
Identifies:
Evidence-based literature on complementary and alternative medicine
Resources
The American Academy of Orthopaedic Surgeons(AAOS):
http://orthoinfo.aaos.org/topic.cfm?topic=A00283
Alternative Therapies in Health and Medicine: http://www.alternative-therapies.com/
National Center for Complementary and Alternative Medicine (NCCAM):
http://nccam.nih.gov/health/
171
Musculoskeletal Conditions
Applies knowledge of general and MSK related basic and clinical science to describe the basic
aetiology, pathogenesis, characteristic clinical manifestations and general principles of assessment
and management for patients suffering from the broad range of MSK-related conditions and
disorders. This includes the management of normal variation and special concern groups.
Knowledge of specific conditions should be prioritised in detail towards the management of the
"MSK/red flag emergencies" and the national priority and high burden MSK conditions.
Normal variation
Disorders of MSK growth and development
MSK Trauma (fractures and dislocations)
Infection (bone, joint and soft tissue)
Soft-tissue trauma including muscles, ligaments,, tendons and skin injuries
Metabolic and Endocrine Disorders
Inflammatory and Immunological Disorders
Skeletal Neoplasia (including primary bone and soft tissue tumours and metastatic bone
disease)
Spine and related conditions
Chronic Pain Syndromes
Compression Neuropathies
Neuromuscular disorders
Mobility/Gait disorders
Occupational MSK disorders
Biomechanical related disorders
Special concerns groups
172
Limb Realignment
General Outcome
Understands key principles of limb realignment, outlines ongoing patient care and education;
knows of the common important fracture reduction and joint relocation procedures; and discusses
and/or performs selected basic realignment procedures at the prescribed levels.
Specific Outcomes
Background
Outlines and discusses key principles and issues related to limb realignment
Consent
Prior discussion with relevant specialist as indicated if available
Assess and document pre-, intra- and post-reduction neurovascular status as
appropriated
Prior preparation of a strategy for maintenance of reduction
Prevent collateral damage
Assess stability of reduction as appropriate
Maintain reduction
Post reduction plan for monitoring maintenance of position, neurovascular status and
pain management
Stabilise adjacent structures as required
Procedures
Performs in the context of primary management at the scene of an accident or on presentation to
an emergency department (not definitive management)
Realignment of fractures
Wrist fractures
Femoral fractures
Tibial fractures
Humeral fractures
Forearm fractures
Relocate/align dislocations
Ankle
Patella
Hip (posterior dislocation)
Knee
Shoulder (anterior dislocation)
Elbow
Finger
173
Shoulder (posterior dislocation)
174
Splinting Procedures
General Objective
Understands key principles of splinting, outlines ongoing patient care and education, knows of the
common important splinting procedures and discusses and/or performs selected basic splinting
procedures at the prescribed levels.
Specific Outcomes
Principles
Outlines and discusses key principles and issues related to splinting procedures
General principles of splinting
Explain the procedure to the patient
Prepare patient: consent, positioning, exposure
Ensure that all necessary equipment and personnel for both application and removal of
splintage is available
Expose and thoroughly inspect extremity for deformity, swelling and soft tissue injury
including open wounds and document findings
Appropriately manage (including application of dressings) any wounds prior to splint
Assess and document neurological and vascular status of effected extremity both prior
and after splint application
Document and notify relevant physicians of examination findings
Immobilise joints both above and below suspect fracture
Immobilise bones both above and below suspected joint injury
Consider the anatomy and deforming muscle forces that may influence the control of the
extremity part in selecting the type of splint
Protect against secondary injury from local pressure
Protect against secondary injury from movement during splint application (e.g. cervical
spine)
Consider the neurovascular consequences of a deformed fracture and/or dislocated joint
Reduce a joint dislocation prior to splinting
Splint in position of deformity only if not correctable
Avoid of circumferential splinting in acute injuries
Explain post-procedure care/ precautions to the patient/guardian
Adjust and/or trim splintage after application
Apply gentle inline traction to partially correct deformity prior to splinting
Protect skin with underlayer/ padding
Consider the optimal alignment and position of the bones and joints in the splint for a
given injury
Splint characteristics
Materials
175
Plaster of Paris
synthetic materials (e.g. Dynacast)
Splint liners/padding
"soft band"
+ waterproof liners
appropriate fit
heat generation
hardening/drying characteristics (time)
appropriate use and temperature of water
pressure point risks
durability
weight
“removability”
patient acceptance
cost
Patient education/instructions
Care and protection of splint
Allowed/desired positioning and movements of both affected and not directly affected (but
relevant) extremity parts
Monitoring for neurovascular compromise and/or localised pressure
Ensuring timely follow up
Procedures
Applies/ Maintains
Broad arm sling
"Safe immobilisation" position hand splint
Below elbow dorsal splint
Knee immobiliser
Above knee dorsal slab
Below knee dorsal slab
Pelvic Binder
Cervical soft collar
Cervical Hard collar
Above elbow dorsal splint
Buddy strapping
Duke of Edinburgh sling
Wrist support orthosis
Spine immobiliser
Thumb spica
Ankle stirrup
Ankle support orthosis
Humeral U – slab
176
Application of a leg traction splint
Bulky Jones
Jones bandage
Above elbow cast
Below elbow cast
Ulnar gutter splint
Finger splints
Above knee cast
Long leg cylinder
Below knee cast
Thomas Splint
Hamilton Russel traction
Halo traction
Removal Techniques
plaster saw
plaster cutters
plaster spreaders
177
Injection Procedures
General Objective
Understands key principles of injection, outlines ongoing patient care and education, and knows of,
or performs, common and important injection/ aspiration procedures at the prescribed levels.
Specific Outcomes
General Principles
Outlines and discusses key principles and issues related to injection procedures
Explain the procedure to the patient
Prepare patient – consent, positioning, exposure
Prepare injection site with bactericidal solution
Observe universal precautions
Select appropriate gauge and length of needle
Use a drawing needle
Select and plan site of injection with reference of anatomical landmarks
Knows characteristics of injectable solution with respect to actions, indications, dose,
duration of action, local and systemic side effects, complications and contraindications
Aspirate before injecting and forward aspirate for microscopy, culture and crystals
Be prepared to manage local and systemic complications
Consider possible interactions where more than one solution to same site is required
Consider risks of direct tendon injection
Contraindications (absolute and relative)
Allergy
Sepsis – local or systemic
Fracture site
Prosthetic joint
Reluctant or uninformed patient (excluding child or cognitively impaired)
Diabetes
Immunosuppression
Psychogenic pain
Bleeding disorders
Anticoagulation therapy
Local skin conditions
Procedures
Performs injections, aspiration or apply regional nerve blocks
Joint injection and/or aspiration
local anaesthesia
178
knee joint
shoulder joint
elbow joint
lumbar puncture (spinal tap)
fracture haematoma (wrist)
wrist joint
ankle joint
MTP (1st) joint
radio-ulna joint
hip joint
Regional nerve blocks
femoral
digital
wrist
brachial plexus
facial
foot
sciatic
Bursal injection and/or aspiration
prepatellar bursa
olecranon bursa
subacromial bursa
trochanteric bursa
wrist ganglion
Intramuscular injection
deltoid
vastus lateralis
gluteus maximus
Tendon/sheath
lateral epicondylitis (tennis elbow)
medial epicondylitis (golfer's elbow)
Achilles tendonitis
de Quervain tenosynovitis
carpal tunnel
Image-guided injections
CT
Ultrasound
Fluoroscopic
179
Open Fractures
General Objective
Understands the aetiology, pathogenesis, clinical manifestations and principles of management of
open fractures; is able to identify and characterise the injury and associated complications or other
injuries through patient enquiry, examination and limited investigations; and able to initiate timely
and appropriate management and referral.
Specific Outcomes
Baseline/ Supporting Knowledge
Pathophysiology of infection
Therapeutic guidelines for antibiotics and tetanus prophylaxis
Wound management
MSK Trauma
Assessment
Explains the significance of key factors that need to be assessed in contaminated open wounds
Energy/ Mechanism of injury
Depth of potential penetration remote to wound site
Type of contaminant
Clothing
Soil
Grass
Grease
Paint
Environment of injury
Farmyard
Marine
Initial investigations
Describes evidence that NOT required:
Microbiology
+Wound swabs
+Tissue biopsy
Emergency management steps
Outlines and discusses
Antibiotics/ Tetanus Prophylaxis
Likely bacterial contaminants and appropriate antibiotic management plan based on initial
assessment and consistent with suitable evidence-based guidelines
180
NB: guidelines may vary depending on location and regional microbial and antibiotic sensitivity
differences
Relationship of time to initial antibiotics and subsequent infection/outcomes
Wound irrigation/dressings
Explains
Clinical significance of key terms used to describe bacterial burden in contaminated
wounds
Contamination
Colonisation
Critical-colonisation
Infection
The role of antiseptics vs. normal saline and dressings in the initial management
The role of fluid irrigation/washout in the primary care
The timing of closure of open fracture wounds (basic principles)
The role of conventional dressings and negative wound pressure dressings in early and
ongoing management (basic principles)
+ The role of wound coverage techniques including grafts and flaps (local and remote)
Splintage
Discusses
The role of limb realignment
Resources
Zalavras, CG & Patzakis, MJ 2003, ‘Open Fractures: Evaluation and Management’
Journal of the American Academy of Orthopaedic Surgeons, May/June; 11, pp. 212 219.
181
Musculoskeletal Injuries with
Neurological, Vascular and/or Visceral
Involvement
General Objective
Outlines and explains the key issues in the assessment and management of fractures/injuries with
vascular, neurological or visceral involvement.
Specific Outcomes
Classification of neurological injuries and natural history of biologic regeneration or
degeneration
MSK investigations
Neurological examination
MSK trauma
Assessment
Injury Patterns
Outlines potential complications based on known injury associations
knee dislocation and popliteal artery
pelvic fractures
head and chest and spinal injuries (lateral compression)
major pelvic bleeding (open book fractures)
vaginal or rectal perforations
bladder ruptures
urethral/prostate injuries
distal radial or carpal fractures
median nerve injury
humeral shaft fractures
radial nerve injuries
supracondylar fractures elbow
anterior interosseous nerve
shoulder dislocations
axillary nerve
brachial plexus
182
Investigations
Discusses selection and timing of most suitable investigations for diagnostic and monitoring
purposes
vascular injury
arteriography
plain
CT
MRI
scintigraphy
ultrasound and Doppler studies
nerve injury
imaging
ultrasound
MRI
ancillary
NCT
EMG
visceral injury
NB: Assessment of specific visceral injuries is beyond the scope of MSK trauma
CT +/- contrast
MRI
Ultrasound
Management
Outlines:
Accurate initial assessment of neurovascular status and timely monitoring for changes
Timely notification and engagement of specialty groups
Potential dangers associated with timing and location of investigations in potentially
haemodynamically unstable patients
The role of expedient fracture realignment and stabilisation in the management of
fractures with vascular and/or nerve compromise
Principles of post-operative management in patients with vascular injuries
Rationale for fasciotomies in patients with vascular injuries
Principles of post-operative rehabilitation following nerve injury or repairs including the
roles of allied health professionals
+ Prognosis and potential complications associated with vascular injuries and repair
+ Role and timing of surgical exploration of nerve injuries
+ Principles of tendon transfers for irrecoverable nerve injuries
183
Compartment Syndrome
General Objective
compartment syndrome, and is able to identify this through patient inquiry, examination and limited
investigation, and initiate timely and appropriate management and referral.
Specific Outcomes
Anatomical compartments and their contents
Normal form and function of MSK tissues
Specific Reactions of MSK tissues to injury
Pathophysiology of Compartment Syndrome
Potential causes and effect of raised pressures in muscle compartments with fascial
coverings
Relationship of diastolic pressure to compartment pressure
Effect of temperature on the ischaemic time of muscle and nerve
Differential vulnerability of different nerve fibre types and how this relates to clinical
presentation and potential for recovery
Complications
reperfusion injury
contractures
muscle death and paralysis
rhabdomyolysis
myoglobinuria and renal failure
Assessment and Management
Pain
severity
analgesic requirements
Predisposition to and/or associated risk factors
drug addition
burns
hypoperfusion states
plaster/ dressings
crush injuries
sports injuries
184
high energy injuries
Sensitivity and relative importance of clinical findings and relation to
timing of diagnosis
pain on passive stretch
tense compartment on palpation
paraesthesia
in distribution of sensory nerve of compartment
paralysis
pulselessness
Factors effecting compartment measurements
+ positioning of needle relative to injury/fracture site
+ tip design
+ needle diameter
Release or removal of potential constrictions
casts
splints
circumferential dressings
Performs compartment pressure measurements using:
Level 2 performance - explains performance of procedure and has seen demonstrated - not
expected to have actually performed
a specialised commercial compartment pressure measuring device (tonometer)
+ a "make your own" measuring apparatus using an electronic transducer
+ a "make your own" measuring apparatus using a manual "Whitesides" setup or
equivalent
Rationale for laboratory investigations
Full blood count (FBC) with differential
Serum biochemistry including U&Es and LFTs
coagulation studies
Prothrombin time (PT)
Activated partial thromboplastin time (APTT)
Creatine phosphokinase (CPK)
+ Serum and urine myoglobin
+ Urine toxicology screen
Surgical management/fasciotomies
urgency and recommended time range to avoid tissue necrosis
effect of delayed diagnosis
++ choice of approach
++ incision placement
++ incision number
++ the timing and methods of wound closure following fasciotomy
185
++ the use of negative pressure wound dressings
++ infection and risks of "late" surgery
Timing of specialist referral
Medico-legal issues associated with failure to diagnose or delayed
diagnosis/intervention
Resources
Olson, SA & Glasgow, RR 2005, ‘Acute Compartment Syndrome in Lower Extremity
Musculoskeletal Trauma’ Journal of the American Academy of Orthopaedic Surgeons,
November; 13, pp. 436 - 444.
Whitesides, TE & Heckman, MM 1996, ‘Acute Compartment Syndrome: Update on
Diagnosis and Management’, Journal of the American Academy of Orthopaedic
Surgeons, July/August , 4, pp. 209-218.
186
Cauda Equina Syndrome
General Objective
cauda equina syndrome, and is able to identify this through patient inquiry, examination and limited
Specific Outcomes
Anatomy principles
Clinical anatomy
Cauda equina - that is the neural elements within the thecal sac between the conus
medullaris and the lumbosacral nerve roots
lumbar vertebrae and disks and their normal relation to the spinal cord, conus medullaris
and cauda equina.
Normal form and function of MSK tissue
Pathophysiology of Cauda Equina syndrome
Explains and knows of major causes
Trauma/injury
Disc Herniation
Spinal stenosis
Infection
Spinal Tumours
Iatrogenic
Signs and symptoms
Outlines and describes these in a patient presenting with CES
back pain
lower limb motor or sensory deficit
bladder or bowel dysfunction
lower limb motor function
lower limb sensory function
anal tone
lower limb and plantar reflexes
bulbocavernous and/or anal reflexes
187
Natural history
Treatment
Explains
principles of surgical decompression
rationale for timely diagnosis and urgent specialist referral
Medicolegal
Recognises the medicolegal consequences of missed or delayed intervention
188
Bone and Joint Infections
General Objective
musculoskeletal infections, and is able to identify this through patient inquiry, examination and
limited investigation, and initiate timely and appropriate management and referral.
Specific Outcomes
Microbial biology and infection
MSK Assessment
Imaging principles
Laboratory Investigations
Injection/ Aspiration Procedures
Key terms associated with infection
Defines:
suppuration
necrosis
inflammation
granule reaction
resolution
bacteraemia
haematogenous seeding
septicaemia
endotoxins
osteomyelitis
septic arthritis
bactericidal vs. bacteriostatic effect of antibiotics
biofilm
sequestrum
involucrum
debridement
Factors influencing the pathophysiology and clinical manifestations of
infection
Outlines and explains:
gram staining of organisms
pyogenic vs. non-pyogenic infections
189
pathophysiology of tuberculosis
local and systemic host responses to infection
HIV and other viral hepatic infections
diabetes
corticosteroids and other immunosupressives
necrotic material
foreign material
partial treatment with antibiotics
+ pathophysiology and natural progression of untreated bone infection
+ raised intraosseous pressure
+ blood transfusion and immunomodulation
+ BMI (body mass index)
+ acute vs. subacute vs. chronic infections
+ differences related to anatomical locations
+ age related anatomical differences
Key signs of infection
Identifies and interprets
vital observations including BP, pulse and temperature
peripheral circulation
skin rash or necrosis
evidence of pain and sites of tenderness
abnormalities of local temperature
regional lymphadenopathy
hepatomegaly/splenomegaly
lymphangitis
cellulitis
bursitis
arthritis
tenosynovitis
meningism
Natural history and complications associated with untreated
osteomyelitis
Pathogenesis, clinical manifestations and potential urgency of MSK
infections
Describes and recognises need for timely diagnosis and urgent specialist referral
General
acute haematogenous osteomyelitis
subacute haematogenous osteomyelitis
chronic osteomyelitis
190
acute septic arthritis
septic bursitis
cellulitis
myositis
periprosthetic infection
post-traumatic infection
postoperative infection
necrotising fasciitis
meningococcal septicaemia
gas gangrene
Spine
Discitis
Tuberculous arthritis
Tuberculous spondylitis
Hand
paronychia infection
pulp-space infection
pyogenic tenosynovitis
deep fascial space infection
human bite septic arthritis
animal bite infections
Principles of administration for commonly used antibiotics in MSK
infection
Initiation, dosing, duration, route of administration
General principles of management in infections
Outlines and explains
decompression/drainage (collections)
debridement (necrotic and foreign tissue)
timing of commencement of antimicrobials
AFTER tissue collection for culture
AFTER discussion with treating in surgeon in post op infections
rehabilitation
rest
aids and splintage
mobilisation
Common challenges in infection management
effect on clinical signs and bacteriological examinations when antibiotics are commenced
prior to collection of tissue
191
presence of metal/foreign material for fixation
Medico-legal
Recognises the consequences of missed or delayed intervention
Laboratory and imaging diagnostic modalities
bloods
white cell count
red cell count
platelet count
blood cell microscopy
coagulation
Gram stain
CRP
ESR
blood culture
blood glucose
U&E's
Liver function tests
urate
creatine phosphokinase
tissue/fluids
microscopy and culture of aspirate, swab, pus or deep tissue
microscopy for crystals (urate and pyrophosphate)
lumbar puncture
imaging
plain radiography
sinography
ultrasonography
radionuclide bone labelling scans (e.g. technetium)
radionuclide WBC labelling scans (e.g. gallium, indium)
CT
MRI
Describes and/or performs tissue collection for investigation
joint aspiration
bursa aspiration
lumbar puncture
bone biopsy
synovial biopsy
192
Resources
Therapeutic Guidelines - Antibiotics
193
Temporal Arteritis
General Objective
temporal arteritis, and is able to identify this through patient inquiry, examination and limited
Specific Outcomes
Biology of Tissue Response to Disease
Immune Responses
Pharmacokinetics - steroids
Incidence, pathogenesis and associated clinical manifestations
The American College of Rheumatologists (1990) Diagnostic Criteria
Main vessels involved
Region of vessel involved
Type of inflammatory reaction
Age, sex and race characteristics
Prevalence in the over 50 population
Laboratory and imaging diagnostic modalities and their limitations
Initial management and urgency
Natural history
Complications associated with the condition
Risks associated with failure to treat
Patient education
Explanation of prognosis
Risks/ benefits associated with long term treatment
Resources
Hunder GG, Arend WP, Bloch DA, Calabrese LH, Fauci AS, Fries JF, et al. 1990, The
American College of Rheumatology 1990 criteria for the classification of vasculitis.
Introduction. Arthritis & Rheumatism. vol. 33, pp. 1065-7. [Medline]
<http://www.medscape.com/medline/abstract/2390119?src=emed_ckb_ref_0>.
194
Musculoskeletal Mimickers
General Objective
Demonstrates ability to identify "Red Flag MSK Mimickers" from a targeted history, examination
and investigations, and to initiate immediate referral of a patient with such a condition for urgent
specialist management.
Specific Outcomes
MSK presentation of life threatening diseases
Chest pain
Thoracic back pain
Low back pain
Groin pain
Calf pain
Neck pain
Shoulder pain
Arm pain
Important life-threatening diseases that may present with common MSK
presentations
Has knowledge of the pathogenesis, clinical manifestations and potential urgency for intervention
of these conditions
Thoracic aneurysm
Acute myocardial infarction
Ischaemic Heart Disease
Abdominal aortic aneurysm
Pancreatitis
Biliary pathology
Vertebral artery dissection
Meningitis
Ectopic Pregnancy
Subarachnoid haemorrhage
Splenic Injury
Pancoast tumours
DVT/PE
Tension pneumothorax
Severe Pneumonia
Oesophageal Rupture
Epidural Abscess
195
Pathological or surgical sieve for clinical evaluation and to reduce risk
of missed diagnosis
196
Back Pain and Sciatica
General Objective
Identifies the symptoms, signs and predisposing factors, outlines the assessment and appropriate
investigation, proposes a limited differential diagnosis and outlines the principles of management
including patient education and self management strategies for patient with back pain and/or
sciatica.
Specific Outcomes
Baseline/Supporting Knowledge
Biomedical Science
Tissue response to disease
inflammation
repair
MSK Basic Science
Anatomy of the vertebral column, discs, spinal cord and supporting soft tissues
Reactions of MSK tissues to disease
Clinical Science
Principles of assessment including imaging
Principles of acute and chronic pain management
Special concern groups
Pain history
Spine examination
Background
Demonstrates understanding of the following key terms and conditions as applied to
pathophysiology of spinal disorders
Disc disease
Disc prolapse
Radiculopathy
Osteoarthritis
Osteoporosis/fragility fractures
Osteophytes
Spondyloarthropathies
Cauda equina
Saddle anaesthesia
Spondylolysis
Spondylolisthesis
Spinal stenosis
Neurogenic claudication
197
Describes the pathophysiology to explain the clinical, laboratory and imaging manifestations of
acute and chronic pain and the rationale for therapeutic interventions
Discusses the incidence and burden of back pain and sciatica in Australia
Describes the natural history of acute LBP and sciatica
Knowledge and understanding of significance of physical risk factors or "red flags"
Features of Cauda Equina Syndrome
Severe worsening pain, especially at night or when lying down
Significant trauma
Weight loss, history of cancer, fever
Use of intravenous drugs or steroids
Patient over 50 years old
Knowledge and understanding of significance of psychosocial risk factors or "yellow flags"
Belief that pain and activity are harmful
‘Sickness behaviours’ (like extended rest)
Low or negative moods, social withdrawal
Treatment that does not fit best practice
Problems with claim and compensation
History of back pain, time-off, other claims
Problems at work, poor job satisfaction
Heavy work, unsociable hours
Overprotective family or lack of support
Assessment
Describes and discusses the key symptoms associated with back pain and sciatica
Mechanism, onset and nature of pain
Pain referral/distribution
Neurological symptoms
Aggravating activities
Previous episodes
Functional demands and limitations
Red Flags
Yellow flags
Discusses key features to differentiate disk or degenerative related causes from other conditions
Neoplasia
Infection
Vascular
Bleeding-haematoma
Non organic/functional
Performs and appropriately interprets a targeted physical examination distinguishing normal from
abnormal
Spinal
Neurological
198
Functional/non organic
General constitutional
Discusses the role of investigations in the first 4-6 weeks in the absence of red flags
Specifies and justifies appropriate use of further laboratory investigations and correctly interprets
findings
CBE / ESR/CRP
Urea and electrolytes
LFT's
Coagulation screen
Immunological markers - RhF, HLA B27
MSSU - MCS
Bence Jones protein
Blood cultures
Specifies and justifies appropriate use of imaging studies and correctly interprets findings
plain X-rays
CT scan
Nuclear Medicine Imaging
Management
Outlines and discusses the principles and use of key non pharmacological therapy options
Advice to stay active (including work)
Bed rest, with or without traction
Nutrition and Weight reduction
Aerobic conditioning
Land-based exercise
Aquatic exercise
Multimodal physical therapy
Assistive devices - braces and orthotic supports
Self management education programs
Core Stabilisation Exercises e.g. Pilates
Physical agents and passive modalities (includes ice, heat, short wave diathermy,
ultrasound)
TENS
Acupuncture
Shoe lifts or corsets
Biofeedback
Massage
Simple analgesia (paracetamol)
Manipulation
Outlines and discusses the principles and use of short and longer term pharmacological therapy
Oral NSAID/COX-2
Benzodiazepines
Weak and strong opioids
199
Topical NSAIDs
Epidural steroid injections
Facet joint injections
Outlines general principles of care plans
Develop goal setting care plan
identified need
evidence for effectiveness
patient preferences
Optimise conservative therapy
Optimise quality of life
Minimise risk of adverse events
Monitor and review
Outlines the role of other health professionals in multidisciplinary care
Physiotherapy
Occupational therapy
Exercise physiology
Nursing
Pharmacy
CAM practitioners
Outlines the indications for specialist referral
Specifies the general types of operative procedures available for back pain and sciatica and
explains the general principles and rationale on which they are based
Decompression
Fusion
Vertebral Arthroplasty
Specifies and outlines general role of key relevant consumer organisations
Resources
New Zealand Low Back Guide
NHMRC acute pain assessment guidelines
200
Osteoporosis
General Objective
including patient education and self management strategies for patient with osteoporosis.
Specific Outcomes
Normal processes
Calcium and Phosphate Metabolism
Bone biology / homeostasis / fracture repair
Abnormal processes
General Pathological Processes in Musculoskeletal Conditions
Reactions of MSK tissues to disorders and injury
Fundamentals of image production
Background
Describes the pathophysiology to explain the clinical, laboratory and imaging manifestations of OP
and the rationale for therapeutic interventions
Discusses the epidemiology of OP including the current and projected burden in Australia and
internationally
Assessment
Outlines and discusses features from the history suggestive of osteoporosis and fragility fractures
Identifies presence of major risk factors associated with diagnosis and management of
osteoporosis including falls assessment
Age over 60 years
Family history of osteoporotic fractures
Hypogonadism
Prolonged (>3 months) glucocorticoid use
Inflammatory conditions
Malabsorption
Hyperparathyroidism
Hyperthyroidism
Low body weight
Smoking
Recurrent falls
High alcohol intake
201
Existing medication - antihypertensives and sedatives/tranquilisers
Ethnicity- skin pigmentation
Explains and performs a targeted physical examination and discusses features of conditions that
may associated with osteoporosis and appropriately interprets findings
clothing preventing sun exposure
skin pigmentation
increased kyphosis
decreased height
prior fractures / scars/ deformity
hyperthyroidism
glucocorticoid induced changes
Explains the rationale for the key blood and urine studies/markers in the assessment of bone
turnover and monitoring osteoporosis and appropriately interprets results
Serum calcium
Serum 25-hydroxyvitamin D
Serum phosphate
Serum alkaline phosphatase (ALP)
serum Gamma GT
Serum creatinine and eGFR
ESR and C-reactive protein
Serum protein electrophoresis
Serum testosterone (with LH) in men
Serum TSH
Discusses the role and limitations of imaging in the diagnosis and ongoing monitoring of
osteoporosis and appropriately interprets results
Plain radiographs, vertebral wedge fractures and detection of osteopaenia
Principles of Dual energy X-ray absorptiometry (DEXA) and BMD assessment
Interpretation of T and Z scores
Use of fracture risk nomograms
Management
Outlines and discusses the principles of the range of management/treatment options including
education, self management and referral for patients with osteoporosis
Calcium requirements and special circumstances (e.g. growth and pregnancy)
dietary
supplementation
Pain management
Lifestyle
adequate but safe exposure to sunlight as a source of vitamin D
diet and body mass index (BMI)
smoking
alcohol
202
exercise prescription
Fall reduction strategies
Education and psychosocial support including major consumer support organisations
e.g. Osteoporosis Australia
Outlines and discusses falls prevention including risk assessment and reduction strategies
Outlines indications for specialist referral
OP is unexpectedly severe or has unusual features at the time of initial assessment
intolerance of approved therapies or experiencing problems
failing to respond to treatment
having fractures despite treatment or normal bone density
not having access to appropriate bone densitometry
Explains the rationale for current anti-osteoporotic pharmaceutical treatments with particular
reference to calcium and phosphate/Vitamin D physiology and anabolic/catabolic processes in
bone turnover
Calcium and vitamin D supplements
Bisphosphonates
Hormone replacement therapy
Parathyroid hormone (teriparatide)
Strontium ranelate
Selective Estrogen Receptor Modulators (SERMs) (raloxifene)
anti Sclerostin agents
Discusses primary and secondary fracture prevention and the implications on subsequent fracture
risk and management
Discusses the basic principles of interventional/surgical treatment for common osteoporotic
fractures and general risk associated with stabilisation or fixation of osteoporotic bone
distal radial fractures
hip fractures
intracapsular vs. extracapsular
vertebral fractures
rationale for vertebroplasty and kyphoplasty
Osteoporosis Australia
Resources
RACGP's evidence-based guidelines for management of OP
Osteoporosis Australia information for health professionals and patient information
203
Osteoarthritis
General Objective
including patient education and self management strategies for the patient with osteoarthritis.
Specific Outcomes
inflammation
repair
Normal form and function of MSK tissue
MSK deformity
Assessment
MSK management modalities
Background
Describes the pathophysiology to explain the clinical, laboratory and imaging manifestations of OA
and the rationale for therapeutic interventions
Discusses the incidence and burden of RA in Australia and the implications of early versus delayed
diagnosis
Assessment
Specifies and discusses the key symptoms associated with OA
Joint pain
Night pain
Stiffness
Swelling
Instability
Deformity
Analgesic requirements
Use of assistive devices
Other treatments
Functional impairment (related to affected joint)
falls or "near falls"
Discusses key features to differentiate OA from other conditions
Trauma
204
Soft tissue conditions
Referred pain syndromes
Septic/crystal arthritis
Haemarthrosis
Performs and appropriately interprets a targeted physical examination distinguishing normal from
abnormal
Joint tenderness
Swelling/ effusions
Osteophytes
Deformity
Crepitus
Stiffness
Instability
Functional impairment
Specifies and justifies appropriate use of further laboratory investigations and correctly interprets
findings
FBC / ESR
Urea and electrolytes
LFT's
Coags
Specifies and justifies appropriate use of imaging studies and correctly interprets findings
Plain X-rays
Weight bearing views
Bone Scans
Management
Outlines and discusses the principles and use of non pharmacological therapy options
Nutrition and weight reduction
Land-based exercise
Aquatic exercise
Assistive devices: walking aids, braces and orthotic supports
Self-management education programs
Tai chi
Thermotherapy
TENS
Acupuncture
Outlines and discusses the principles and use of short and longer term Pharmacological therapy
Simple analgesia (paracetamol)
Oral NSAIDs/COX-2
glucosamine +/- chondroitin sulphate
205
Weak and strong opioids
Intra-articular corticosteroids
Topical NSAIDs
Viscosupplementation
Discusses the effect of comorbid conditions to patient self-management and use of OA
medications (particularly NSAIDs)
Cognitive impairment
Cardiovascular disease
Peptic ulcer disease
Renal disease
Type II diabetes
Asthma
Allergies
Liver disease
Depression and anxiety
Outlines general principles of care plans
identified need
patient preferences
Monitor and review
Outlines the role of other health professionals in the multidisciplinary care of OA
Physiotherapy
Exercise physiology
Nursing
Pharmacy
CAM practitioners
Explains the general role of the hip and knee questionnaire (MAPT) in patient selection for
arthroplasty
Outlines the indications for specialist referral
Specifies the general types of operative procedures available for OA and explains the general
principles and rationale on which they are based
Australian Arthritis Foundation
206
Resources
RACGP's evidence-based guidelines for management of knee and hip OA
RACGP’s guidelines for arthoplasty referral
207
General Objective
including patient education and self management strategies for patient with Rheumatoid Arthritis.
Specific Outcomes
cell biology
biochemistry and molecular biology
tissue response to disease
inflammation
repair
immune responses
normal form and function MSK tissue
inflammation, immune mediated
reactions of MSK tissues to disease
MSK deformity
Background
Describes and relates the pathophysiology of RA to the clinical, laboratory and imaging
manifestations and the rationale for therapeutic interventions
Discusses the current and predicted burden of RA in Australia
Assessment
Outlines the key diagnostic and distinguishing features in the assessment of early RA
characteristic history
targeted physical examination findings
Three or more tender and swollen joint areas
Symmetrical joint involvement in hands and/or feet
Positive squeeze at MCP or MTP joints
clinical signs and symptoms characteristic of alternative diagnoses to RA
Infective arthritis
fever
rash
Reactive arthritis
post URTI
208
GIT
Sexually-acquired
Other inflammatory arthritides
psoriatic rash
nail pits
asymmetrical joint pattern
decreased spinal ROM
diarrhoea
Crystal arthritis
tophi
Connective tissue diseases
Raynaud's
butterfly rash
Metabolic
laboratory and imaging investigations
Diagnosis
Raised ESR and/or CRP
Level of RhF and anti-cyclic citrullinated peptide antibody
Prognostic indicators/monitoring
Full blood count
Renal function
Fasting lipids, glucose
Liver function test
X-ray chest, hands and feet
Urinalysis
Differential diagnosis
ANA
urate
synovial fluid analysis
American College of Rheumatology diagnostic criteria for RA
Management
Outlines and discusses the general management principles and the role of treatment options in RA
with reference of current Australian evidence based guidelines where available
risk reduction strategies
pharmacological approaches
early RA
advanced RA
non pharmacological therapies
Weight reduction
Exercise
209
Patient education and self management education programs
Thermotherapy
TENS
Acupuncture
Psychosocial support
Sleep promotion
Foot care
personalised care plans
identified need
patient preferences
Monitor and review
other specialist and allied health professionals in multidisciplinary care
and ongoing management
Outlines the relevant referral pathways and clinical rational for referral for the ongoing
management of advanced RA
Outlines and explains in general terms the basic principles and rationale of interventional/surgical
treatment options
synovectomy
nerve decompression
tendon repair
arthrodesis
excision arthroplasty
replacement arthroplasty
Identifies and outlines general role of key relevant consumer organisations and information
sources
Arthritis Australia
Resources
Rheumatology Therapeutic Guidelines www.tg.com.au
National Service Prescribing Guidelines www.nps.org.au
www.rheumatology.org.au
Arthritis Australia
www.racgp.org.au
210
Juvenile Idiopathic Arthritis
General Objective
including long term care planning and coordination of multidisciplinary care needs for patient with
Juvenile Idiopathic Arthritis (JIA).
Specific Outcomes
Baseline/supporting knowledge
Cell biology
Biochemistry and molecular biology
Inflammation
Repair
Immune responses
Normal form and function MSK tissue
Inflammation, immune mediated
MSK deformity
General Principles
Describes and relates the pathophysiology of JIA to the clinical, laboratory and imaging
manifestations and the rationale for therapeutic interventions
Discusses the current and predicted burden of JIA in Australia
Outlines the general subtypes of JIA
1. Oligoarticular
2. Polyarticular (RhF negative)
3. Polyarticular (RhF positive)
4. Systemic
5. Enthesitis related
6. Psoriatic
7. Undifferentiated arthritis
Explains basic reasons for improved prognosis
Outlines and explains the diagnosis and management of JIA
consistent with the summary recommendations and good practice points of the RACGP clinical
guidelines
211
Aim for early diagnosis
Criteria for referral
Targeted history
Targeted general and MSK examination
Diagnostic investigations
Defines role of
Laboratory
Basic
ESR/CRP
FBC
Additional
As indicated to classify subtype or exclude alternative diagnoses
RhF
ANA
Imaging
Plain radiographs
Diagnostic criteria
Pain and swelling of single or multiple joints
Persistent or worsening loss of function
Fever of at least 10 days with unknown cause, often associated with transient
erythematous rash
Decreased range of motion (ROM)
Joint warmth
Effusion
Differential diagnosis
Septic arthritis
Post-infectious/reactive arthritis
Systemic lupus erythematosus (SLE)
Acute lymphoblastic leukaemia (ALL)
Trauma/non-accidental injury
Osteomyelitis
Bone tumour
Inﬂammatory bowel disease (IBD)
Henoch-Schönlein purpura and other vasculitides
Rheumatic fever
Hypermobility
General principles of management
Preservation of function and quality of life
Minimisation of pain and inflammation
Joint protection
Control of systemic complications
212
Multidisciplinary care
Defines potential role of:
Physiotherapists
Occupational therapists
Mental health specialists
Ophthalmologists
Podiatrists or orthotists
Orthopaedic surgeons
Social workers
Pain management teams
Indigenous health workers
Community nursing teams
Personalised care planning
Development with multidisciplinary team
Defined treatment goals
Planned monitoring and review
Patient education and psychosocial support
Patient/family education
Psychosocial interventions/support services
Community resources
School-based resources
Information and referral regarding insurance coverage and benefit coordination
Pharmacological interventions
Defines general role of including key contraindications
Basic therapy
Simple analgesics/Paracetamol
Weak opioids
Traditional NSAIDs
Topical NSAIDs
CAMs
Advanced therapy (Rheumatologists)
Corticosteroids (IV, oral, intra-articular)
DMARDs (e.g. methotrexate)
Biological modifying therapies (bDMARDs)
Non pharmacological interventions
Defines general role of
Nutritional therapy
Adequate diet
Ca & Vit D supplementation
Land-based exercises
213
Aquatic exercises
Splints
Foot orthoses
Thermotherapy
Complementary/alternative physical therapies
Disease Monitoring and comorbidities
Resources
RACGP - clinical guideline for the diagnosis and management of Juvenile Idiopathic
Arthritis
www.racgp.org.au
www.rheumatology.org.au
Arthritis Australia
214
Priority Ambulatory Conditions
General Objective
Knows of the common and important ambulatory MSK conditions that present to general practices,
emergency departments and rural and/or remote indigenous settings as the basis for prioritising
more advanced learning and application of the key basic and clinical science assessment and
management principles.
Specific Outcomes
Priority Ambulatory Conditions- appendix.doc
Note: The conditions listed below are generally considered the more common ambulatory
conditions seen in general practice or less common but important diagnoses which are either
commonly missed or delayed in management. The list is neither exhaustive nor definitive but a
current guide to the range of MSK conditions for which at least a general awareness of the
diagnoses and associated potential "red flags" for referral is required for safe general practice. The
MSK and emergency and high burden priority conditions have been duplicated in this list.
Spine/Chest
Vertebral fractures
acute traumatic
fragility compression
Non specific pain/strain (lumbar, thoracic, cervical)
Spinal pain (lumbar, thoracic, cervical)
localised
with somatic referred pain
with radicular pain +/- radiculopathy
Degenerative spinal conditions
intervertebral disc
facet joint
Spinal stenosis
Cauda equina syndrome
Failed back syndrome
Metastatic disease
Spondylolysis/listhesis
Ankylosing spondylitis/spondyloarthropathies
Diffuse idiopathic skeletal hyperostosis (DISH)
RA neck manifestations
Costochondritis
Sternoclavicular joint pain
Scoliosis
Kyphosis
Torticollis
Discitis
215
Hip/Pelvis
Hip and Pelvic Ring fractures (fragility)
Degenerative joint disease (DJD)
Sacroiliac (SI) joint dysfunction/arthropathy
Greater trochanteric bursitis
Hip insertional tendinopathies (gluteal, adductor)
Piriformis syndrome
Avascular necrosis (AVN)
Snapping hip
Transient synovitis of the hips
Slipped capital femoral epiphysis (SCFE)
Perthes disease
Developmental dysplasia of hip (DDH)
Knee/Leg
Tibial plateau fractures
Patellofemoral pain syndrome
Degenerative joint disease/Osteoarthritis
Cruciate ligament (ACL/PCL) tear
Collateral ligament (LCL/MCL) tear
Meniscus tears
Muscle strains/tears
Popliteal cyst
Iliotibial band syndrome (ITBS)
Osgood-Schlatter’s disease
Patellofemoral dislocation/ instability
Tendinopathies (patellar/quadriceps)
Medial tibial stress syndrome (shin splints)
Tibial stress fracture
Compartment syndrome of leg
Genu Valgum
Genu Varum
Ankle/Foot
Ankle fractures
Stress fractures
Ankle sprains
TMT ligament injuries
Achilles tendon rupture
Ankle and subtalar arthritis
Plantar fasciitis
216
Achilles tendinosis/posterior heel pain
Bruised heel pad
Posterior tibial tendon dysfunction
Corns and Calluses
Metatarsalgia
Hallux Valgus (Bunion)
Hallux Rigidus
Interdigital Neuroma
Diabetic foot
Toe deformities
Plantar warts
Ingrown toenail
In-toeing/Out-toeing
Flat foot
Calcaneal apophysitis
Cavus foot
Clubfoot
Toe-walking
Shoulder
Proximal humeral fracture
Clavicle fracture
ACJ Injuries
Rotator cuff pathology (tear/strain/tendinopathy)
Impingement syndrome
Adhesive capsulitis/frozen shoulder
Subacromial bursitis
Shoulder arthritis
Proximal biceps rupture/ tendinopathy
Shoulder instability
Thoracic Outlet syndrome
SLAP lesions
Brachial Plexus injuries
Wrist/ Hand/ Elbow
Distal radius fracture
Radial head fracture
Elbow dislocation
Wrist sprain
Scaphoid fracture
Keinböck's disease
Supracondylar fracture (children)
217
Nursemaid’s elbow (radial head subluxation)
Metacarpal and finger fractures
Hand/wrist lacerations
Flexor tendon injuries
Fingertip injuries
Mallet finger
Nail bed injuries
Flexor tendon sheath infections
Human bites
Carpal tunnel syndrome
Nerve entrapments (ulnar nerve)
Wrist ganglions
Epicondylosis (lateral & medial)
Olecranon bursitis
Thumb CMC DJD
De Quervain’s tenosynovitis
Dupuytren’s disease
Trigger finger
Rheumatologic conditions
Osteoarthritis
Rheumatoid arthritis
Juvenile idiopathic arthritis
Reactive arthritis
Crystal Arthropathy
Gout
Pseudogout
Idiopathic inflammatory myositis
Psoriatic arthritis
Spondyloarthropathies
Polymyalgia rheumatica
Temporal Arteritis
Lupus
Scleroderma
Other Autoimmune/Connective tissue disorders
General & other conditions
Osteoporosis
Paget's disease
Fibromyalgia
Paediatric Non Accidental Injury
Complex Regional Pain Syndrome
218
Compartment syndrome
Open Fractures
MSK Mimickers
Infections of MSK tissues (Bone/Joints/muscles etc)
Tumours of MSK tissues
219
Publications
Woolf, AD, Walsh, NE & Åkesson, K 2004, ‘Global core recommendations for a
musculoskeletal undergraduate curriculum’, Annals of the Rheumatic Diseases, vol. 63,
no. 5, pp. 517-524.
Chehade, MJ & Bachorski, A 2008, ‘Development of the Australian Core Competencies in
Musculoskeletal Basic and Clinical Science Project – phase 1’ Medical Journal of
Australia, vol. 189, no. 3, pp. 162-165.
Chehade, MJ & Woolf, AD 2008, ‘Musculoskeletal education initiatives and the Bone and
Joint Decade’, US Musculoskeletal Review’, vol. 3, no. 2, pp. 86-87.
Chehade, MJ, Bentley, DJ & Burgess, TA 2011, ‘The AMSEC project - a model for
collaborative interprofessional and interdisciplinary evidence-based competency education
in health’, Journal of Interprofessional Care, vol. 25, no. 3, pp. 218-220.
Chehade, MJ, Burgess, TA & Bentley, DJ 2011, ‘Ensuring quality of care through
implementation of a competency-based musculoskeletal education framework’, Arthritis
Care & Research, vol. 63, no. 1, pp. 58-64.
220
Acknowledgements
We gratefully acknowledge the support of the Australian Government in funding the
AMSEC Project, and the Depart of Health and Ageing for their support and assistance
throughout the competency development process.
The AMSEC Framework was made possible by the contributions of a significant number of
people from across Australia who have generously given of their time and expertise in
developing the AMSEC Framework and Competencies. We would particularly like to thank
the following for their ongoing support and assistance:
 Associate Professor Norm Eizenberg, Department of Anatomy and Developmental
Biology, Monash University
 Associate Professor Shane Brun, Musculoskeletal and Sports Medicine James
Cook University
 Dr Victor Wilk, Australasian Faculty of Musculoskeletal Medicine
 Associate Professor Tony Pohl, Director of Orthopaedic Trauma, Royal Adelaide
Hospital
 Associate Professor Michael Shanahan, Associate Dean, Flinders Clinical
Effectiveness Cluster, Faculty of Health Sciences, Flinders University
 Professor Justin Beilby, Executive Dean, Faculty of Health Sciences, University of
Adelaide and Chair, AMSEC National Steering Committee
221
CONTRIBUTORS TO THE DEVELOPMENT OF AMSEC
We gratefully acknowledge the support and advice of the following individuals and organisations
who have assisted with the development of the AMSEC Framework and Competencies.
Individuals:






Dr Wayne Hazell, Australasian College of Emergency Medicine
Professor Nik Bogduk, Director, Newcastle Bone and Joint Institute
Associate Professor Michael Yelland, Primary Health Care, Griffith University
Professor John Slavotinek. Royal Australian and New Zealand College of Radiologists
Dr Mary Moss Director of Training, Department of Radiology, Royal Adelaide Hospital
Associate Professor Martin Richardson, University of Melbourne at Royal Melbourne Hospital
Organisations:’







RACGP
ANZACA
Osteoporosis Australia
Sports Medicine Australia
Confederation of Postgraduate Medical Councils
Australian Physiotherapy Association
Bone and Mineral Society
The AMSEC Project National Steering Committee




















Professor Justin Beilby (Chair), Medical Deans of Australia and New Zealand
A/Prof Mellick Chehade, (Project Director), Australian Orthopaedic Association (AOA)
Professor Geoff McColl, Australian Rheumatology Association (ARA)
Professor Richard Osborne (Deputy Chair), Public Health and Epidemiology
Professor Rebecca Mason, Australian and New Zealand Bone and Mineral Society
(ANZBMS) & Endocrine Society of Australia (ESA)
Professor Helen McCutcheon, Council of Deans of Nursing and Midwifery (CDNM) (until
2010)
Professor Fred Ehrlich, Australian Faculty of Rehabilitation Medicine (AFRM)
James Schomburgk, Australian Physiotherapy Association (APA)
Chad Donnelly, Australian Medical Students’ Association (AMSA) (until 2009)
Ross Roberts-Thompson Australian Medical Students’ Association (AMSA) (From 2010)
D Xavier Yu, Australian Medical Association’s Council of Doctors in Training (AMAsDT)
Professor Peter Brooks, Committee of Deans of Health Sciences (CDHS)
Mr Ben Horgan, C, F / Arthritis WA / BJD Australia
Dr Morton Rawlin, Royal Australian College of General Practitioners (RACGP)
Observers from the Australian Government Department of Health and Ageing (DoHA)
Ms Kerry Dent, (until 2009)
Ms Jeanette Scott, (until 2008)
Mr Mick Hoare (until 2008)
Mr Stan Piperoglou, (2008 onwards)
Ms Kim Wight (2009) / Ms Dianne Pentland (2009 onwards)
222
Working Groups
PHYSICAL EXAMINATION*
A/Prof Tony Pohl
Orthopaedics (RAH –SA) (Chair)
Dr Michael Ahern
Rheumatology (FMC- SA)
Dr John Beadle
General Practice (Tas)
A/Prof Shane Brun
MSK Medicine (Qld – JCU)
Dr Peter Cundy
Ortho/Paediatrics (WCH – SA)
A/Prof Leon Kleinman
Orthopaedics (Newcastle)
A/Prof Bruce McPhee
Orthopaedics (Qld)
Dr Susanna Proudman
Rheumatology (RAH – SA)
A/Prof Michael Yelland
Primary Health Care (Qld)
James Schomburgk
Physiotherapy (SA)
Mr Ben Horgan
CHF / Arthritis WA / BJD Australia
Dr David Wheatley
AMACDT
Dr Simon Koblar
Neurology (TQEH – SA)
Dr Lorenzo Ponte
Rural GP
MUSCULOSKELETAL EMERGENCY CONDITIONS
Dr Wayne Hazell
ACEM (Chair)
Dr Manya Angley
Sansom Institute
Dr Yun Hom Yau
(RAH) Spinal specialist
Dr Ian Harris
Orthopaedic/Trauma surgeon
A/Prof Tony Pohl
Orthopaedics (RAH -SA)
Prof John Turnidge
WCH (SA)
Dr David Wheatley
AMACDT
Dr Lorenzo Ponte
Rural GP
BASIC SCIENCE
Prof David Findlay
University of Adelaide
Dr Manya Angley
Sansom Institute
A/Prof Martin Richardson
Orthopaedics (UniMelb)
Prof Rebecca Mason
Endocrine
Prof Howard Morris
Hansen Institute
Prof Ranjeny Thomas
Rheumatology – UQ
A/Prof Norm Eizenberg
Anatomy (Melbourne)
Dr Mounir Ghabriel
Anatomy (Adelaide)
Dr Dror Maor
AMACDT
223
PATIENT EDUCATION AND SELF MANAGEMENT
Prof Malcolm Battersby
Flinders University (Chair)
Mr Ben Horgan
CHF / Arthritis WA / BJD Australia
Dr Morton Rawlin
Primary Health Care
Dr Katherine Baverstock
Pharmacy Guild
Dr Dror Maor
AMACDT
PROCEDURAL SKILLS
Dr Vidya Limaye
Rheumatology
Dr Andrew Briggs
NHMRC PostDoc fellow
Dr Adrian von de Borch
Orthopaedics
Dr David Wheatley
AMACDT
REHABILITATION
Prof Maria Fiatarone Singh
University of Sydney (Chair)
A/Prof Shane Brun
MSK Medicine
A/Prof Norm Broadhurst
MSK Medicine
Dr Terry Haines
Conjoint Physiotherapy Research Fellow (UQ)
Prof Ian Cameron
Professor of Rehabilitation Medicine (USyd)
Dr Dror Maor
AMACDT
Karen Dixon
Country Health SA
CLINICAL SCIENCE
A/Prof Mark Kotowicz
University of Melbourne (Chair)
A/Prof Martin Richardson
Orthopaedic - upper limb
Dr Morton Rawlin
Primary Health Care (RACGP)
A Prof Richard Osborne
Epidemiology UniMelb
Dr Yun Hom Yau
(RAH) Spinal specialist
James Schomburgk
Physiotherapy
Prof Keiran Fallon
Sports Medicine (AIS)
Prof David Little
Paediatrics (UniNSW)
Prof Rachelle Buchbinder
Rheumatology (Monash)
Dr Tania Winzenberg
RACGP
Dr Victor Wik
AFMM
Dr Meg Stuart
National Prescribing Service
Prof Norm Broadhurst
MSK Medicine
Dr Dror Maor
AMACDT
Dr John Slavotinek
The Australasian MSK Imaging Group (AMSIG)
Dr Charles Inderjeeth
Geriatrics
Dr Simon Vanlint
Rural GP
224
Dr Christina Boros
Paediatrician (WCH – SA and UA)
ASSESSMENT
Dr Alison Jones
RACP
Dr Chad Donnelly
AMSA
Dr Xavier Yu
AMA
A/Prof Michael Shanahan
Rheumatology
Dr Morton Rawlin
Primary Health Care (RACGP)
225
226

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