Musculoskeletal Health

Musculoskeletal conditions are one of the most common reasons for GP consultations and are well represented in the AKT. Questions focus on diagnosis, red flag recognition, and management pathways.

Low back pain is extremely common. NICE guideline NG59 recommends against routine imaging for non-specific low back pain. Red flags requiring urgent investigation include cauda equina syndrome (bilateral leg weakness, saddle anaesthesia, urinary retention or incontinence), suspected spinal fracture (significant trauma, osteoporosis risk, corticosteroid use), suspected malignancy (weight loss, history of cancer, age over 50 with new onset), and suspected infection (fever, IV drug use, immunosuppression). Management of non-specific back pain includes staying active, analgesia, and physiotherapy. Avoid prolonged bed rest.

Osteoarthritis is the most common joint disease. Diagnosis is clinical: joint pain that worsens with activity and improves with rest, morning stiffness lasting less than 30 minutes, crepitus, and bony enlargement. X-ray findings include joint space narrowing, osteophytes, subchondral sclerosis, and subchondral cysts. NICE recommends core treatments for all patients: exercise, weight management, and written information. Pharmacological options: paracetamol is no longer recommended as a standalone treatment (evidence of limited benefit). Topical NSAIDs are first-line for hand and knee OA. Oral NSAIDs at the lowest effective dose for the shortest duration if topical treatment is insufficient. Intra-articular corticosteroid injections provide short-term relief. Joint replacement referral when symptoms significantly impair quality of life despite conservative management.

Rheumatoid arthritis presents with symmetrical small joint polyarthritis, morning stiffness lasting more than 30 minutes, and systemic symptoms. NICE recommends urgent referral if persistent synovitis (even in just one joint) lasting more than 6 weeks, or positive squeeze test of the MCP or MTP joints. Blood tests include RF, anti-CCP antibodies (more specific than RF), ESR, and CRP. Early aggressive treatment with DMARDs (methotrexate is first-line) improves long-term outcomes.

Osteoporosis assessment uses FRAX or QFracture tools. DEXA scan is the gold standard for diagnosis. T-score of -2.5 or below indicates osteoporosis. Treatment includes bisphosphonates (alendronate first-line), calcium and vitamin D supplementation, and lifestyle measures. Take alendronate on an empty stomach with plenty of water, remain upright for 30 minutes.

Gout presents with acute monoarthritis, typically affecting the first MTP joint. Serum urate may be normal during an acute attack. Acute treatment: NSAID or colchicine. Long-term urate-lowering therapy (allopurinol, started 2-4 weeks after acute attack resolves) is indicated after two or more attacks per year or if tophi, joint damage, or renal stones are present.