An Overview of MSK Management by Most Common Conditions

Global Pathologies[edit | edit source]

Osteoarthritis[edit | edit source]

Education regarding weight reduction and exercise;

Aids The provision of appropriate simple orthoses, aids and appliances to alleviate distress and disability;

A stick (of the right height, with a good ferrule and held in the hand on the opposite side of the worst affected hip or knee) can make a big difference by partly off-loading the arthritic joint.. Foot and ankle orthoses, such as shoe wedging or insoles can be hugely beneficial again by redistributing loading through affected joints15 . Braces or simple bandages applied to the knee can relieve pain and increase the sense of security walking

Exercise and Rehabilitation

If an individual has developed OA, it is still beneficial to them to keep fit and physically active, even though activity will cause pain. The idea that you can ‘wear out your joints’ through activity is a dangerous myth, which results in many people becoming inappropriately disabled to the detriment of their general health as well as their joints.

Formal, supervised programmes of physical therapy have been shown to be one of the most beneficial interventions that we have for established OA of the knee joints9 , and similar benefits probably accrue to people with hip disease. Trials have also shown that home-based exercise programmes are effective11-13 , particularly if supported and monitored

Rheumatoid Arthritis[edit | edit source]


Screen for those at greatest risk of loss of function, self-efficacy, physical and psychological status and pain;

Intensive co-ordinated in or day patient rehabilitation for people with active or severe RA;

People suspected of having RA should be seen by a Consultant Rheumatologist within 12 (preferably six) weeks of referral for diagnosis and to start Disease Modifying Anti-Rheumatic Drug (DMARD) therapy. DMARDs limit joint damage, maintain function and reduce later disability. Delaying DMARDs adversely affects functional outcome

Make best use of the MDT

A co-ordinated management programme, including patient education, joint protection training, exercise therapy, and appropriate provision of orthoses, mobility aids and environmental adaptations;

Behaviourally based interventions (ie including goal-setting, contracting and feedback) are significantly more effective in improving health status than information and/or counselling


Wrist splints reduce pain, improve grip and functional ability during wear Resting splints reduce pain at night. There is no evidence as yet that splinting maintains function long-term or prevents deformity.


Hand exercise (provided by both Occupational Therapist and Physiotherapist (PT)). Acombination of range of motion and strength exercises is more effective than range of motion or wax therapy alone in improving grip and pinch strength, reducing pain and maintaining hand function

Fibromyalgia and CRPS[edit | edit source]

In both fibromyalgia and CRPS, the severity of the disabling pain needs to be acknowledged

CRPS: strategies to alleviate pain are seldom effective long-term, but the use of local treatments eg regional nerve blocks, protective and/or off-loading orthoses, may facilitate commencing rehabilitation.

Cognitive behavioural therapy (CBT) combined with rehabilitation to promote independence and return to normal lifestyle are the mainstays of treatment.

Fibromyalgia: Initial management should include patient education supplemented by physiotherapy, particularly graded aerobic exercise programmes, CBT again plays a crucial role

These are conditions where success is probably more dependent on the interest and commitment of treating physiotherapists & other clinicians than their professional background and speciality.

Osteoporosis[edit | edit source]

Ensure high risk groups presenting with fractures are appropriately screened, and osteoporosis treatment initiated when indicated.

Adequate bone densitometry should be provided to ensure the screening of all high-risk groups.

Other secondary health problems associated with poor mobility such as thrombo-embolic disease and pressure sores need to be considered and appropriate preventative strategies introduced.

Local Conditions[edit | edit source]

Patients with ‘red flags’ denoting risk of serious underlying pathology should be given prompt access to appropriate investigations

Joint replacement surgery[edit | edit source]

Include a pre-operative assessment, and adequate provision of peri-operative and post-operative therapy. With current trends in sub-specialisation, orthopaedic correction for inflammatory polyarthritis can involve four or five different surgeons

Soft tissue problems[edit | edit source]

Triage & anti-inflammatory measures

After initial triage to identify those who may require immobilisation or surgical repair, PRICE (protection, rest, ice, compression, and elevation) should be used for the first 72 hours to alleviate early inflammation.


This needs to be followed by a carefully co-ordinated programme of rehabilitation, which encourages mobilisation and addresses risk factors (eg vulnerability to falls in the elderly), thus reducing the likelihood of chronicity.

As well as providing symptom relief, physiotherapy (and in some cases orthoses to stabilise unstable joints), the role of rehabilitation is to identify trigger situations and develop strategies to alter/reduce mechanical demands. This will usually involve task observation. Psychological actors and concerns, which might impede recovery, eg impact on income, will also need to be considered.

Spinal pain[edit | edit source]


Those with acute spinal pain need adequate pain relief and advice to keep as active as possible.

For those with subacute or chronic pain, rehabilitation should include postural re-education, a graded exercise programme, and access to psychological interventions including cognitive behavioural therapy and vocational rehabilitation.

Acute Back Pain:

Pain Management

Good evidence supports the use of non-steroidal anti-inflammatory drugs (NSAIDs) and analgesics. Reasonable evidence supports the use of muscle relaxants to facilitate activity 10 and use of manual therapy or manipulation in acute low back pain 11, 12 . There is inconsistent evidence that specific exercise programmes are better than advice to simply keep active11,13 . Evidence does not support the use of acupuncture 14 or transcutaneous electrical nerve stimulation (TENS)15

Act early

Early physiotherapy, including education and activity for acute episodes of back pain (seen within three days instead of ten) has shown that 57% of patients returned to work within ten days compared with 36% of the control group 16 . The risk of developing chronic pain was eight times lower for patients in the early intervention group, with only 2% remaining out of work at seven month follow-up 16 compared with 15% in the other group.

Subacute Back Pain (10 days to 3 months):

Multimodal approach

Strong evidence supports multidisciplinary rehabilitation approaches and exercises7 , manipulation and manual therapy 13 and muscle relaxants if clear evidence of muscle spasm is found on examination 10 . Workplace visits increase the effectiveness of rehabilitation 7 . There is inconsistent evidence to support massage.

Address cognitive factors

Patients attitudes and beliefs about back pain, behaviours, compensation and emotional issues can be noted early during the subacute period 7, 19 . Psychological factors may inhibit resolution of symptoms. These ‘yellow flags’ are amenable to psychological or psychiatric intervention.

Prevent chronicity

Delays in obtaining specialist advice contribute to non-resolution of acute/subacute back pain, increasing the risk of pain becoming intractable. This is costly for employers and the state20 .

Multi-professional integrated programs within three months can abort this process

Chronic Back Pain:


Exercise regimes aim to increase range of movement, strengthen muscles, stretch tightened structures or toughen up physically and mentally. Exercises combined with behavioural methods are more effective than exercise alone at reducing sickness behaviour and getting people back to work quicker 21,22 .

Intensive outpatient physical retraining consisting of pain relief and mobilisation, increasing movement and muscle strengthening and work conditioning reduces sickness absence. In North America, health care costs were offset by savings in ‘wages loss cost’

Manual therapy

Manual therapy including manipulation is effective in reducing chronic pain 13 .

There is inconsistent evidence to support the use of lumbar corsets 24 .


Outcome is enhanced if workplace visits are performed 7 . There is no evidence that analgesia or NSAIDs give benefit beyond short-term symptom relief. There is inconsistent evidence to support the use of tricyclic antidepressants

Ankle and Neck[edit | edit source]

Most common sites of soft tissue injury are the ankle (5,000 per day in UK), and neck (nearly 700 per day).

Risk of chronicity

Whilst spontaneous recovery is to be expected in the majority of cases, a minority (e.g. secondary to ankle instability) will have persistent or recurrent problems leading to pain and disability, often affecting work and lifestyle.

Shoulder problems[edit | edit source]


Patients with complete rotator cuff tears or other significant underlying (rheumatological or neurological) problems need referral for investigation and/or surgery.

Some 40-50% have persistent pain and disability. Of greatest concern is when aspects of personal care could be hampered. These aspects require early recognition and intervention, if necessary, with aids as well as home and/or workplace adaptations.