CCE-CE-075

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, including onset, severity, risk factors, functional limitations, and red flags for serious pathology.

The competent candidate should:

• Obtain a detailed history, including:
  • Onset and progression (gradual, no specific injury).
  • Symptoms (pain over the top and outer shoulder, aggravated by overhead activities, reaching behind the back).
  • Functional limitations (difficulty sleeping on affected side, reduced range of motion).
  • Impact on work and activities (manual labourer, unable to lift properly).
  • Self-management attempts (occasional ibuprofen, heat, resting).
• Screen for red flags, including:
  • Severe night pain unrelieved by rest (concern for malignancy or inflammatory arthritis).
  • Numbness, tingling, weakness (possible nerve involvement).
  • History of trauma or systemic illness (fractures, referred pain from cardiac or abdominal pathology).

Task 2: Conduct a clinical assessment to differentiate between common causes of shoulder pain and determine if investigations are needed.

The competent candidate should:

• Consider the most likely diagnoses:
  • Rotator cuff tendinopathy/impingement (most likely, given repetitive overhead use, pain with abduction).
  • Adhesive capsulitis (if significant stiffness with global movement restriction).
  • Osteoarthritis (if gradual progression, crepitus, morning stiffness).
  • Referred pain (if systemic features, cardiac history, or liver disease present).
• Assess whether imaging is needed:
  • Ultrasound if rotator cuff pathology suspected.
  • X-ray if considering arthritis or bony abnormalities.
  • MRI if severe symptoms or concern for a full-thickness rotator cuff tear.
• Determine if referral is necessary:
  • To physiotherapy for rehabilitation and strengthening.
  • To orthopaedics if symptoms persist despite conservative management.

Task 3: Provide a diagnosis and discuss an initial management plan, including pain relief, physiotherapy, lifestyle modifications, and follow-up.

The competent candidate should:

• Explain the likely diagnosis:
  • “Your symptoms suggest a rotator cuff tendinopathy, which is a common overuse injury of the shoulder muscles.”
  • “The good news is that most cases improve with conservative treatment.”
• Management plan:
  • Pain relief:
    • First-line: NSAIDs (e.g., ibuprofen, naproxen, topical NSAIDs).
    • Paracetamol as an alternative or adjunct.
    • Consider corticosteroid injection if severe.
  • Physiotherapy:
    • Shoulder strengthening and stretching exercises.
    • Postural and ergonomic adjustments at work.
  • Activity modification:
    • Avoid heavy lifting and repetitive overhead movements.
    • Gradual return to activity.
• Follow-up plan:
  • Review in 4-6 weeks to assess progress.
  • Refer to orthopaedics if no improvement despite treatment.

Task 4: Educate the patient on expected prognosis, self-care strategies, and when to seek further medical attention.

The competent candidate should:

• Explain prognosis:
  • “Most cases improve within 6-12 weeks with the right treatment.”
  • “It’s important to keep moving the shoulder to prevent stiffness.”
• Self-care strategies:
  • Daily shoulder exercises and stretches.
  • Use of ice or heat packs as needed.
  • Avoiding activities that exacerbate symptoms.
• Safety-netting:
  • “If you experience worsening pain, weakness, or inability to move your shoulder, please return for reassessment.”

SUMMARY OF A COMPETENT ANSWER

• Takes a comprehensive history, identifying functional limitations and red flags.
• Differentiates between common causes of shoulder pain and determines if imaging is needed.
• Provides a structured management plan, including pain relief, physiotherapy, and workplace modifications.
• Educates on prognosis, preventive strategies, and self-care.
• Provides clear safety-netting advice for worsening symptoms.

PITFALLS

• Failing to consider red flags, such as severe night pain, neurological symptoms, or systemic illness.
• Over-relying on imaging instead of clinical assessment and conservative management.
• Not addressing workplace modifications, leading to continued aggravation of symptoms.
• Dismissing patient concerns about surgery, instead of explaining when it may or may not be needed.
• Lack of follow-up planning, missing the opportunity to reassess and escalate care if needed.

REFERENCES

• RACGP Guidelines for Musculoskeletal Conditions
• Science Direct on Shoulder Pain Management
• Better Health Channel on Shoulder Impingement and Rotator Cuff Injuries
• Australian Physiotherapy Association on Shoulder Pain and Rehabilitation
• GP Exams – Shoulder syndrome

MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Communication is appropriate to the person and the sociocultural context.
1.2 Engages the patient to gather information about their symptoms, ideas, concerns, expectations of healthcare and the full impact of their illness experience on their lives.
1.3 Provides clear and structured explanations about diagnosis, prognosis, and management.

2. Clinical Information Gathering and Interpretation

2.1 Takes a structured history, including symptom onset, progression, and impact on function.
2.2 Conducts a focused musculoskeletal examination to differentiate between possible causes.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between common shoulder conditions (e.g., rotator cuff tendinopathy, adhesive capsulitis, osteoarthritis).
3.2 Identifies when further investigations (e.g., imaging, specialist referral) are required.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides an evidence-based treatment plan, including pain management and physiotherapy.
4.2 Educates the patient on prognosis, recovery expectations, and self-management strategies.

5. Preventive and Population Health

5.1 Identifies risk factors for chronic shoulder pain and dysfunction.
5.2 Encourages strategies to prevent recurrence and long-term complications.

6. Professionalism

6.1 Demonstrates empathy and a patient-centred approach.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate documentation and follow-up for unresolved symptoms.

8. Procedural Skills

8.1 Identifies when corticosteroid injection or other procedures may be indicated.

9. Managing Uncertainty

9.1 Recognises when to observe, investigate, or refer for specialist opinion.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies serious shoulder conditions requiring urgent intervention.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD