EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are your differential diagnoses for James’ symptoms?

• Prompt: What is the most likely diagnosis and why?
• Prompt: What alternative conditions should be considered?

Q2. What red flags would indicate the need for urgent referral or further investigations?

• Prompt: What findings would suggest a serious knee injury requiring orthopaedic assessment?
• Prompt: What initial investigations would you consider?

Q3. How would you manage James’ condition?

• Prompt: What acute management strategies would you implement?
• Prompt: When would imaging or specialist referral be necessary?

Q4. James is worried about returning to soccer. How would you counsel him?

• Prompt: What is the expected recovery timeline for his injury?
• Prompt: What rehabilitation strategies are important for optimising recovery?

Q5. What preventive strategies can James implement to reduce his risk of future knee injuries?

• Prompt: What role do strength training and proprioception exercises play?
• Prompt: How can sport-specific modifications help prevent re-injury?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What are your differential diagnoses for James’ symptoms?

James’ most likely diagnosis is anterior cruciate ligament (ACL) rupture, given the history of twisting injury, popping sensation, immediate swelling, and positive Lachman’s and anterior drawer tests.

Key Differential Diagnoses:

1. ACL Tear (Most Likely) – Sudden twisting mechanism, pop sound, immediate swelling, and positive Lachman’s test.
2. Meniscal Tear – Pain with twisting, intermittent locking, joint-line tenderness, and positive McMurray’s test.
3. Medial Collateral Ligament (MCL) Injury – Medial knee pain and instability, often with valgus stress injury.
4. Patellar Dislocation/Subluxation – Acute lateral displacement, pain, and positive patellar apprehension test.
5. Tibial Plateau Fracture – Requires X-ray or CT, consider if severe pain, bony tenderness, or inability to bear weight.

Further assessment, including imaging, will confirm the diagnosis and guide management.

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Q2: What red flags would indicate the need for urgent referral or further investigations?

Red flags requiring urgent orthopaedic referral:

• Suspected fractures – Severe bony tenderness, gross deformity, or inability to bear weight.
• Neurovascular compromise – Absent pulses, cold limb, or sensory loss.
• Severe instability or mechanical symptoms – Suggests multiple ligament injury or meniscal entrapment.
• Persistent knee effusion (>24–48 hours) – Concern for haemarthrosis or joint infection.

Recommended Investigations:

• X-ray Knee (AP/Lateral/Sunrise views) – To exclude fractures.
• MRI Knee – Gold standard for assessing ACL, meniscus, and ligamentous injuries.
• Joint Aspiration (if haemarthrosis present) – Assess for fat globules (fracture) or infection.

Timely imaging and referral are crucial to prevent long-term knee instability or osteoarthritis.

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Q3: How would you manage James’ condition?

Acute Management (RICE + Analgesia):

• Rest – Avoid weight-bearing, use crutches if needed.
• Ice & Compression – Reduce swelling.
• Elevation – To minimise oedema.
• NSAIDs (e.g., ibuprofen 400mg TDS) – For pain relief.

Immobilisation & Referral:

• Knee brace or hinged knee support for initial stability.
• Urgent orthopaedic referral for MRI and surgical consideration.

Rehabilitation:

• Physiotherapy-led strengthening of quadriceps, hamstrings, and proprioception training.
• Surgical vs Non-Surgical Management:
  • ACL reconstruction is recommended for young active individuals.
  • Non-surgical options for low-demand patients include bracing and physiotherapy.

Regular follow-up is needed to monitor recovery and return to sport.

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Q4: James is worried about returning to soccer. How would you counsel him?

1. Acknowledge Concerns & Set Expectations
   • “ACL injuries are common in athletes, but with proper treatment and rehab, most people return to sport.”
2. Recovery Timeline
   • Non-surgical rehab: ~6–9 months for stability improvement.
   • Surgical ACL reconstruction: Full return to high-impact sport ~9–12 months.
3. Rehabilitation Plan
   • Early range of motion exercises, followed by progressive strength training.
   • Proprioception and agility training to prevent re-injury.
4. Re-injury Prevention & Monitoring
   • Knee bracing initially, sport-specific drills, and graded return to training.
   • Regular physiotherapy and orthopaedic follow-up.

Most athletes resume full activity within a year with proper adherence to rehabilitation.

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Q5: What preventive strategies can James implement to reduce his risk of future knee injuries?

1. Strength Training & Conditioning:
   • Quadriceps & hamstring strengthening improves knee stability.
   • Core and hip stabilisation exercises reduce stress on the knee.
2. Proprioceptive & Neuromuscular Training:
   • Balance drills and plyometrics reduce ACL re-injury risk.
   • Sport-specific agility training (e.g., FIFA 11+ program for soccer players).
3. Biomechanical Optimisation:
   • Correct landing techniques (knee alignment, avoiding valgus stress).
   • Footwear & orthotic support if required.
4. Appropriate Warm-Up & Recovery:
   • Dynamic warm-up before sports.
   • Gradual return to sport post-injury.

A structured injury prevention program can significantly reduce ACL injuries in athletes.

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SUMMARY OF A COMPETENT ANSWER

• Comprehensive differential diagnosis, distinguishing ACL rupture, meniscal injury, and fractures.
• Identification of red flags, requiring urgent imaging and orthopaedic referral.
• Structured evidence-based management plan, including acute stabilisation, analgesia, and referral.
• Clear patient-centred counselling, addressing return-to-sport expectations and rehabilitation.
• Preventive strategies, focusing on strength, proprioception, and sport-specific training.

PITFALLS

• Failing to assess for fractures, leading to missed tibial plateau fractures.
• Not recognising red flags, delaying urgent referral for surgical management.
• Inadequate pain and swelling control, affecting early rehabilitation.
• Providing unrealistic return-to-sport timelines, leading to poor adherence to rehab.
• Neglecting long-term prevention strategies, increasing risk of re-injury.

REFERENCES

• RACGP – RACGP Guidelines for Musculoskeletal Injuries
• GP Exams – Acute internal damage knee

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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 Takes a detailed history to assess mechanism of injury and functional impact.
1.2 Provides clear explanations of diagnosis, treatment options, and prognosis.

2. Clinical Information Gathering and Interpretation

2.1 Performs a structured knee examination.
2.2 Identifies red flags suggesting fractures or neurovascular compromise.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between common knee injuries.
3.2 Determines when imaging or specialist referral is required.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an initial management plan, including immobilisation, physiotherapy, and analgesia.
4.2 Identifies cases requiring urgent orthopaedic review or surgical intervention.

5. Preventive and Population Health

5.1 Provides advice on injury prevention and rehabilitation strategies.

6. Professionalism

6.1 Provides empathetic care, acknowledging the impact of the injury on daily life and sport participation.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate documentation and follow-up for acute knee injuries.

9. Managing Uncertainty

9.1 Recognises when specialist referral is warranted.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies serious complications requiring urgent intervention.

Competency at Fellowship Level

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