CASE INFORMATION

Case ID: MSK-2025-002
Case Name: Peter Thompson
Age: 45
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: L92 (Bursitis/tendonitis/synovitis NOS)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Establishes rapport and communicates effectively 1.2 Elicits patient’s concerns and expectations 1.5 Provides clear and tailored health education
2. Clinical Information Gathering and Interpretation	2.1 Obtains a thorough history including functional impact 2.3 Performs a targeted musculoskeletal examination 2.4 Orders and interprets appropriate investigations
3. Diagnosis, Decision-Making and Reasoning	3.2 Forms a working diagnosis based on clinical findings 3.4 Identifies red flags requiring urgent intervention
4. Clinical Management and Therapeutic Reasoning	4.1 Provides evidence-based management plan 4.4 Prescribes appropriate pharmacological and non-pharmacological treatments 4.6 Advises on activity modification and rehabilitation
5. Preventive and Population Health	5.1 Implements strategies to prevent recurrence of tendon/bursal injuries
6. Professionalism	6.2 Demonstrates patient-centred care and shared decision-making
7. General Practice Systems and Regulatory Requirements	7.1 Documents consultation and investigation results appropriately
9. Managing Uncertainty	9.1 Considers differential diagnoses and treatment response
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises when referral to a specialist is warranted

CASE FEATURES

Middle-aged male presenting with gradual onset of shoulder pain affecting daily activities.
History of repetitive overhead movements at work (electrician).
No history of trauma but reports pain worsening over the last 6 weeks.
Functional limitation in lifting and reaching.
Key differential diagnoses: subacromial bursitis, rotator cuff tendinopathy, adhesive capsulitis.
Discussion on conservative vs. interventional management options.

INSTRUCTIONS

Review the following patient record summary and scenario.

Your examiner will ask you a series of questions based on this information.

You have 15 minutes to complete this case.

The time allocation for each question is roughly as follows:

Question 1 – 3 minutes
Question 2 – 3 minutes
Question 3 – 3 minutes
Question 4 – 3 minutes
Question 5 – 3 minutes

PATIENT RECORD SUMMARY

Patient Details

Name: Peter Thompson
Age: 45
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

No known drug allergies

Medications

Occasional paracetamol and ibuprofen for pain relief.

Past History

No prior musculoskeletal injuries.
No history of inflammatory arthritis.

Social History

Works as an electrician, frequently using his arms overhead.
Enjoys tennis on weekends, but has stopped due to pain.
Non-smoker, consumes 5-6 standard drinks per week.

Family History

No known family history of rheumatoid arthritis or other autoimmune diseases.

Smoking

Non-smoker.

Alcohol

5-6 standard drinks per week.

Vaccination and Preventative Activities

Up to date with influenza and tetanus vaccinations.

SCENARIO

Peter Thompson, a 45-year-old electrician, presents with a 6-week history of right shoulder pain. He reports a gradual onset, with no specific trauma. The pain is worse with overhead activities and is now affecting his work, sleep, and recreational activities.

He has tried paracetamol and ibuprofen, with some relief, but the pain persists. He denies weakness, fever, or systemic symptoms. He is worried about long-term disability and whether he needs imaging or injections.

EXAMINATION FINDINGS

General Appearance: Well, no distress.
Inspection: No swelling, redness, or deformity.
Palpation: Tenderness over subacromial space and lateral deltoid.
Range of Motion:

Active abduction limited to 80° due to pain.
Painful arc between 60°–120°.
External rotation limited.
Full passive range of motion (suggests tendinopathy rather than adhesive capsulitis).

Special Tests:

Positive Hawkins-Kennedy and Neer impingement tests.
Negative drop arm test (suggests no full-thickness tear).

INVESTIGATION FINDINGS

X-ray Shoulder:

No fractures or dislocations.
Mild subacromial space narrowing.

Ultrasound Shoulder (if ordered):

Thickened subacromial bursa.
Mild supraspinatus tendinosis, no full-thickness tear.

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What key aspects of history would you explore further to refine your diagnosis?

Prompt: Ask about occupational demands, daily functional limitations, and aggravating movements.
Prompt: Explore red flag symptoms (e.g., night pain, constitutional symptoms, acute trauma).

Q2. What are the most likely diagnoses, and what features support your conclusion?

Prompt: Explain why subacromial bursitis and rotator cuff tendinopathy are likely.
Prompt: Justify why adhesive capsulitis or inflammatory arthritis are less likely.

Q3. What are your initial management steps for Peter?

Prompt: Address pain management (oral NSAIDs, ice, physiotherapy referral).
Prompt: Discuss activity modification and ergonomic adjustments at work.

Q4. When would you consider imaging, injections, or referral?

Prompt: Explain when ultrasound-guided corticosteroid injection is appropriate.
Prompt: Indicate when MRI or referral to an orthopaedic specialist is needed.

Q5. How would you counsel Peter about his prognosis and prevention strategies?

Prompt: Reassure about natural course and recovery time.
Prompt: Advise on rehabilitation exercises and gradual return to activity.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What key aspects of history would you explore further to refine your diagnosis?

A thorough history is essential to differentiate bursitis, tendonitis, and synovitis from other shoulder pathologies. The candidate should systematically explore the following:

1. Symptom Onset and Progression

Timeframe: Confirm the gradual onset over six weeks and assess any previous episodes.
Precipitating Factors: Identify if work-related activities (e.g., overhead tasks, repetitive use) or sporting activities contributed.
Pain Characteristics:
- Location: Is it localised over the subacromial region, lateral shoulder, or anterior shoulder?
- Type: Is it dull, aching, sharp, or burning?
- Radiation: Any pain extending to the arm, neck, or scapula?
- Night pain: Is the pain worsened at night or affecting sleep?

2. Functional Impairment

Impact on daily activities: Difficulty in reaching overhead, dressing, or carrying objects?
Work limitations: Assess impact on his job as an electrician.
Effect on sports: Has he stopped playing tennis due to pain?

3. Aggravating and Relieving Factors

Movements that worsen pain: Overhead reaching, lifting, or specific shoulder positions.
Rest improvement: Does immobilisation relieve pain, or is it persistent?
Response to analgesia: Has paracetamol or NSAIDs provided relief?

4. Red Flags for Alternative Diagnoses

Neurological symptoms: Numbness, tingling, or weakness suggesting cervical radiculopathy.
Systemic symptoms: Weight loss, fevers, night sweats (infection, malignancy, inflammatory arthritis).
Acute trauma: Falls or injuries suggesting fractures, dislocations, or rotator cuff tears.

5. Past Medical History

Previous shoulder conditions: Any prior bursitis, rotator cuff pathology, or frozen shoulder?
Autoimmune conditions: History of rheumatoid arthritis or psoriatic arthritis?
Diabetes: Higher risk of adhesive capsulitis.

A structured history allows differentiation between bursitis, tendinopathy, adhesive capsulitis, and inflammatory conditions, guiding appropriate investigation and management.

Q2: What are the most likely diagnoses, and what features support your conclusion?

Peter’s presentation is most consistent with subacromial bursitis and rotator cuff tendinopathy. The supporting clinical features are:

1. Subacromial Bursitis

Gradual onset, worsening over six weeks.
Pain with overhead activities.
Tenderness over subacromial space.
Positive Hawkins-Kennedy and Neer impingement tests.
Ultrasound: Thickened bursa, no tear.

2. Rotator Cuff Tendinopathy (Supraspinatus)

Painful arc (60°–120°) suggests supraspinatus involvement.
No weakness on testing (rules out full-thickness tear).
Repetitive use as an electrician contributes to chronic tendinopathy.

Differential Diagnoses and Why They Are Less Likely

Adhesive Capsulitis: Would cause progressive stiffness and reduced passive range of motion.
Inflammatory Arthritis: No bilateral joint pain, swelling, or systemic symptoms.
Rotator Cuff Tear: No sudden weakness, trauma, or positive drop-arm test.

The history and examination findings strongly suggest subacromial bursitis with associated rotator cuff tendinopathy.

Q3: What are your initial management steps for Peter?

1. Pain Management

First-line: NSAIDs (e.g., naproxen 500 mg BD) for 2–4 weeks.
Paracetamol PRN if NSAIDs are contraindicated.

2. Activity Modification

Avoid aggravating movements, particularly overhead activities.
Ergonomic workplace adjustments (e.g., repositioning work setup).

3. Physiotherapy Referral

Rotator cuff strengthening exercises to reduce impingement.
Postural correction and scapular stabilisation.
Range of motion exercises to prevent stiffness.

4. Ice and Heat Therapy

Ice packs for acute inflammation.
Heat therapy before movement to improve flexibility.

5. Education and Reassurance

Explain the benign nature and favourable prognosis.
Emphasise the importance of gradual return to activity.

Q4: When would you consider imaging, injections, or referral?

1. Imaging

Ultrasound if symptoms persist beyond 6–8 weeks despite conservative therapy.
MRI if concern for rotator cuff tear.

2. Corticosteroid Injection

Consider subacromial corticosteroid injection if:
- Pain remains severe despite NSAIDs and physiotherapy.
- Functional impairment is significant.

3. Specialist Referral

Orthopaedic or sports physician referral if:
- Persistent symptoms beyond 3–6 months.
- Suspected full-thickness tear.
- Suspected adhesive capsulitis requiring hydrodilatation.

Q5: How would you counsel Peter about his prognosis and prevention strategies?

1. Prognosis

Most cases resolve within 3–6 months with conservative care.
Recurrence risk is high if risk factors (e.g., repetitive strain, poor posture) are not addressed.

2. Preventive Strategies

Shoulder-strengthening program to prevent impingement.
Workplace ergonomics: Modify overhead tasks.
Gradual return to activity: Avoid sudden increases in workload.
Stretching and warm-up before sports.

Educating Peter about realistic recovery expectations and prevention ensures long-term shoulder health.

SUMMARY OF A COMPETENT ANSWER

Detailed history-taking, including functional impairment and red flags.
Correct identification of bursitis/tendinopathy and exclusion of alternative diagnoses.
Evidence-based management, including pain relief, physiotherapy, and activity modification.
Appropriate use of imaging and injections, avoiding overuse of investigations.
Clear patient education on prognosis and prevention strategies.

PITFALLS

Failing to assess functional impact on work and activities.
Misdiagnosing adhesive capsulitis (not considering passive ROM).
Over-relying on imaging before trialling conservative therapy.
Inappropriate use of corticosteroid injections as first-line.
Not addressing ergonomic and lifestyle modifications.

REFERENCES

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

Competency at Fellowship Level

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