CASE INFORMATION

Case ID: MSK-008
Case Name: Daniel Carter
Age: 38
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: L81 (Injury Musculoskeletal NOS)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Engages the patient effectively to obtain a clear history of the injury 1.3 Provides clear explanations of the diagnosis, investigations, and treatment options
2. Clinical Information Gathering and Interpretation	2.1 Conducts a thorough musculoskeletal examination 2.3 Identifies red flag symptoms that may indicate serious injury (e.g., fractures, ligament tears)
3. Diagnosis, Decision-Making and Reasoning	3.1 Accurately diagnoses common musculoskeletal injuries 3.3 Determines when imaging or specialist referral is required
4. Clinical Management and Therapeutic Reasoning	4.1 Provides initial pain management and functional rehabilitation advice 4.4 Develops an appropriate return-to-activity plan
5. Preventive and Population Health	5.1 Provides education on injury prevention and strengthening exercises
6. Professionalism	6.2 Ensures patient-centred care with shared decision-making
7. General Practice Systems and Regulatory Requirements	7.1 Provides appropriate documentation for work or sports-related injuries
8. Procedural Skills	8.2 Performs appropriate bedside tests (e.g., Ottawa Ankle Rules, Lachman’s test)
9. Managing Uncertainty	9.1 Recognises when delayed diagnosis or referral may be necessary
10. Identifying and Managing the Patient with Significant Illness	10.2 Recognises complications such as chronic pain or post-injury stiffness

CASE FEATURES

Adult male presenting with acute knee pain after a recreational sports injury
Concerned about potential ligament or meniscus injury
Needs assessment, pain management, and return-to-activity advice
Determining whether imaging or specialist referral is required
Providing injury prevention strategies to reduce recurrence

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 for each question will be managed by the examiner.

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: Daniel Carter
Age: 38
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Nil regular medications

Past History

Mild knee sprain 5 years ago (resolved with physiotherapy)
No prior fractures or ligament injuries

Social History

Works full-time as an electrician, physically demanding job
Plays recreational soccer on weekends
Active lifestyle, regular gym workouts

Presenting Symptoms

Acute right knee pain after twisting injury while playing soccer
Felt a “pop” sensation, followed by swelling and difficulty weight-bearing
No numbness or tingling in the lower limb

Examination Findings

Moderate knee swelling and joint effusion
Pain on palpation of medial joint line
Lachman’s test: Mild laxity (suggestive of ACL injury)
McMurray’s test: Positive for medial meniscus irritation
No bony tenderness or signs of fracture

INVESTIGATION FINDINGS

X-ray knee: No fractures or bony abnormalities
MRI knee: Pending (GP to determine necessity)

SCENARIO

Daniel Carter, a 38-year-old electrician, presents with acute right knee pain following a twisting injury during soccer. He recalls a “popping” sensation and developed immediate swelling. He is concerned about a ligament or meniscus injury and wants advice on management and return to sport.

On examination, there is moderate swelling, medial joint line tenderness, and mild knee instability. Special tests suggest possible ACL and medial meniscus involvement.

An X-ray has ruled out a fracture, but Daniel is uncertain whether an MRI is needed. He is keen to recover quickly for work and sport.

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. How would you assess Daniel’s knee injury and determine the likely diagnosis?

Prompt: What key aspects of history and examination are important?
Prompt: What clinical tests help differentiate knee injuries?

Q2. What is your initial management plan for Daniel?

Prompt: What are the key components of acute injury management?
Prompt: When would you consider imaging such as MRI?

Q3. How would you counsel Daniel about return to work and sport?

Prompt: What factors determine readiness to return?
Prompt: How can he reduce the risk of reinjury?

Q4. When would you refer Daniel to a specialist?

Prompt: What injuries require orthopaedic review?
Prompt: What role does physiotherapy play in recovery?

Q5. What injury prevention strategies would you discuss with Daniel?

Prompt: How can he modify training to avoid future injuries?
Prompt: What strengthening exercises are beneficial for knee stability?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: How would you assess Daniel’s knee injury and determine the likely diagnosis?

Daniel presents with acute right knee pain following a twisting injury while playing soccer. A structured approach includes history, examination, and bedside tests.

1. History

Mechanism of injury – twisting, direct blow, hyperextension
Immediate symptoms – pain, swelling, instability, clicking
Weight-bearing status – ability to walk after injury
Popping sound – suggests ACL injury
Previous injuries – past knee issues affecting stability

2. Examination

Inspection – swelling, bruising, deformity
Palpation – medial joint line tenderness (meniscus involvement)
Range of motion – painful or restricted flexion/extension
Special tests:
- Lachman’s test – mild laxity suggests ACL injury
- McMurray’s test – medial meniscus irritation

3. Differential Diagnosis

ACL tear – common with popping sound, swelling, instability
Meniscus tear – joint line tenderness, positive McMurray’s test
MCL sprain – medial knee tenderness
Patellar dislocation – would expect lateral displacement, apprehension sign

A combination of history and examination suggests ACL and meniscus involvement.

Q2: What is your initial management plan for Daniel?

1. Acute Injury Management (RICE Protocol)

Rest – avoid aggravating activities
Ice – reduces swelling
Compression – knee brace for support
Elevation – aids in reducing swelling

2. Pain Management

Paracetamol and NSAIDs
Consider crutches for non-weight-bearing support

3. Indications for Imaging

X-ray (already done) – ruled out fracture
MRI (next step) – indicated due to suspected ACL and meniscus injury

4. Short-Term Plan

Referral to physiotherapy for strength and stability
Reassess in 1-2 weeks if symptoms persist

Early conservative management supports healing and function.

Q3: How would you counsel Daniel about return to work and sport?

1. Return to Work

Office duties may be possible if non-weight-bearing
Physically demanding tasks may require modification
Review in 2-4 weeks to reassess work capabilities

2. Return to Sport

Depends on severity of ligament injury
Physiotherapy-led rehabilitation essential
If ACL tear confirmed – may require 6-12 months post-surgical rehab

3. Reducing Reinjury Risk

Progressive strengthening (quadriceps, hamstrings)
Neuromuscular training (balance, agility drills)

A stepwise return ensures optimal knee function and prevents reinjury.

Q4: When would you refer Daniel to a specialist?

1. Orthopaedic Referral Indications

Complete ACL rupture (confirmed on MRI)
Meniscal tear with persistent symptoms
Failure to improve with conservative management

2. Role of Physiotherapy

Essential for conservative ACL management or post-op rehab
Aids in restoring knee stability and function

A multidisciplinary approach ensures optimal recovery.

Q5: What injury prevention strategies would you discuss with Daniel?

1. Warm-up and Strengthening

Dynamic warm-ups before sport
Strength training – quadriceps, hamstrings, core stability

2. Neuromuscular Training

Balance and proprioception drills
Agility exercises to improve knee control

3. Protective Equipment

Knee bracing (if high risk of reinjury)
Proper footwear for support

A preventative program reduces the likelihood of future knee injuries.

SUMMARY OF A COMPETENT ANSWER

Conducts thorough history and examination to diagnose ACL and meniscus involvement
Implements acute injury management with RICE and pain relief
Determines MRI necessity based on clinical findings
Provides clear guidance on return to work and sport
Refers appropriately to orthopaedics and physiotherapy for long-term management
Educates on injury prevention strategies

PITFALLS

Failing to perform special tests (Lachman’s, McMurray’s) to assess ligament and meniscus injuries
Ordering unnecessary imaging without clinical indications
Not considering physiotherapy as a first-line rehabilitation strategy
Providing unrealistic return-to-sport expectations without proper rehab
Overlooking injury prevention strategies in high-risk sports

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

1. Communication and Consultation Skills

1.1 Engages the patient effectively to obtain a clear history of the injury.
1.3 Provides clear explanations of the diagnosis, investigations, and treatment options.

2. Clinical Information Gathering and Interpretation

2.1 Conducts a thorough musculoskeletal examination.
2.3 Identifies red flag symptoms that may indicate serious injury (e.g., fractures, ligament tears).

3. Diagnosis, Decision-Making and Reasoning

3.1 Accurately diagnoses common musculoskeletal injuries.
3.3 Determines when imaging or specialist referral is required.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides initial pain management and functional rehabilitation advice.
4.4 Develops an appropriate return-to-activity plan.

5. Preventive and Population Health

5.1 Provides education on injury prevention and strengthening exercises.

6. Professionalism

6.2 Ensures patient-centred care with shared decision-making.

7. General Practice Systems and Regulatory Requirements

7.1 Provides appropriate documentation for work or sports-related injuries.

8. Procedural Skills

8.2 Performs appropriate bedside tests (e.g., Ottawa Ankle Rules, Lachman’s test).

9. Managing Uncertainty

9.1 Recognises when delayed diagnosis or referral may be necessary.

10. Identifying and Managing the Patient with Significant Illness

10.2 Recognises complications such as chronic pain or post-injury stiffness.

Competency at Fellowship Level

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