EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are your differential diagnoses for David’s knee pain?

• 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 symptoms or signs would suggest an urgent or serious knee pathology?
• Prompt: What initial investigations would you consider?

Q3. How would you manage David’s condition?

• Prompt: What conservative measures would you recommend?
• Prompt: When would pharmacological therapy or referral be appropriate?

Q4. David is worried about needing surgery in the future. How would you counsel him?

• Prompt: What factors determine the need for surgery?
• Prompt: What role does non-surgical management play in long-term knee health?

Q5. What preventive strategies can David implement to maintain knee function and prevent worsening symptoms?

• Prompt: What lifestyle modifications can help?
• Prompt: What role does physiotherapy play in knee pain management?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What are your differential diagnoses for David’s knee pain?

David’s most likely diagnosis is early knee osteoarthritis (OA) given his gradual onset of pain, morning stiffness, crepitus, mild effusion, and worsening symptoms with activity. His risk factors include obesity, occupational strain, and family history of knee OA.

Key Differential Diagnoses:

1. Knee Osteoarthritis (OA) – Insidious onset, worsens with weight-bearing, crepitus, and morning stiffness <30 minutes.
2. Meniscal Injury – Locking, catching, joint line tenderness, positive McMurray’s test.
3. Patellofemoral Pain Syndrome – Pain with prolonged sitting, stair climbing, positive patellar grind test.
4. Inflammatory Arthritis (e.g., Rheumatoid Arthritis, Gout) – Consider if prolonged morning stiffness >60 minutes, symmetrical joint involvement, or acute swelling with erythema.
5. Septic Arthritis – Red flag if acute swelling, fever, significant warmth, or systemic symptoms.

Further assessment, including history, examination, and targeted investigations, will guide diagnosis.

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

Red flags requiring urgent referral or imaging:

• Severe joint swelling, erythema, or warmth – Concern for septic arthritis or inflammatory arthritis.
• Fever, malaise, or night pain – Consider infection or malignancy.
• Acute locking, catching, or instability – Suggests significant meniscal or ligamentous injury.
• Sudden-onset severe pain with inability to bear weight – Consider fracture or avascular necrosis.

Investigations to consider:

• X-ray Knee (Weight-bearing, AP/Lateral/Sunrise views) – Assess for OA changes, fractures, or patellofemoral abnormalities.
• CRP & ESR – If inflammatory arthritis is suspected.
• Joint Aspiration (if effusion present with red flags) – Assess for infection or crystal arthritis (gout/pseudogout).

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Q3: How would you manage David’s condition?

Lifestyle and Non-Pharmacological Management:

• Weight loss – Reduces knee load and slows OA progression.
• Exercise therapy (Physiotherapy-led program) – Strengthening quadriceps, low-impact activities (e.g., swimming, cycling).
• Activity modification – Avoid prolonged standing, consider knee support for work.
• Heat or ice therapy – Symptom relief.

Pharmacological Therapy (if needed):

• Paracetamol 1g PRN – First-line for mild symptoms.
• NSAIDs (e.g., ibuprofen, celecoxib) – If no contraindications, short-term use.
• Intra-articular corticosteroid injection – For significant flares.

Referral Considerations:

• Physiotherapy referral – Essential for exercise-based management.
• Orthopaedic referral – If symptoms progress despite optimal conservative therapy or significant structural damage on imaging.

Regular follow-up is needed to monitor symptoms and adjust treatment.

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Q4: David is worried about needing surgery in the future. How would you counsel him?

1. Acknowledge Concerns & Set Expectations
   • “Knee osteoarthritis is a chronic but manageable condition. Surgery is a last resort if other treatments fail.”
2. Explain Non-Surgical Management Success
   • “Most people with knee OA do not require surgery if they engage in weight management, physiotherapy, and appropriate activity modification.”
3. Indications for Surgery (Knee Replacement)
   • “We consider surgery if there is severe pain affecting daily activities despite optimal treatment, or if there is significant joint deformity on imaging.”
4. Encourage Active Self-Management
   • “Regular physiotherapy and lifestyle changes can significantly delay or prevent the need for surgery.”

Regular review will help assess progress and tailor management.

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Q5: What preventive strategies can David implement to maintain knee function and prevent worsening symptoms?

1. Weight Management:
   • Losing 5-10% of body weight can significantly reduce knee pain and slow OA progression.
2. Strengthening & Physiotherapy:
   • Quadriceps-strengthening exercises improve knee stability and function.
3. Low-Impact Activity Modification:
   • Encourage cycling, swimming, or walking instead of high-impact sports like football.
4. Ergonomic Workplace Adjustments:
   • Minimise prolonged standing, use knee support if needed.
5. Early Intervention for Flares:
   • Seek medical review early for worsening symptoms to adjust management.

Long-term knee health relies on proactive lifestyle modifications and ongoing monitoring.

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SUMMARY OF A COMPETENT ANSWER

• Comprehensive differential diagnosis, distinguishing degenerative, traumatic, and inflammatory causes.
• Identification of red flags requiring urgent referral or further investigations.
• Structured evidence-based management plan, incorporating lifestyle, physiotherapy, and pharmacological options.
• Clear patient-centred counselling, addressing concerns about long-term knee function and surgical intervention.
• Preventive strategies to maintain joint health and function.

PITFALLS

• Failing to assess red flags, missing septic arthritis, fractures, or inflammatory conditions.
• Overprescribing NSAIDs without addressing underlying risk factors (e.g., obesity, joint overload).
• Not involving physiotherapy early, delaying functional recovery.
• Providing vague reassurance about surgery, without a clear structured management plan.
• Neglecting workplace modifications, which could contribute to ongoing strain.

REFERENCES

• RACGP – RACGP Guidelines for Musculoskeletal Conditions
• GP Exams – Knee symptom/complaint

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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 structured history to understand the impact of knee pain on function and quality of life.
1.2 Provides clear explanations of diagnosis and management options.

2. Clinical Information Gathering and Interpretation

2.1 Performs a systematic musculoskeletal examination of the knee.
2.2 Identifies red flags indicating need for further investigation.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between common knee pathologies.
3.2 Determines when imaging or specialist referral is warranted.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an evidence-based management plan including physiotherapy and pharmacological options.
4.2 Provides advice on exercise, weight management, and activity modification.

5. Preventive and Population Health

5.1 Educates on injury prevention and long-term joint health strategies.

6. Professionalism

6.1 Acknowledges patient concerns and ensures shared decision-making in treatment planning.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate documentation and follow-up for chronic knee conditions.

9. Managing Uncertainty

9.1 Recognises when additional investigations (e.g., MRI, specialist referral) are required.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies urgent knee conditions requiring immediate referral.

Competency at Fellowship Level

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