Musculoskeletal and Sports Medicine
Approach
Most musculoskeletal complaints resolve without imaging. Acute low back pain without red flags: no imaging in the first 6 weeks, encourage activity, NSAIDs, and reassurance about natural history. Red flags: age over 50 with new pain, cancer history, fever, injection drug use, night pain, bowel or bladder dysfunction, saddle anesthesia, or progressive neurologic deficit - cauda equina requires emergent MRI.
Joints and soft tissue
- Ottawa ankle and knee rules determine who needs radiographs.
- Acute gout: NSAIDs, colchicine, or corticosteroids. Do not stop a urate-lowering drug already in place, and do not start allopurinol during a flare without anti-inflammatory coverage.
- Rotator cuff: painful arc, positive Hawkins or Neer; most improve with physical therapy.
- Carpal tunnel: nocturnal symptoms, positive Phalen or Tinel; night splinting and steroid injection first.
- Stress fracture: focal bony tenderness with weight-bearing pain; MRI or bone scan if radiographs are negative.
Sports specifics
- Concussion: no same-day return to play; graduated return to school, then a stepwise return to sport.
- Relative energy deficiency in sport (RED-S): a young athlete with amenorrhea and a stress fracture.
- Tendinopathy responds to progressive loading, not indefinite rest.
Rule of thumb
Image when the result would change management or when red flags are present - not simply because the patient is in pain.
Worked example: an ankle inversion injury with tenderness over the posterior edge of the lateral malleolus and inability to bear weight four steps calls for an ankle series; tenderness confined to the midfoot without those findings does not.