Musculoskeletal Physiotherapy
This domain tests clinical reasoning rather than memorised protocols: can you take a history, clear red flags, weigh special tests against pretest probability, and match a loading strategy to the tissue state and its irritability?
History and screening first
Classify pain as somatic, radicular or visceral. Use the SINSS framework - severity, irritability, nature, stage, stability - to set dose. Screen red flags for fracture (significant trauma, age over 65, corticosteroid use, night pain), infection, tumour and cauda equina. Screen yellow flags too: fear-avoidance and catastrophising predict chronicity and are addressed with education and graded exposure, not more passive treatment.
Special tests are never diagnostic alone
Lachman is more sensitive than the anterior drawer for the ACL; McMurray is specific but insensitive for meniscal tears; Neer and Hawkins have low specificity for subacromial pain; Spurling's is specific for cervical radiculopathy. Always combine tests, and quote likelihood ratios rather than a bare positive or negative.
Maitland grading
Grade I–II (small or large amplitude at the start of range) for pain; Grade III (large amplitude to the limit of range) and Grade IV (small amplitude at the limit) for stiffness; Grade V is a high-velocity thrust, avoided in anticoagulated patients, severe osteoporosis, upper cervical inflammatory instability and vertebrobasilar insufficiency.
Loading by tissue state
Tendinopathy responds to progressive eccentric or heavy slow resistance, 3–4 sets of 12–15 repetitions, 2–3 times weekly for around 12 weeks; isometrics give short-term analgesia. Acute muscle strain needs relative rest, early pain-free range and graded reloading. After fracture or immobilisation, respect the surgeon's limits on range and weight-bearing.
Worked example
A 45-year-old teacher has 3 months of lateral elbow pain with no trauma, pain on resisted wrist extension and on gripping, and no red flags. Reasoning: lateral elbow tendinopathy with moderate irritability. Start isometric wrist extension holds (about 5 × 45 s at 30–50% maximal voluntary contraction) for analgesia and load tolerance, then progress to eccentric or heavy slow resistance 3 × 15, add grip retraining and load modification. Do not make corticosteroid injection the first-line plan: it gives short-term relief but worse long-term outcomes.
Traps that cost marks
- Equating pain intensity with tissue damage.
- Reporting a special test result without pretest probability.
- Ignoring the thoracic spine and scapula in neck and shoulder presentations.