Title

Knee Musculoskeletal Curriculum

Authors

Ambica Sethi Samuel Miller Sofia Castaneda

Introduction

Musculoskeletal (MSK) complaints are one of the most common clinic complaints in the primary care setting. However, internal medicine (IM) residents consistently report low comfort and competence in performing MSK physical exams which can lead to over-reliance on imaging and specialist referrals. There is also variability in outpatient MSK skills training with higher reported resident proficiency in IM residencies with dedicated MSK training sessions. After an internal faculty survey on the most common MSK complaint at the outpatient Austin Veterans Affairs (VA) Clinic, we determined knee pain accounted for almost 70% of MSK complaints. With this understanding, our objective was to assess resident confidence and competence in managing knee MSK complaints after completing a hands-on 60-minute MSK educational workshop.

Methods

The Knee MSK workshop consisted of a 30-minute didactic and 30-minute hands-on component which included use of ultrasound. The didactic component was divided into common acute and chronic knee complaints with quick videos on how to perform physical exam maneuvers to elicit specific diagnoses. The hands-on portion consisted of performing/trialing the physical exam maneuvers on willing participants. It also included a 10-minute introduction on how to use ultrasound for assessment of knee effusions, popliteal cysts and intra-articular knee steroid injections. The participants were internal medicine residents (PGY1-PGY3) working in the outpatient Austin VA Clinic. Confidence and Knowledge/Competence levels were tested using pre and post surveys.

Results

30 IM residents participated, 20 IM residents completed the pre and post surveys. 80% of residents felt it was important for their education to be knowledgeable in managing knee pain outpatient. For the surveys assessing confidence levels: Mean confidence in performing a thorough knee exam improved from 2.45 to 4.20 post workshop (p < 0.05). Mean confidence in identifying differentials for acute and chronic knee complaints increased from 2.45 to 4.20 (p < 0.05). Mean confidence in managing knee complaints increased from 2.55 to 4.30 (p < 0.05). There was also a 50% increase in resident confidence in knowing when to use ultrasound for knee complaints. For the surveys assessing knowledge/competence levels: 85% of residents correctly identified the appropriate imaging modality for chronic knee pain post-workshop, compared to 0% pre-workshop. There was also a 65% increase in resident knowledge of specialized physical exam tests such as Noble, Ober and McMurray test.

Conclusion

A dedicated MSK curriculum is vital in improving resident confidence and competence in managing outpatient MSK complaints such as knee pain. Thus, it is important to improve and standardize primary care physician training in the management of common MSK complaints for the goal of higher patient satisfaction, timely and cost-effective care. Additionally, using ultrasound as part of the MSK physical exam might better aid and solidify MSK concepts while simultaneously increasing resident confidence in ultrasound techniques.

References

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6342436/ https://pubmed.ncbi.nlm.nih.gov/33005732/ https://pubmed.ncbi.nlm.nih.gov/35538536/ https://pmrjabstracts.org/abstract/effects-of-early-outpatient-musculoskeletal-exposure-on-inpatient-pmr-rotations/ https://acrabstracts.org/abstract/improving-resident-confidence-with-the-musculoskeletal-exam-through-a-rheumatology-dedicated-musculoskeletal-workshop/