Musculoskeletal Visits in Primary Care

“My shoulder hurts” can mean pain with lifting, a joint that will barely move, or an arm that has lost strength. Each needs a different conversation. A useful first visit identifies the pattern, gives the patient something feasible to do, and establishes how you will judge progress.

A useful first pass

Ask the patient to point with one finger to the worst pain. Establish onset, injury or a change in activity, swelling, neurologic symptoms, and one lost function: walking to work, climbing stairs, sleeping, or opening a jar. Ask what treatment they could actually obtain and try.

Inspect, palpate, compare active and passive motion, and test relevant strength. Assess distal sensation and circulation, particularly after injury or with neurologic symptoms. Look at the adjacent joint or spine when the local findings do not explain the complaint. A special test is most useful when you can say what its result would change.

European Bone and Joint Infection Society: septic arthritis.

Expedited referral below means contacting the receiving service today to agree on the assessment date and interim plan. The necessary interval depends on the findings. If the patient cannot safely wait for the available appointment, arrange same-day acute assessment.

For a stable rehabilitation plan: choose a function to measure and book a review. A 4–6-week check is a practical example for an uncomplicated stable problem, not a universal recovery deadline. Review earlier for substantial disability, medication monitoring, or neurologic symptoms; the escalation instructions below take priority.

Foot pain: distinguish plantar heel pain from focal bone pain

Ask: first steps after rest or pain through the whole period of weight bearing? Heel, arch, forefoot, or midfoot? New running distance, shoes, standing work, trauma, or puncture? Check diabetes, neuropathy, wounds, and ability to bear weight.

Examine: gait, shoes, skin including the sole, focal tenderness, ankle motion, Achilles function, sensation, and circulation. First-step pain with medial plantar heel tenderness supports plantar fasciopathy. Focal bony pain after increased loading should raise concern for a stress injury instead.

Say for a convincing plantar pattern: “The tissue under your heel seems to be the source. Let’s work on the stretching and how much time you spend loading it. What change could you manage during a workday?”

Same-day injury assessment: inability to bear weight after trauma, plantar bruising with midfoot injury, or concern for an unstable/occult fracture. Protect weight bearing while arranging care. A warm swollen foot with neuropathy may be Charcot arthropathy despite modest pain: offload and arrange urgent diabetic-foot assessment. Infection or an ischemic foot needs urgent care.

AAOS: plantar heel pain and illustrated stretches; ACR: chronic foot pain imaging; NICE: diabetic foot and Charcot assessment.

Knee pain: swelling, locking, and the task that hurts

Ask: injury or gradual onset, location, timing of swelling, instability, and locking. “It clicks” differs from “I cannot straighten it.” Clarify stairs, prolonged sitting, walking distance, fever, and a sudden change in a previously arthritic knee.

Examine: gait, warmth, effusion, active/passive motion, patella and joint lines, and active straight-leg raise. Select ligament or meniscal maneuvers from the mechanism. Check hip motion if the knee findings do not explain the pain.

When the OA plan fits: a typical clinical pattern is age 45 or older, activity-related joint pain, and no morning stiffness or stiffness lasting no longer than 30 minutes. Atypical findings, such as a hot joint, rapid deterioration, or prolonged stiffness, need another explanation. Imaging is not required simply to confirm a typical pattern.

A different common pattern: anterior pain with stairs, squatting, or prolonged sitting may fit patellofemoral pain. Assess the whole presentation; a large effusion or true locking needs another explanation. Rehabilitation emphasizes hip and quadriceps strength and adjustment of provoking activity.

Say after an OA assessment: “The symptoms and exam fit arthritis. What would make the biggest difference: easier stairs or being able to walk farther? We can use that to judge the treatment.”

After injury: use an applicable validated rule, such as the Ottawa Knee Rule, to guide fracture imaging. Arrange same-day assessment for inability to bear weight, loss of active extension, a locked knee, or major instability. Neurovascular compromise needs emergency care; a hot effusion needs the septic-joint assessment above.

NICE: clinical OA diagnosis; AAOS: knee OA; 2026 VA/DoD: hip and knee OA; AAOS: patellofemoral pain; ACR: acute knee trauma and imaging rules.

Hip pain: groin, lateral hip, or buttock?

Ask: locate the pain before accepting “bursitis.” Groin pain suggests a joint source; pain on the side when lying on it suggests a peritrochanteric source; buttock pain with radiation may arise from the spine. Ask about falls, weight bearing, steroid exposure, alcohol use, fever, and loss of function.

Examine: gait, hip motion and pain with rotation, lateral tenderness, and abductor strength. Include the lumbar spine, knee, or neurologic examination when symptoms suggest referral. Marked passive-motion pain deserves attention even when tenderness is also present laterally.

Say when the lateral pattern fits: “The pain seems to come from the tissues along the side of the hip. We’ll reduce the pressure there and build strength. Let’s start with what is making sleep or walking difficult.”

If the pattern is hip OA: use an exercise and symptom plan directed at the joint, and consider orthopedic assessment when disability warrants it. Topical NSAIDs do not have the same evidence for a deep joint such as the hip as they do for the knee.

Same-day assessment: inability to bear weight after a fall, persistent fracture concern despite normal films, or an acutely painful restricted joint with infection concern. Protect weight bearing. For occult fracture concern, MRI without contrast or CT without contrast may be the next study; a negative radiograph does not end the evaluation.

AAOS: lateral hip pain; VA/DoD: hip OA; ACR: chronic hip pain and acute hip pain.

Shoulder pain: separate pain, stiffness, and weakness

Ask: trauma, overhead load, night pain, loss of strength, dressing, and reaching. Include neck pain, radiation below the elbow, numbness, and systemic symptoms. Shoulder discomfort with chest symptoms or exertional breathlessness needs a cardiopulmonary assessment.

Examine: compare active and passive elevation and rotation, then assess cuff strength. Better preserved passive motion with painful active motion points toward a different problem from restriction of both, especially external rotation. Consider cuff-related pain in the first pattern and capsular or joint disease in the second; neither finding alone establishes the diagnosis. Distinguish pain-limited effort from persistent objective weakness and assess cervical/neurologic findings when relevant.

Say after an adhesive-capsulitis assessment: “The history and exam fit a frozen shoulder. Recovery can be slow; we’ll work on comfort and gradually recovering movement, and check whether dressing and reaching are getting easier.” Consider alternatives such as arthritis before using this explanation. Use a mobility-focused program; discuss injection or referral if pain or disability is preventing progress.

After trauma: deformity, suspected fracture/dislocation, or sudden major loss of function needs same-day assessment. Neurovascular compromise needs emergency care. Suspected acute cuff tear with objective weakness needs expedited orthopedic referral: contact the service today about imaging and assessment timing, before prescribing a prolonged PT trial.

AAOS: shoulder patterns; adhesive capsulitis; ACR: chronic shoulder imaging.

Wrist and hand pain: which fingers, which structure?

Ask: injury, exact pain location, numb fingers, night waking, grip or pinch weakness, dropping objects, and repetitive tasks. Tingling in the thumb, index, middle, and thumb-side of the ring finger suggests a median-nerve distribution. Small-finger numbness should make you reconsider a carpal tunnel label.

Examine: skin and wounds, swelling, tenderness, motion, tendon function, sensation, and motor strength. In suspected neuropathy, map sensation and look for weakness or atrophy. After trauma, examine the scaphoid region when the mechanism or location raises concern.

Say for a carpal tunnel pattern: “The tingling fits pressure on a nerve at the wrist. The night brace keeps the wrist straight. We’ll check whether you are waking less and whether sensation is improving. Contact us sooner for new weakness or worsening numbness.”

Radial wrist pain: a compatible de Quervain pattern can start with load modification and a thumb-spica support; discuss injection or referral for persistent symptoms. Thumb-base joint pain and a catching digit need their own assessment, so do not extend the carpal tunnel plan to them.

Same-day assessment: bite or infection near a joint/tendon, significant tendon dysfunction after injury, or a hot swollen joint. Neurovascular compromise needs emergency care. For suspected scaphoid fracture despite negative films, immobilize and arrange further assessment; repeat films in 10–14 days, MRI, or CT may be appropriate. Specify the appointment or imaging plan before discharge.

AAOS: carpal tunnel; 2026 APTA carpal tunnel guideline; AAOS: de Quervain; ACR/RSNA: trauma with negative initial films.

Neck pain: check the cord as well as the nerve root

Ask: trauma, local versus radiating pain, sensory distribution, weakness, and new functional loss. Ask about buttons or handwriting, dropping objects, gait or balance, and bladder/bowel change. Include fever, infection/cancer risk, severe unusual headache, and acute neurologic symptoms.

Examine: comfortable neck motion, shoulder, upper-extremity strength, reflexes, and sensation. Add gait and assessment for myelopathy when the history raises concern. Record actual motor and sensory findings so that the next examination can detect a change.

Say for stable radicular symptoms: “The arm symptoms may be coming from a nerve in your neck. We can start treatment while tracking strength and sensation. Please seek assessment sooner if the arm becomes weaker or you develop trouble with your hands or balance.”

Expedited spinal assessment: suspected myelopathy, including hand clumsiness with gait change or pathologic reflexes. Contact the spinal service today to agree on timing. Rapid neurologic progression, major deficits, suspected unstable injury, or sudden unusual neck/head pain with focal neurologic symptoms needs emergency evaluation. Other significant trauma or infection concern needs same-day assessment; systemic instability makes it an emergency.

AAOS: cervical radiculopathy; ACR: cervical imaging pathways; AAOS: cervical cord compression.

When the first plan has not helped

Before calling PT unsuccessful, ask what happened between visits. Was therapy affordable and available? Could the patient leave work, follow the instructions, or tolerate the exercises? Observe the home program. Recheck the original localization and findings as well as the patient’s ability to carry out the plan.

A useful referral states the question: suspected acute tear, unexplained loss of function, or disability despite a documented trial. Include the side, findings, prior treatment, relevant imaging, and desired timing. When access is limited, call about time-sensitive findings instead of relying on the referral label to convey urgency.