When people think about MSK physiotherapy, this is what they imagine. Frequently (wrongly) associated with only treating sports injuries and performing massage.

An outpatient MSK physiotherapist will see an incredibly wide range of issues that effect the musculoskeletal system. It is impossible to write an exhaustive list of the types of injuries or issues that patients present with, however, they are likely to fall under one of these categories:

• Joint or muscle injury (sports related/work related/home related)

• Age-related joint degeneration (e.g. osteoarthritis)

• Unexplained pain in joints or muscles

• Post-fracture or surgery

Outpatient MSK physiotherapists are extremely versatile and need to have a broad knowledge base to accurately assess & treat any issues concerning the MSK system a patient presents with. Outpatient physiotherapists may also specialise in a specific area of physiotherapy.

Inpatient MSK physiotherapy is very different to outpatients. Inpatient MSK physiotherapy is often known as Trauma & Orthopaedics (T&O). As a therapist working in T&O, you see patients who have MSK issues that have had surgical intervention. For example, many people have joint replacements every year - in most joint replacement operations, standard procedure is for these patients to get that joint moving day 1 after surgery.

As physiotherapists working in T&O, we follow protocols set out by the surgeon to mobilise patients early following the precautions set out. After having hip replacement, most patients will be expected to walk day 1 after surgery, however, they are usually told that they cannot cross their legs and that the angle at their hip must remain greater than a certain angle such as 100 degrees.

Joint replacements as discussed are referred to as elective orthopaedic surgery - this means that the surgery was completed out of choice as was not essential to life. On the other hand, when patients come in with traumatic bone or joint injuries, their therapy has to be more closely adapted to their individual injury. For example, someone who previously walked with a wheeled zimmer frame may break their arm - our job is then to provide a different walking aid for this person that will allow them to maintain their level of function despite their trauma.

Overall, inpatient based MSK physiotherapy is most commonly related to surgery and following surgical protocol. It involves less assessment and autonomy but the role of the therapist in a patients recovery is incredibly important.

Carrying out a good subjective assessment is a skill that takes a long time to master but it can help provide you with all of the clues you need to produce a good hypothesis to test in your objective assessment.

Subjective Assessments include:

• Presenting Condition - What has brought the patient to see you today? A full history of the onset of symptoms and how they behave is important here. Often a body chart is also used to locate on a diagram where exactly the symptoms are presenting.

• Past Medical History - Does the patient have any previous medical history? Knowing this can help to inform the diagnosis if the presenting condition relates to a previously known problem. It is also very important to check when performing treatment as certain underlying conditions are contraindications of treatment.

• Social History - These questions are all about how the patient lives. Do they live in a house? Live alone? Make own food? Wash self? Have carers? and many many more.

• Drug History - Any medication they are on - can often remind patients of their past medical history they have forgotten about. Additionally, depending on your level of knowledge, you may find yourself in a position where you could write to the GP to review certain medication - for example pain medication - if you feel like it is an issue for your patient.

• Special Questions - Depending on the presenting condition, there are some special questions that are essential to rule out certain pathology that would be a 'red flag' as a physiotherapist and an emergency onward referral to the GP or A&E would be more appropriate. Questions include screening for cancer and cauda equina syndrome.

When put together, the subjective assessment holds the key to what objective assessments you need to complete in order to provide the patient with a diagnosis.

An objective assessment consists of physical, measurable, impartial observation and testing. Objective assessments should be able to be carried out by any number of physiotherapists and as long as the patient doesn't change, the assessment will be the same because it is not open for interpretation in its nature - it is merely an assessment of what can be observed and measured.

There are a number of parts to a basic objective assessment, these include (but are not limited to):

• Observation - A lot can be gained by just observing a person, even from the minute the person walks into the assessment the physiotherapist will be making constant observations to see how their issue is effecting their function.

• Palpation - It is frequently important to feel (palpate) the effected area for certain signs such as areas of tenderness, swelling, heat, abnormalities etc.

• Range of movement testing - A basic assessment of a join will often involve looking at passive (us moving the patients limb) and active (them moving their limb) through full range of movement to assess where there may be deficit to help identify the issue.

• Strength testing - Looking at strength can be useful to work out where the patient has a weaknesses that may be contributing to the issue.

• Special tests - MSK physiotherapy involves a plethora of specific tests for all different pathologies - these are used in conjunction with the other parts of the assessment to rule in or rule out specific conditions.

There are further more condition specific tests that may be applicable depending upon the presentation but at this level an awareness that an objective assessment involves this is incredibly important. When deciding how to treat a patient, a well performed objective assessment combined with the subjective assessment gives you a good idea of a likely diagnosis to pursue and attempt to treat.