Musculoskeletal Outpatients (NHS Cases)

This section highlights a selection of the most common conditions I’ve seen in an NHS musculoskeletal outpatient setting. It’s not an exhaustive record of every case I’ve treated, but rather a reflection of my experience and the types of patients I regularly work with.

In an NHS outpatient clinic, the caseload is incredibly varied, covering everything from chronic pain management to post-operative rehab and joint or soft tissue injuries. Many patients present with issues linked to workplace ergonomics, daily activities, or the natural ageing process, while others are recovering from surgery or injuries.

The case studies below represent real-world presentations, showcasing the assessment and rehabilitation approaches I commonly use. Whether it’s helping someone regain function after a total knee replacement, managing persistent lower back pain, or guiding a patient through shockwave therapy for plantar fasciitis, my role focuses on providing evidence-based treatment tailored to each individual’s needs.

Foot & Ankle Cases

  • Patient: 48F, presenting with chronic heel pain for over six months, worse in the morning and after prolonged standing. Previous physio exercises provided limited relief.

    Differential Diagnosis:

    • Chronic plantar fasciitis

    • Calcaneal spur irritation

    • Tibialis posterior dysfunction

    Management Focus: ECSWT (extracorporeal shockwave therapy) over 6 sessions, self-massage with a ball, progressive loading of the plantar fascia, and referral to podiatry for insole assessment.

  • Patient: 42M, long-standing Achilles pain, worsened by increased running volume. Stiff in the mornings, pain improves slightly with movement.

    Differential Diagnosis:

    • Midportion Achilles tendinopathy

    • Retrocalcaneal bursitis

    • Partial Achilles tear

    Management Focus: ECSWT, eccentric calf loading programme, graded exposure to running, and footwear assessment.

Neck & Upper Back Cases

  • Patient: 55M, presenting with gradual onset of neck stiffness and tightness, worse after prolonged desk work. No history of trauma.

    Differential Diagnosis:

    • Cervical spondylosis

    • Facet joint stiffness

    • Upper trapezius myofascial pain

    Management Focus: Active ROM exercises, targeted stretches, and postural education.

  • Patient: 47F, reports mid-back discomfort and difficulty maintaining good posture during prolonged sitting. Also struggles with overhead movements.

    Differential Diagnosis:

    • Scapulothoracic joint dysfunction

    • Postural thoracic kyphosis

    • Rib dysfunction

    Management Focus: Scapular control drills, thoracic extension mobility, and strengthening of lower traps and rhomboids.

Shoulder Cases

  • Patient: 52M, reports anterior shoulder pain during overhead activities and gym workouts. Pain eases with rest but returns with loading.

    Differential Diagnosis:

    • Rotator cuff tendinopathy

    • Subacromial impingement

    • AC joint irritation

    Management Focus: Scapular stabilisation work, eccentric rotator cuff loading, and biomechanical retraining for overhead movements.

  • Patient: 56F, presenting with progressive loss of shoulder movement over the past 6 months. Initially experienced mild pain, now reports severe stiffness affecting daily tasks like dressing and reaching overhead. No history of trauma.

    Differential Diagnosis:

    • Adhesive capsulitis (Frozen Shoulder)

    • Glenohumeral joint osteoarthritis

    • Rotator cuff-related shoulder pain with secondary stiffness

    Management Focus:

    • Education on the phases of frozen shoulder (freezing, frozen, thawing)

    • Pain management: gentle mobility exercises within tolerance, possible referral for corticosteroid injection if pain is severe

    • Gradual mobilisation: active-assisted range of motion, capsular stretching, and strengthening as stiffness resolves

Lower Back & Fibromyalgia Cases

  • Patient: 49F, long-standing lower back pain with widespread musculoskeletal discomfort. No clear triggering event.

    Differential Diagnosis:

    • Fibromyalgia

    • Chronic non-specific low back pain

    • Myofascial pain syndrome

    Management Focus: Graded exercise therapy, pain education, and pacing strategies to reduce flare-ups.

Knee Cases

  • Patient: 68M, diagnosed with knee osteoarthritis, reporting difficulty with stairs and prolonged standing.

    Differential Diagnosis:

    • Medial compartment knee OA

    • Patellofemoral pain syndrome

    • Meniscal degeneration

    Management Focus: Education on OA progression, knee strengthening exercises, and activity modification.

  • Patient: 25F, one week post-ACL reconstruction, struggling with knee extension and weight-bearing.

    Differential Diagnosis:

    • Post-operative stiffness

    • Quadriceps inhibition

    • Graft healing phase

    Management Focus: Early knee extension work, weight-bearing tolerance drills, and neuromuscular control exercises.

Hand & Wrist Cases

  • Patient: 60F, post-cast removal for distal radius fracture, struggling with wrist extension and grip strength.

    Differential Diagnosis:

    • Post-fracture stiffness

    • Carpal instability

    • Tendon adhesions

    Management Focus: Hand therapy collaboration, grip strengthening, and progressive ROM exercises.

Multidisciplinary Cases (Specialist Referrals)

  • Patient: 45F, referred from Oral-Maxillofacial department for TMJ pain, worsened with chewing and jaw movement.

    Differential Diagnosis:

    • TMJ dysfunction

    • Myofascial pain syndrome

    • Cervical contribution to jaw pain

    Management Focus: TMJ mobility exercises, cervical postural work, and relaxation techniques.

Hip Cases

  • Patient: 32M, reports deep anterior hip pain, aggravated by deep squatting and prolonged sitting. Describes a pinching sensation at the front of the hip when flexing beyond 90°. No history of trauma but has been increasing gym workload recently.

    Differential Diagnosis:

    • Femoroacetabular impingement (FAI)

    • Labral pathology

    • Hip flexor tendinopathy

    • Early hip osteoarthritis

    Management Focus:

    • Biomechanics education: Adjusting squat depth and modifying movement patterns

    • Hip mobility and strength work: Focus on hip flexor control and glute activation

    • Gradual loading programme: Strengthening deep hip stabilisers while avoiding aggravating positions

  • Patient: 48F, presenting with lateral hip pain, worsening with prolonged standing and side-lying. Reports tenderness over the greater trochanter but no history of acute injury.

    Differential Diagnosis:

    • Greater trochanteric pain syndrome (GTPS)

    • Gluteal tendinopathy

    • Trochanteric bursitis

    • Referred pain from lumbar spine

    Management Focus:

    • Load management: Avoiding prolonged standing and side-lying on the affected side

    • Hip strengthening: Focus on glute medius and minimus activation while avoiding excessive compression of the tendons

    • Gradual return to activity: Isometric exercises progressing to dynamic hip loading