by Andrew Davidson and Nic Colombo
In this second article from the Physio interview preparation series, we thought we could have a look at a specific question from a recent band 5 interview and suggest elements for a possible answer, so you could see what sort of stuff interviewers were looking for. We'll go with a MSK question this time.
Be aware that this is only a single example of a question and its suggested answer, and depending on the type of job, the place of work, or even the interview panel members, you might need to adapt and/or provide other elements in your answer to get all the points.
If you'd like to know more, discuss other questions and answers, and even have a go at practising them, our interview preparation seminars are here for you! (You can also grab our interview preparation packs if our seminars are not available when you read this.)
MSK specific questions in junior interviews tend to focus on:
- Red flags – serious spinal or medical pathology
- Caseload management
- Condition specific questions
- Differential diagnosis
- Peripheral vs spinal
- Condition specific in orthopaedic setting – ward based, post op rehab
- Private setting – slightly different: maintaining CPD, “why you?”
Let's have a look at one example and remember to look out for buzzwords. (B)
Okay, here's our question:
You have completed your subjective assessment and objective assessment of a patient complaining of anterior knee pain. You suspect patella-femoral maltracking. What would your management be? What would be your differential diagnosis and how would you diagnose this?
First, we can see there are two parts in this question. The "management for patella-femoral maltracking" part; and the "differential diagnosis" one. It might sound silly but it's a smart move to write down a few words on paper (usually provided) during the interview to help you remember those two parts and any ideas that might rush to your head when you first hear the question. It's easy to forget things once you start talking! You can always ask to repeat the question later on as well.
Right, so what would be our management for patello-femoral maltracking?
Well, we could start with this for instance:
- Lots of reassurance and education (B): provide the patient with detailed knowledge of the mechanism behind their pain – use knee models and drawings or source some pictures from the web to help the patient visualise exactly what the main cause of their symptoms is. If your patient doesn't get it, you won't get anywhere.
- Pain management (B): advice to seek pain relief or anti-inflammatories from GP or Pharmacist if pain is poorly managed. Tell your patient to try ice 10 minutes a few times a day (not necessarily for swelling, ice can also be an effective and natural pain reliever). If you're dealing with swelling too, think POLICE (Protection, Optimum Loading, Ice, Compression, Elevation).
- Restore normal gait pattern (B): from your assessment findings, decide what structures you and your patient will work on. Patella femoral maltracking is part of a wider diagnosis affecting the patella-femoral joint: PFPS. PFPS has been long thought to be caused by the patella sitting laterally in the femoral grove underneath it. For quite some time, the only answer to PFPS would be to “strengthen the VMO”, this specific part of the quadriceps muscle which was thought to “pull” the patella medially, back in its grove. Most recent research however shows it’s almost impossible to target the VMO on its own through exercise, and that positive results were likely due to increasing quads strength overall. The problem may not be the patella going outwards but in fact the femur underneath it turning inwards. So working hip external rotators and abductors is usually a good start. Design and provide a home exercise programme for your patient. Start with non-weight bearing exercises if pain levels are high and move onto closed chain exercises, functional exercises later on. Make sure your patient knows how to perform each exercise (and the reason why they're doing them) before they leave. You can use diagrams but also things like filming the patient doing the exercise on their phone, so they can access once at home.
- Graded return to previous sports / activity (B) either in a class or gym setting or independently at home. Assess your patient in function, have a look at how they perform specific movements related to their sport. Progress your exercise programme to include activity-related exercises.
- Promote independence and self-management (B): teach your patient how to progress their exercises independently, tell them what to do once they've finished their programme - lots of patients just suddenly stop once symptoms get better and end up coming back in 6 months’ time because of lack of long-term guidance from the therapist! Remember, self-management is key, especially in a busy NHS department (fewer follow ups and lower re-referral rate)!
Now we can move on to the second part of our answer which, if you've followed our advice, should be easy enough with the prompts you've put down on paper.
What would be our differential diagnosis and how would we diagnose this?
We know that patellar maltracking is part of a larger diagnosis called patella-femoral joint syndrome. Other things you would want to rule out would be:
- Meniscal tear or irritation: by palpating the joint line and performing the McMurry’s test for example.
- Hoffa’s fat pad irritation: with the Hoffa’s fat pad test – however this is occasionally seen with maltracking as the maltracking patella ends up compressing the fat pad.
- Patellar tendinopathy: by asking the patient to contract the quads, palpate the tendon and do a ‘squeeze’ test. As tendons are avascular structures they don’t have pain signals unless there is trauma in a specific area.
- Suprapatellar bursitis: usually a small lump above patella can be palpated, with sharp pain in response.
- Other things you could look at include ligament tears or muscle tears but this would present very differently, and the knee would likely give way or lock.
- If all fails, reconsider your hypothesis by re-exploring your ‘special questions’ (B) for the knee and ruling out possible significant trauma.
Here we go, here's one more question answered and we can now breathe, have a sip of water, and wait for the next one. Now, I know you feel like "there's no way I can say all this in my answer", and don't worry interviewers know that. Most interviews, especially in the NHS, need to be standardised; to do so, interviewers have a tick list with what they expect you to say in your answer. The more you tick, the more points you get - simples. (This highlights the fact that taking 1 minute to write down your ideas before starting to talk is a pretty damn good thing to do!)
We hope this has helped you gain some insight into what kind of answer interviewers can look for. Remember, this is only one specific example and questions can vary greatly, as well as the type of answers expected from you.
Interview buzzwords (B)
In every blog post from the Physio interview series, you'll see (B) next to some words. These are buzzwords and buzzphrases - stuff that interviewers are waiting for you to say in your interview, as they help demonstrate your understanding of the topic.
Here's the list of buzzwords and buzzphrases in this article:
- Reassurance and education
- Pain management
- Restore normal gait pattern
- Graded return to previous sports / activity
- Promote independence and self-management
- Knee special questions (give way, lock, click, swells)
About the author(s)
Andrew is a Senior Physiotherapist based in East London. He primarily specialises in the management of chronic musculoskeletal pain but also works in research, particularly the management of tendinopathies. He has presented his work to a number of conferences around the UK and as a result has built up an extensive network of contacts he has made available to QualifiedPhysio. Andrew also runs our MSK seminar and has contributed to the writing of our MSK interview pack.
Nic works as a Senior Physiotherapist both in a busy NHS hospital in East London and privately. Since he qualified, he has gained a large amount of experience assessing and treating various conditions, but also meeting and working alongside all sorts of healthcare professionals. He set up QualifiedPhysio with the idea of making available to future and new physios all the advice, guidance and resources he got along the way, to bridge that gap between Uni and their first job.
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