Lane 02 — Musculoskeletal.

POCUS — long axis of supraspinatus, 12 MHz linear, depth 3.5 cm.

Minute 03 — Why MSK belongs in primary care

Roughly a third of adult primary-care visits in the United States involve a musculoskeletal complaint¹, but most primary-care training programs hand it off to physical therapy and orthopedics with a perfunctory exam. We do not — for two reasons. The first is that the seven-minute visit cannot reliably distinguish a rotator-cuff tear from a frozen shoulder, and the consequence of getting it wrong is a long and expensive detour through specialty care that mostly ends with the same patient back in primary care eight months later. The second is that AMSSM-trained sports-medicine fellowship graduates can do most office MSK work — including diagnostic ultrasound and ultrasound-guided injection — and we have one on staff.

Week 02 — Low back, on a clock

Roughly 90% of acute low-back pain in working-age adults resolves within six weeks regardless of intervention². The job of primary care in those six weeks is to (a) rule out the small fraction of presentations that are a red flag — cauda equina syndrome, fracture, infection, malignancy — and (b) keep the patient moving. We use the STarT Back screening tool at the first visit; we send low-risk patients home with a single sheet of advice (movement, heat, ibuprofen, no bed rest, no MRI) and a follow-up at week three; we send high-risk patients to physical therapy on the same call.

What we don't do: order an MRI before six weeks unless there's a red flag, prescribe muscle relaxants beyond a five-day course, or prescribe opioids. The 2017 American College of Physicians clinical practice guideline on low-back pain³ agrees with us on every one of those points.

Week 06 — Tendinopathy is a loading problem

Achilles, patellar, gluteal, lateral elbow, supraspinatus — the management is, with caveats, the same. Pain on loading. A failure of the tendon to remodel under load. The treatment is graded loading, not rest. We follow the British Journal of Sports Medicine consensus on tendinopathy management⁴: heavy slow resistance work, eccentric loading where indicated, isometrics for pain modulation, no corticosteroid injection except as a last resort because the long-term outcomes are worse⁵. We measure progress with the VISA-A for Achilles, the VISA-P for patellar, and a simple numeric pain-on-loading rating for the others. The pain log is on paper and lives in the chart.

Week 08 — Knee, especially the ones the X-ray missed

Most adult knee complaints in this practice are osteoarthritis, patellofemoral pain syndrome, or a meniscal flap with degenerative-tear features rather than an acute injury. The first two are managed conservatively, with a 2021 AAOS guideline-anchored loading and weight-bearing program. For the third, we do not order an MRI before twelve weeks of conservative care unless the exam suggests a true mechanical block. The FIDELITY trial⁶ showed arthroscopic partial meniscectomy was no better than sham surgery in patients with degenerative tears; that result has held up across replications and meta-analyses.

Office point-of-care ultrasound has displaced about a third of the knee imaging we used to send to MRI. We can see effusion, suprapatellar plica, an extruded medial meniscus on dynamic exam, and a Baker's cyst directly. The MRI we no longer order is not a saving for us; it's a saving for the member's high-deductible plan.

Week 12 — Shoulder, and the rotator-cuff myth

The phrase "rotator-cuff tear" has done more clinical mischief in primary care than any other musculoskeletal label. Asymptomatic rotator-cuff tears are present in roughly half of adults over age 60⁷. The presence of a tear on imaging does not, by itself, decide whether a patient needs surgery; the function of the cuff and the patient's activity demand do. We assess with a graded loading exam and a focused POCUS view; we image with MRI only when the exam and ultrasound disagree, when the patient is a surgical candidate, or when the function loss is acute and traumatic. Where indicated, we offer ultrasound-guided subacromial injection in office (lidocaine + 40 mg triamcinolone, $48 cash for the procedure, billed at our cost).

Tools — point-of-care ultrasound

We carry a Butterfly iQ3 handheld with a linear and curvilinear preset; Vass logs every scan into an Obsidian vault that doubles as our teaching archive. The vault is searchable; if a member wants to see their own scan, we send them the clip. Image quality on a $2,200 handheld is now adequate for office MSK work; we do not pretend it is a replacement for radiology when radiology is what's needed.

Tools — two physical therapists we trust

The single best clinical decision a primary-care MSK lane can make is which physical therapists to refer to. Most members of our panel see one of two PTs in town: Dana Hjelmtvedt, DPT, OCS, at Duluth Physical Therapy & Rehabilitation on East Superior, and Frances Larkin, DPT, SCS, at the Lake Avenue practice on the Canal Park side. We have working relationships of more than a decade with both. They return calls inside of an hour. We share notes both ways. The members can read about both of them in our colophon.

Cross-references: most of this lane runs alongside 07 · Sports & performance, especially for the marathon and ski-racing population; the chronic-pain end of MSK overlaps with 03 · Mental health at almost every visit. A working case log: case log 002 — tib-post tendinopathy at the 11-mile training plateau.