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Recommended Musculoskeletal and Sports Medicine Model Curriculum for Emergency Medicine Residency Training

Chow, Yvonne C. MD, MSMS1; Waterbrook, Anna L. MD2; Suffoletto, Heidi N. MD3; Dolbec, Katherine MD4; Myers, Rebecca A. MD5; Denq, William MD2; Hwang, Calvin Eric MD6; Kiel, John M. DO, MPH7; Monseau, Aaron J. MD8; Balcik, Brenden J. MD8; Santelli, Jaron A. MD9; Oshlag, Benjamin L. MD, MS10; Hudson, Korin B. MD11; Delasobera, Bronson Elizabeth MD12; Feden, Jeffrey P. MD13; Davenport, Moira MD14; Childress, John M. MD15; Desai, Natasha N. MD16; Gould, Sara J. MD, MPH17; Holschen, Jolie C. MD18

Author Information
Current Sports Medicine Reports: January 2021 - Volume 20 - Issue 1 - p 31-46
doi: 10.1249/JSR.0000000000000800
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Abstract

Introduction

Emergency physicians (EPs) should possess sound clinical skills in diagnosing and treating musculoskeletal (MSK) and sports medicine-related conditions, as these disorders comprise 13.8% to 18.7% of emergency department (ED) visits (1,2). Despite a reasonable amount of MSK core content in The Model of the Clinical Practice of Emergency Medicine (EM model), the core document for the specialty that “represents essential information and skills necessary for the clinical practice of EM by board-certified emergency physicians” (3), evidence suggests emergency medicine (EM) residents may not be adequately trained in MSK and sports medicine (4). MSK and sports medicine is underrepresented in United States medical school curricula, with only 15% of schools requiring a clinical MSK clerkship (5). This has led to medical students entering residency programs with deficient knowledge in this area. As a result of these gaps in undergraduate and graduate medical MSK and sports medicine education, a majority of new EM residency graduates feel unprepared to care for patients presenting with MSK and sports medicine complaints (6). Practicing EPs describe the need to augment their MSK and sports medicine training through continuing medical education after graduation from residency (6,7). Subspecialists, such as orthopedic surgeons and primary care sports medicine (PCSM) physicians, have raised concerns about the inconsistency of MSK and sports medicine education in EM residencies and a recent study showed that only 61% of attending EPs passed a validated MSK knowledge examination (4,8).

To become board-eligible, physicians specializing in EM in the United States must complete either 36 or 48 months of postgraduate education in a residency program accredited by the Accreditation Council for Graduate Medical Education (ACGME). Educational program requirements are outlined in the ACGME Program Requirements for Graduate Medical Education in Emergency Medicine (9), and incorporate the six ACGME competencies of professionalism, patient care and procedural skills, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, and systems-based practice. The clinical curriculum specifies mandatory experiences in critical care, pediatrics, EM, and emergency medical services. The ACGME does not discuss MSK and sports medicine curricula for EM training, other than requiring a minimum of 10 dislocation reductions as one of the key index procedures considered essential for the practice of EM (9). Programs have variable experiences in place to provide exposure to MSK and sports medicine, which may include 1 to 4 weeks in an orthopedic or sports medicine clinic, an inpatient orthopedic surgery rotation, an urgent care experience, or isolated lectures or workshops on splinting and specific injuries. Some academic EDs see very few numbers of “urgent care” type complaints, or these cases may be treated primarily by advanced practice providers rather than EM residents. The variability in clinical exposure results in some graduating EM residents having little experience to manage MSK and sports medicine conditions.

Although designed to provide the foundation for residency curricula and board certification examinations, the EM model is not a compulsory document. Individual residency programs are tasked with administering a longitudinal curriculum covering the core content listed in the EM model. Many programs take the approach of correlating the amount of instruction time to the relative weight given to different topics in the EM model on the resident in-training and board certification examinations. Nontraumatic MSK disorders comprise only 3% of questions on these examinations, while traumatic disorders (which encompasses MSK trauma) take up the third highest number of questions at 9%, following cardiovascular disorders and signs, symptoms, and presentations at 10% each (10,11). This latitude in curriculum application and relative low weighting of nontraumatic MSK and sports medicine topics has led to wide variations in how MSK and sports medicine core content is taught across EM residency programs in the United States.

While the frequency of MSK and sports medicine disorders seen in the ED has remained steady over the last decade, availability of orthopedic on-call coverage for community EDs has diminished during this time (12–14). Academic EDs at institutions with an orthopedic residency program may continue to receive adequate orthopedic on-call coverage. However, most graduating EM residents go on to practice in a community setting (15), where this growing gap in orthopedic on-call coverage necessitates EP proficiency with the initial management of orthopedic emergencies. Furthermore, the majority of MSK and sports medicine disorders presenting to the ED do not fall into the category of major trauma (1), especially in community EDs that are not trauma centers, and should be managed independently by the EP without any need for orthopedic consultation. Thus, a comprehensive MSK and sports medicine education is crucial during EM residency training to ensure high quality patient care.

As a result of this shortfall in fundamental MSK and sports medicine skills and knowledge among EPs, the American Medical Society for Sports Medicine (AMSSM) has tasked members of the AMSSM EM Curriculum Subcommittee with developing a standardized EM Musculoskeletal and Sports Medicine Curriculum to promote increased competency in MSK and sports medicine concepts pertinent to general EM practice. The purpose of this statement is to provide EM residency training programs with MSK and sports medicine curricular goals and objectives, suggest implementation methods, share resources for MSK and sports medicine education, and consider methods for measuring desired outcomes from implementing this curriculum, to ensure that all residents completing an EM residency are competent to treat ED patients presenting with MSK and sports medicine complaints.

Knowledge and Skills

The EM model outlines a description of physician tasks that must be performed while providing appropriate emergency care (3). Graduating EM residents should be able to complete the following as they relate to caring for patients with MSK and sports medicine complaints:

  • participate in prehospital care, which includes assimilating information from prehospital personnel, such as athletic trainers, coaches, or sideline physicians, into the assessment and management of the patient;
  • conduct a primary assessment and provide emergency stabilization as indicated, while incorporating appropriate and safe removal of protective sporting equipment;
  • perform a focused MSK history and physical examination;
  • recognize modifying factors that may affect patient management, such as risks associated with specific sporting activities;
  • select and interpret appropriate diagnostic studies;
  • develop an appropriate differential diagnosis and establish the most likely diagnosis;
  • perform therapeutic interventions or procedures;
  • select appropriate pharmaceutical agents with awareness of potential adverse effects and relevant clinical guidelines, include potential banned substances in athletes;
  • evaluate the effectiveness of treatment through observation and reassessment of patients;
  • obtain appropriate emergent consultation or determine appropriate referrals to other physicians for optimal management of patients;
  • ensure effective transitions of care, such as hospital admission or discharge follow up plan, including timely and accurate documentation in the medical record to facilitate comparison examinations by subsequent providers;
  • conduct patient education and promote injury prevention as appropriate, including primary, secondary, tertiary prevention of MSK injuries and concussion;
  • understand and apply the principles of disaster and mass casualty management, including development of an emergency action plan;
  • apply patient- and family-centered communication skills;
  • provide prognosis for a medical or traumatic condition.

In addition to demonstrating competency in the above clinical tasks, EM residents should possess knowledge and skill across a spectrum of topics to provide safe and effective patient care for the broad range of MSK and sports-related complaints that are treated in the ED. Table 1 is a recommended list of MSK and sports medicine knowledge and procedural skills adapted from the 2019 EM model core content list. This list is more comprehensive than the original EM model by design, taking into account that desired learning outcomes may range from familiarity through proficiency depending on the topic. Further mastery in select topics may be achieved through a sports medicine fellowship after residency.

Table 1 - Musculoskeletal and sports medicine knowledge, patient care, and procedural skills applicable to emergency medicine practice.
SIGNS, SYMPTOMS, AND PRESENTATIONS
1.2 Pain
 1.2.1 Pain (unspecified)
 1.2.7 Back pain
 1.2.8 Chronic pain
   1.2.8.1 Complex regional pain syndromea
 1.2.9 Extremity pain
 1.2.10 Neck pain
1.3 General
 1.3.4 Ataxia
 1.3.13 Dehydration
 1.3.26 Joint swelling
 1.3.29 Limp
 1.3.34 Palpitations
 1.3.35 Paralysis
 1.3.36 Paresthesia/dysesthesia
 1.3.45 Syncope/near syncope
CARDIOVASCULAR DISORDERS
3.1 Cardiopulmonary Arrest
3.4 Disturbances of Cardiac Rhythm
 3.4.1 Cardiac dysrhythmias
   3.4.1.1 Commotio cordisa
 3.4.2 Conduction disorders
3.4.3 Physiologic and nonphysiologic ECG changes in athletesa
3.5 Diseases of the Myocardium, Acquired
 3.5.2.1 Cardiomyopathy, hypertrophic
 3.5.4 Coronary syndromes
 3.5.7 Myocarditis
   3.5.7.1 COVID-19 related myocarditisa
3.11 Exertional Syncope a
CUTANEOUS DISORDERS
4.4 Infections
 4.4.1 Bacterial
  4.4.1.1 Abscess
  4.4.1.2 Cellulitis
  4.4.1.3 Erysipelas
  4.4.1.4 Impetigo
   4.4.1.6 Folliculitisa
 4.4.2 Fungal
  4.4.2.2 Dermatophytes
 4.4.4. Viral
  4.4.4.3 Herpetic infections
  4.4.4.5 Molluscum contagiosum
ENDOCRINE, METABOLIC, AND NUTRITIONAL DISORDERS
5.3 Fluid and Electrolyte Disturbances
 5.3.2 Hypervolemia/hypovolemia
 5.3.4 Sodium metabolism
5.5 Nutritional Disorders
 5.5.1 Vitamin deficiencies
 5.5.4 Malnutrition
   5.5.4.1 Low energy availability/Relative energy deficiency in sporta
ENVIRONMENTAL DISORDERS
6.1 Bites and Envenomation
6.2 Dysbarism
6.3 Electrical injury (lightning)
6.4 High-altitude Illness
6.5 Submersion Incidents
6.6 Temperature-related Illness
HEMATOLOGIC AND ONCOLOGIC DISORDERS
8.5 Red Blood Cell Disorders
 8.5.1.2.1 Sickle cell anemia
   8.5.1.2.3 Sickle cell traita
    8.5.1.2.3.1 Sickle cell trait associated collapsea
IMMUNE SYSTEM DISORDERS
9.1 Collagen Vascular Disease
 9.1.2 Reactive arthritis (See 11.3.1.6)
 9.1.3 Rheumatoid arthritis (See 11.3.1.3)
9.2 Hypersensitivity
 9.2.1 Allergic reaction
 9.2.2 Anaphylaxis
   9.2.2.1 Exercise-induced anaphylaxisa
SYSTEMIC INFECTIOUS DISORDERS
10.6 Viral
 10.6.1 Infectious mononucleosis
MUSCOLOSKELETAL DISORDERS (NONTRAUMATIC)
11.1 Bony Abnormalities
 11.1.1 Aseptic/avascular necrosis
 11.1.2 Osteomyelitis
 11.1.3 Tumors
 11.1.4 Atypical fractures
11.2 Disorders of the Spine
 11.2.1 Disc disorders
 11.2.2 Inflammatory/infectious spondylopathies
 11.2.3 Radiculopathy (see 12.7.3)
 11.2.4 Spinal stenosis
 11.2.5 Cervical pain
 11.2.6 Thoracic pain
 11.2.7 Lumbosacral pain
  11.2.7.1 Cauda equina syndrome
  11.2.7.2 Sacroiliitis
  11.2.7.3 Sciatica
11.2.7.4 Spondylolysis/spondylolisthesisa
 11.2.8 Discitis
11.2.9 Epidural abscessa
11.3 Joint Abnormalities
 11.3.1 Arthritis
  1.3.1.1 Septic
  11.3.1.2 Crystal arthropathies
  11.3.1.3 Rheumatoid (see 9.1.3)
  11.3.1.4 Juvenile
  11.3.1.5 Osteoarthrosis
  11.3.1.6 Reactive arthritis (see 9.1.2)
   11.3.1.7 Lyme arthritisa
 11.3.2 Developmental dislocation of the hip
 11.3.3 Slipped capital femoral epiphysis
 11.3.4 Synovitis
11.4 Muscle Abnormalities
 11.4.1 Myositis
 11.4.2 Rhabdomyolysis
11.4.3 Chronic exertional/exercise-induced compartment syndromea
11.5 Overuse Syndromes
 11.5.1 Bursitis
 11.5.2 Muscle strains
 11.5.3 Peripheral nerve syndromes
 11.5.4 Tendinopathy
 11.5.5 Stress reaction/fracture
11.5.6 Apophysitisa
11.6 Soft Tissue Infections
 11.6.1 Fasciitis
 11.6.2 Felon
 11.6.3 Gangrene
 11.6.4 Paronychia
 11.6.5 Tenosynovitis
NERVOUS SYSTEM DISORDERS
12.7 Neuromuscular Disorders
 12.7.3 Peripheral neuropathy (See 11.2.3)
   12.7.3.1 Thoracic outlet syndromea
12.10 Spinal Cord Compression
OBSTETRICS AND GYNECOLOGY
13.1 Female genital tract
 13.1.5.1 Abnormal bleeding
   13.1.5.1.1 Amenorrheaa
13.2 Normal pregnancy
13.2.1 Exercise in pregnancya
PSYCHOBEHAVIORAL DISORDERS
14.1 Substance use disorders
 14.1.1 Alcohol use disorder
 14.1.2 Illicit drug use
 14.1.3 Prescription drug use
 14.1.4 Tobacco use disorder
 14.1.6 Opioid use disorder
 14.1.7 Stimulant use disorder
14.9 Feeding and Eating disorders
THORACIC-RESPIRATORY DISORDERS
16.2 Disorders of Pleura, Mediastinum, and Chest wall
 16.2.1 Costochondritis
16.4 Obstructive/Restrictive Lung Disease
 16.4.1 Asthma/reactive airway disease
   16.4.1.1 Exercise-induced bronchoconstrictiona
   16.4.1.2 Exercise-induced laryngospasma
TOXICOLOGIC DISORDERS
 17.1.1 Analgesics
  17.1.1.1 Acetaminophen
  17.1.1.2 NSAIDs
  17.1.1.3 Opioids
  17.1.1.4 Salicylates
 17.1.6 Antidepressants
  17.1.6.1 Bupropion
  17.1.6.2 Selective serotonin reuptake inhibitors
  17.1.6.3 Tricyclic antidepressants
 17.1.19 Local anesthetics
 17.1.23 Nutritional supplements
  17.1.23.2 Performance enhancing and weight-loss drugs
 17.1.24 Recreational drugs
  17.1.24.1 Cannabis
  17.1.24.2 Synthetic cannabinoids
  17.1.24.4 GHB
 17.1.26 Stimulants/sympathomimetics
  17.1.26.1 Amphetamines
  17.1.26.2 Cocaine
TRAUMATIC DISORDERS
18.1.0 Penetrating trauma
 18.1.0.1 Abdominal (18.1.1.3)
 18.1.0.2 Chest (18.1.2.5)
 18.1.0.3 Globe (18.1.10.6)
 18.1.0.4 Neck (18.1.9.2)
 18.1.0.5 Soft tissue extremity (18.1.14.5)
18.1.1 Abdominal trauma (blunt)
 18.1.1.1 Diaphragm
 18.1.1.2 Hollow viscus
 18.1.1.4 Retroperitoneum
 18.1.1.5 Solid organ
 18.1.1.6 Vascular
 18.1.1.7 Abdominal wall
18.1.2 Thoracic trauma (blunt)
 18.1.2.2 Contusion
  18.1.2.2.1 Cardiac
  18.1.2.2.2 Pulmonary
 18.1.2.3 Fracture
  18.1.2.3.1 Clavicle
  18.1.2.3.2 Ribs/flail chest
  18.1.2.3.3 Sternum
  18.1.2.3.4 Scapula
 18.1.2.4 Hemothorax
 18.1.2.6 Pericardial tamponade
 18.1.2.7 Pneumothorax
  18.1.2.7.1 Simple
  18.1.2.7.2 Tension
  18.1.2.7.3 Open
18.1.3 Cutaneous trauma
 18.1.3.1 Avulsions
 18.1.3.2 Bite wounds
 18.1.3.4 Lacerations
 18.1.3.5 Puncture wounds
 18.1.3.6 Nail injuries
18.1.4 Facial trauma
 18.1.4.1 Dental
 18.1.4.2 Le Fort
 18.1.4.3 Mandibular
 18.1.4.4 Orbital
 18.1.4.5 Nasal
 18.1.4.6 Zygomaticomaxillary complex
18.1.5 Genitourinary trauma
 18.1.5.1 Bladder
 18.1.5.2 External genitalia
 18.1.5.3 Renal
 18.1.5.4 Ureteral
 18.1.5.5 Urethral
18.1.6 Head trauma
 18.1.6.1 Intracranial injury
  18.1.6.1.1 Concussion
    18.1.6.1.1.1 Second impact syndromea
    18.1.6.1.1.2 Chronic traumatic encephalopathya
  18.1.6.1.2 Intracranial hemorrhage
 18.1.6.3 Scalp lacerations/avulsions
 18.1.6.4 Skull fractures
18.1.7 Spine trauma
 18.1.7.1 Dislocations/subluxations
 18.1.7.2 Fractures
 18.1.7.3 Sprains/strains
18.1.8 Extremity bony trauma
 18.1.8.1 Dislocations/subluxations
 18.1.8.2 Fractures (open and closed)
18.1.9 Neck trauma
 18.1.9.1 Laryngotracheal injuries
 18.1.9.3 Vascular injuries
18.1.10 Ophthalmologic trauma
 18.1.10.1 Corneal abrasions/lacerations
 18.1.10.3 Periorbital lacerations
 18.1.10.4 Foreign body
 18.1.10.5 Hyphema
 18.1.10.7 Retinal injuries
  18.1.10.8.1 Retinal detachment
   18.1.10.8.2 Commotio retinaea
 18.1.10.8 Traumatic iritis
 18.1.10.9 Retrobulbar hematoma
18.1.10.10 Lens dislocationa
18.1.11 Otologic trauma
 18.1.11.1 Hematoma
 18.1.11.2 Perforated tympanic membrane
18.1.11.3 Auricular lacerationsa
18.1.12 Pediatric fractures
 18.1.12.1 Epiphyseal
  18.1.12.1.1 Salter-Harris classification
 18.1.12.2 Greenstick
 18.1.12.3 Torus
 18.1.12.4 Apophyseal avulsion
18.1.13 Pelvic fracture
18.1.14 Soft-tissue extremity injuries
 18.1.14.1 Amputations/replantation
 18.1.14.2 Compartment syndromes (acute) a
 18.1.14.4 Injuries to joints
 18.1.14.6 Periarticular
 18.1.14.7 Sprains/strains
 18.1.14.8 Tendon injuries
  18.1.14.8.1 Lacerations/transections
  18.1.14.8.2 Ruptures
 18.1.14.9 Extremity vascular injuries
18.1.15 Spinal cord and nervous system trauma
 18.1.15.1 Cauda equina syndrome (see 11.2.7.1)
 18.1.15.2 Injury to nerve roots
 18.1.15.3 Peripheral nerve injury
 18.1.15.4 Spinal cord injury
  18.1.15.4.1 Spinal cord injury without radiologic abnormality (SCIWORA)
PROCEDURES AND SKILLS
19.3 Anesthesia and Acute Pain Management
 19.3.1 Regional anesthesia (nerve block)
 19.3.3 Analgesia
19.3.4 Local anesthesiaa
19.4 Diagnostic and Therapeutic Procedures
 19.4.2 Cardiovascular and Thoracic
  19.4.2.3 ECG interpretation
    19.4.2.3.1 ECG interpretation in athletesa
 19.4.3 Cutaneous
  19.4.3.4 Wound closure techniques
  19.4.3.5 Wound management
 19.4.4 Head, ear, eye, nose, and throat
  19.4.4.1 Control of epistaxis
  19.4.4.7 Tooth stabilization
 19.4.5 Systemic infectious
  19.4.5.1 Personal protection (equipment and techniques)
  19.4.5.2 Universal precautions and exposure management
 19.4.6 Musculoskeletal
  19.4.6.1 Arthrocentesis and joint injectiona
  19.4.6.2 Compartment pressure measurement
  19.4.6.3 Fracture/dislocation immobilization techniques
  19.4.6.4 Fracture/dislocation reduction techniques
  19.4.6.5 Spine immobilization techniques
   19.4.6.7 Interpretation of radiologic studiesa
19.5 Ultrasound
 19.6.1 Diagnostic ultrasound
   19.6.1.1 Thoracoabdominal trauma (e-FAST) a
   19.6.1.2 Joint effusiona
   19.6.1.3 Tendon rupture/injurya
   19.6.1.4 Muscle tear/hematomaa
   19.6.1.5 Fracturea
 19.6.2 Procedural ultrasound
   19.6.2.1 Joint aspiration/injectiona
   19.6.2.2 Regional anesthesia (nerve block) a
Legend: aSuggested additions not currently in the model curriculum.
Adapted from Table 4, EM model (3).

Goals and Objectives

As a companion to the EM model, the Council of Emergency Medicine Residency Directors (CORD) provides a comprehensive set of goals and objectives for EM training (16). Existing goals and objectives were modified to create the following recommended MSK and sports medicine goals and objectives. Given the expected diversity in implementation of this curriculum, it may not be feasible to achieve these goals and objectives upon completion of a specific block rotation or training year. Rather, EM residents should aim to achieve objectives by the time of graduation.

Goal: Develop relevant history and physical examination skills for assessing MSK complaints in the ED.

Objectives:

  1. Perform a relevant history in patients with MSK disorders, using questions focused on location/distribution of pain, mechanism of injury, duration of symptoms, aggravating/alleviating factors, swelling, and prior injury to the area;
  2. perform a basic joint examination on the cervical spine, shoulder, elbow, wrist/hand, lumbar spine, hip, knee, and ankle/foot, using the principles of inspection, palpation, range of motion, strength testing, neurovascular testing, and special tests.

Goal: Learn the use of diagnostic imaging modalities available for the evaluation of orthopedic disorders in the ED

Objectives:

  1. Correctly order and interpret radiographs, including chest; cervical, thoracic, and lumbar spine; pelvis; and extremity films;
  2. perform basic diagnostic MSK ultrasonography in patients with soft tissue disorders including muscle tear, acute tendon rupture, and joint effusion;
  3. understand the role of CT and MRI studies for MSK disorders in the ED.

Goal: Develop skill in the diagnosis and management of MSK trauma.

Objectives:

  1. Describe fractures using standard orthopedic nomenclature including open vs closed, anatomic location (name of bone and location in bone), direction of fracture line, simple vs comminuted, position (angulation, displacement), and articular involvement;
  2. describe the five fracture patterns in the Salter-Harris classification of pediatric fractures;
  3. perform appropriate splinting and/or immobilization of fractures, including clavicle, humeral neck, mid-shaft humerus, supracondylar, occult proximal radius, forearm, both-bone forearm, scaphoid, metacarpal, digit, mid-shaft femur, patella, tibial plateau, tibia/fibula, and tarsal/metatarsal fractures;
  4. develop familiarity with commercially available braces and orthoses used in the ED;
  5. demonstrate acceptable techniques to reduce a dislocated joint, including glenohumeral, elbow, carpal, metacarpal, interdigital, hip, patella, total knee, ankle, and subtalar joints;
  6. describe the presentation, complications, diagnosis, and management of compartment syndromes, including chronic exertional/exercise-induced compartment syndrome;
  7. discuss evaluation and treatment of soft tissue injuries, such as strains, sprains, ligament tears, acute tendon ruptures, penetrating soft tissue injuries, crush injuries, and high-pressure injection injuries;
  8. provide the appropriate disposition for patients with traumatic MSK injuries, including correct specialist and follow-up timeframe;
  9. provide appropriate patient counseling on treatment and follow up plan, expected course of illness, return to sports precautions, potential complications, and indications to return for emergency care.

Goal: Develop skill in the diagnosis and treatment of inflammatory, infectious, and overuse disorders of the MSK system.

Objectives:

  1. Discuss the differential diagnosis and the worrisome historical features and physical examination findings of patients with back pain, including epidural abscess and osteomyelitis;
  2. describe the general diagnostic and management approach of overuse syndromes, such as tendinopathy and apophysitis;
  3. differentiate between the presentation, diagnostic test results, and treatment of transient synovitis and septic joint;
  4. provide the appropriate disposition for patients with inflammatory, infectious, or overuse syndromes of the MSK syndrome, including correct specialist and follow up time frame;
  5. perform and accurately interpret the results of an arthrocentesis.

Goal: Develop procedural skill in joint aspiration and regional anesthesia techniques.

Objectives:

  1. Perform landmark-guided joint injections or aspirations of the glenohumeral (when dislocated), elbow, wrist, knee, and ankle joints;
  2. demonstrate ability to provide regional anesthesia, including hematoma blocks, Bier blocks, and facial, digital, radial, ulnar, median, axillary, femoral, posterior tibial, and sural nerve blocks;
  3. demonstrate ability to perform ultrasound-guided joint injections/aspirations and regional blocks of the joints and extremity nerves listed above.

Goal: Diagnose and provide initial treatment of injuries to the central and peripheral nervous system in the ED.

Objectives:

  1. Describe the symptoms, initial evaluation, and appropriate home care and follow-up instructions for the management of sports-related concussions;
  2. describe the clinical features, physical examination findings, and management for cauda equina syndrome;
  3. recognize spinal cord disorders that require urgent or emergent neurosurgical intervention;
  4. describe the clinical presentation, physical examination findings, risk factors, and initial management plan for common peripheral neuropathies, including cervical radiculopathy, radial nerve palsy, ulnar neuropathy, median neuropathy, lumbar radiculopathy, meralgia paresthetica, and common peroneal neuropathy;
  5. provide the appropriate disposition for patients with spinal cord and peripheral nerve conditions, including correct specialist and follow up time frame.

Goal: Evaluate, stabilize, and treat patients with acute medical disorders related to physical exertion and/or environmental exposure in the ED.

Objectives:

  1. Describe the clinical presentation, typical electrocardiogram (ECG) findings, pathophysiology, and treatment of conditions leading to sudden cardiac arrest or exertional syncope in athletes and patients without cardiac risk factors, including commotio cordis, hypertrophic cardiomyopathy, prolonged QT syndrome, Brugada syndrome, arrhythmogenic right ventricular dysplasia (ARVD), myocarditis, and anomalous coronary artery syndrome;
  2. develop awareness of acute medical illnesses associated with exercise, such as exercise-induced anaphylaxis, exercise-induced bronchoconstriction, rhabdomyolysis, and exercise-associated hyponatremia;
  3. demonstrate correct care for the hypothermic patient, including specific considerations regarding rewarming techniques, blood gas interpretation, intubation, cardiopulmonary resuscitation, and use of cardiovascular medications;
  4. differentiate between the diagnostic criterion, clinical presentation, and proper treatment of heat exhaustion and classic and exertional heat stroke;
  5. differentiate between the clinical presentation, pathophysiology, and proper treatment of dysbaric injuries, including barotrauma of descent, barotrauma of ascent, air embolism, and decompression sickness;
  6. differentiate between the presentation and appropriate therapy for acute mountain sickness, high-altitude cerebral edema, and high-altitude pulmonary edema.

Goal: Foster opportunities for MSK and sports medicine research and scholarship in the ED.

Objectives:

  1. Identify potential topics for investigation related to MSK and sports medicine, such as concussion or acute pain management;
  2. perform a literature review relevant to the topic of study;
  3. demonstrate necessary skills to write a publishable manuscript;
  4. discuss evidence-based best practices through MSK and sports medicine themed journal clubs.

Educational Strategies

Since the core content material crosses cognitive and psychomotor domains, a variety of educational strategies is necessary to meet curriculum objectives. Table 2 matches curricular goals and tasks with suggested educational strategies.

Table 2 - Suggested educational strategies for accomplishing recommended curricular tasks and goals.
Task/Goal Methods to Accomplish
Participate in prehospital care or collaborate with prehospital personnel – ED shifts
– Faculty supervised mass participation, event, or sideline coverage (any type)
– Emergency Medical Services (EMS) rotations
– Online medical control for EMS agencies
Perform a focused MSK and sports medicine history and physical examination – ED shifts
– Orthopedic or PCSM rotations
– Faculty supervised mass participation, event, or sideline coverage (any type)
– Readings, didactic lectures and workshops
– Simulated patient encounters
– Online teaching modules
– National or regional conferences or courses
Appropriately order and interpret diagnostic imaging modalities, including plain radiographs and ultrasonography – ED shifts
– Ultrasound rotations
– Radiology rotations
– Orthopedic or PCSM rotations
– Online teaching modules
– Readings, didactic lectures, and workshops
– National or regional conferences or courses
Manage traumatic MSK and sports injuries, such as fractures and dislocations using closed reduction techniques and splint application – ED shifts
– Orthopedic or PCSM rotations
– Simulation or oral board cases
– Faculty supervised event or sideline coverage (ideally contact sports)
– Online teaching modules
– Readings, didactic lectures, and workshops
– National or regional conferences or courses
Develop skill in management of nontraumatic MSK and sports injuries, such as overuse or infectious disorders – ED shifts
– Orthopedic or PCSM rotations
– Simulation or oral board cases
– Online teaching modules
– Readings and didactic lectures
– National or regional conferences or courses
Provide initial management for central and peripheral nervous system injuries, including sport-related concussions – ED shifts
– Neurology or PCSM rotations
– Faculty supervised event or sideline coverage (ideally contact sports)
– Simulation or oral board cases
– Readings and didactic lectures
– National or regional conferences or courses
Develop procedural skill in joint aspiration and regional anesthesia – ED shifts
– Orthopedic or PCSM rotations
– Anesthesia rotations
– Simulation task trainers or low-fidelity models
– Cadaver lab
– Readings and didactic lectures
– Online teaching modules
– National or regional conferences or courses
Manage patients with acute medical disorders related to physical exertion
and/or environmental exposure
– ED shifts
– Faculty supervised mass participation or event coverage (ideally endurance race/event)
– Simulation and oral board cases
– Readings and didactic lectures
Determine appropriate outpatient referrals or ED consultations for MSK and sports medicine disorders – ED shifts
– Orthopedic or PCSM rotations
– Readings and didactic lectures
– National or regional conferences or courses

The foundation begins with access to reference materials including textbooks, journal articles, online databases, and mobile apps. Free online access medical education (FOAMed) is increasingly dominating the educational workspace, offering MSK and sports medicine teaching through blogs, interactive clinical cases, podcasts, instructional videos for MSK and sports medicine physical and ultrasound examinations, and social media platforms. The accessibility as well as diverse educational delivery of these online resources are well suited for multiple learning styles and, thus, make them a logical approach for this curriculum. A list of high-yield teaching resources curated by this subcommittee are summarized in Table 3.

Table 3 - Recommended teaching resources.
Books
 1. Waterbrook AL, editor. Sports Medicine for the Emergency Physician: A Practical Handbook. Cambridge: Cambridge University Press; 2016.
 2. Sherman SC, editor. Simon’s Emergency Orthopedics. 8th ed. New York: McGraw-Hill; 2019. (available as eBook)
 3. Khodaee M, Waterbrook AL, Gammons M, editors. Sports-related Fractures, Dislocations and Trauma. Advanced On-and Off-field Management. Springer International Publishing, 2020. (available as eBook)
 4. O’Connor FG, Casa DJ, Davis BA, St. Pierre P, Sallis RE, Wilder RP, editors. ACSM Sports Medicine: A Comprehensive Review. Philadelphia: Lippincott Williams & Wilkins, 2012.
 5. Thompson, JC. Netter’s Concise Orthopedic Anatomy, 2nd ed. Elsevier, 2015. (available as eBook)
 6. Madden CC, Putukian M, McCarty EC, Young CC. Netter’s Sports Medicine, 2nd ed, Elsevier; 2018. (available as eBook)
 7. Egol KA, Koval KJ, Zuckerman J, editors. Handbook of Fractures, 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2020 (available as eBook)
 8. Eiff MP and Hatch R. Fracture Management for Primary Care, 3rd ed. Philadelphia: Elsevier Saunders; 2018. (available as eBook)
 9. Brukner and Khan. Clinical Sports Medicine, 5th Ed. Vol 1 Injuries and Vol 2 The Medicine of Exercise. McGraw-Hill Education; 2017
 10. Miller MD and Thompson SR. DeLee, Drez & Miller’s Orthopedic Sports Medicine: Principles and Practice. 5th ed. Philadelphia: Elsevier; 2020.
 11. Miller M. Orthopedic Knowledge Update OKU 5: Sports Medicine. 5th edition. Hutchinson M, ed. Rosemont, IL: AAOS; 2018.
 12. Bianchi S, Martinoli C. Ultrasound of the Musculoskeletal System. Springer; 2016
 13. Jacobson JA. Fundamentals of Musculoskeletal Ultrasound. United States, Elsevier Science; 2018.
 14. Spinner DA, Kirschner JS, Herrera JE. Atlas of Ultrasound Guided Musculoskeletal Injections. New York: Springer New York; 2016.
Online resources
Physical examination videos:
 1. ACEP Musculoskeletal Videos. Chow Y, project manager: https://www.acep.org/how-we-serve/sections/sports-medicine/musculoskeletal-exam-series/
This is a series of videos that will walk the viewer through a proper MSK examination by anatomic location.
Teaching blogs and resources:
 2. https://www.aliem.com/splinter-series/
This is an online series featuring practical, evidence-based orthopedic-related education that is peer reviewed by EM/sports physicians.
 3. https://www.emrap.org/corependium
This is an online Emergency Medicine textbook with multiple chapters covering tendinopathy, trauma, and orthopedic injuries.
 4. https://foundationsem.com/
This is an online flipped classroom curriculum that includes a comprehensive framework of EM educational material and “cannot miss” diagnoses including MSK and orthopedic topics.
 5. ACEP “The Sports Medicine Core Curriculum Lecture Series.” Holschen J, editor: https://www.acep.org/administration/resources/the-sports-medicine-core-curriculum-lecture-series/.
This comprehensive lecture series includes the most common and the most serious medical illness and injuries associated with athletes and physically active individuals. The series was created by the ACEP Sports Medicine Section to fill a current area of deficit in the curriculum of emergency medicine residency programs while also serving to promote one of the five board-certified subspecialties in the specialty.
 6. https://www.cordem.org/resources/education--curricula/curricular-toolkit/
A series of sports medicine teaching modules using assorted methods of instruction for residency programs to incorporate into their curriculum (under development).
Sports ECG:
 7. https://www.amssm.org/ECG-Training-Module.php
Links to two free ECG training modules from University of Washington Center for Sports Cardiology and the British Journal of Sports Medicine.
Online databases:
 8. http://www.wheelessonline.com/
This is an online orthopedic textbook presented by Duke University that provides a comprehensive discussion of orthopedic topics.
 9. https://www.orthobullets.com/
This is an online orthopedic learning resource with educational content, questions, videos, and cases.
 10. https://www.sportsmedreview.com
A web site dedicated to topics in primary care sports medicine.
 11. http://wikism.org/Main_Page
A global open access wiki page for sports medicine.
 12. https://now.aapmr.org
PM&R Knowledge Now is an evolving, dynamic online resource highlighting clinical topics in central nervous system disorders, musculoskeletal medicine, pain medicine, and more.
 13. https://www.uptodate.com
An evidence-based clinical decision support resource (requires paid subscription).
MSK Ultrasound and imaging:
 14. American Medical Society for Sports Medicine (AMSSM) sports ultrasound online didactics: https://www.amssm.org/UltrasoundOnlineDidactics.php
35 video demonstrations covering regional diagnostic ultrasound and interventional procedures for various joints. Free to nonmembers without CME.
 15. European Society of Musculoskeletal Radiology (ESSR): https://www.essr.org/subcommittees/ultrasound/
There are a series of chapters that describes systemic ultrasound scanning techniques by anatomic location.
 16. University of Washington online musculoskeletal radiology book: https://rad.washington.edu/about-us/academic-sections/musculoskeletal-radiology/teaching-materials/online-musculoskeletal-radiology-book/
An online syllabus presenting different conditions in musculoskeletal radiology with a real-world approach to working them up.
 17. Northwestern University EM orthopedic teaching files: https://www.nuemblog.com/ortho-teaching-files
Online teaching files using a case based approach to understanding core diagnostic and management principles of orthopedic injuries in the ED.
 18. https://radiologyassistant.nl/musculoskeletal
This is an online teaching resource that provides written explanation and modules to improve MSK radiology skills.
 19. http://freitasrad.net/
This is an MRI specific site that starts with basic MSK MRI reading and progresses to more advanced.
Educational listservs and social media
 20. Wild Ortho Wednesdays: [email protected]
A peer-reviewed, weekly subscription e-mail targeted at delivering high quality, sports medicine tidbits as they pertain to EM.
 21. Twitter feeds:
  SportsMedicineReview, @SportsMedReview
  Fundamentals of Sports Medicine, @fundamentalofSM
CME Courses
 1. AMSSM Annual Meetings, AMSSM Advance Team Physician Course, AMSSM Sports Ultrasound courses, https://www.amssm.org/Conferences.html
 2. ACSM Annual and Regional Meetings, https://www.acsm.org
 3. ACEP Annual Meeting, https://www.acep.org/
 4. SAEM Annual Meeting, https://www.saem.org
 5. American Institute of Ultrasound in Medicine (AIUM) Musculoskeletal Ultrasound Hands-on Training Course for Beginners, AIUM video programs and webinars, https://www.aium.org/communities/musculoskeletal.aspx
 6. Sideline Management Assessment Response Techniques (SMART).
This course is held at the AMSSM Annual Meeting with a goal of helping enable community physicians develop skills in sideline preparedness. This course includes but is not limited to spine boarding, emergency injury management, and concussion evaluation.
Articles
AMSSM Top 120 Articles for Fellows: http://amssm.blogspot.com/p/amssm-100.html
A list of the current and landmark articles centered on sports medicine topics, updated annually.
Concussion:
 1. Bazarian JJ, Raukar N, Devera G, et al. Recommendations for the emergency department prevention of sport-related concussion. Ann Emerg Med. 2020;75(4):471–82.
 2. Mannix R, Bazarian JJ. Managing pediatric concussion in the emergency department. Ann Emerg Med. 2020;75(6):762–6.
 3. Harmon KG, Clugston JR, Dec K, et al. American Medical Society for Sports Medicine position statement on concussion in sport. Br J Sports Med. 2019;53:213–25.
 4. McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med. 2017;51:838–47.
 5. Manley G, Gardner AJ, Schneider KJ, et al. A systematic review of potential long-term effects of sport-related concussion. Br J Sports Med. 2017;51:969–77.
 6. Marin JR, Weaver MD, Yealy DM, Mannix RC. Trends in visits for traumatic brain injury to emergency departments in the United States. JAMA. 2014;311:1917–9.
 7. Giza CC, Kutcher JS, Ashwal S, et al. Summary of evidence-based guideline update: Evaluation and management of concussion in sports. Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. Jun 2013; 80(24): 2250–7.
Heat Illness:
 1. Case DJ, DeMartini JK, Bergeron MF, et al. NATA Position Statement: Exertional heat illness. J Athl Train. 2015;50(9):986–1000.
 2. Armstrong, LE, Casa, DJ, Millard-Stafford M, et al. Exertional heat illness during training and competition. Med Sci Sports Exerc. 2007;39(3)3: 556–72.
 3. Belval LN, Casa DJ, Adams WM, et al. Consensus Statement: prehospital care of exertional heat stroke. Prehosp Emerg Care. 2018;22:3, 392–7.
 4. Pryor RR, Casa DJ, Holschen JC, et al. Exertional heat stroke: Strategies for prevention and treatment from the sports field to the emergency department. Clin Pediatr Emerg Med. 2013;14(4):267–78.
Cardiovascular:
 1. Drezner JA, O’Connor FC, Harmon KG, et al. AMSSM position statement on cardiovascular preparticipation screening in athletes: current evidence, knowledge gaps, recommendations and future directions. Br J Sports Med. 2017;51(3):153-67.
 2. Drezner JA, Ackerman MJ, Anderson J, et al. Electrocardiographic interpretation in athletes: The ‘Seattle Criteria.’ Br J Sports Med. 2013;47(3):122–24.
 3. Kovacs R and Baggish AL. Cardiovascular adaptation in athletes. Trends Cardiovasc Med. 2016;26(1): 46–52.
 4. Corrado D, Biffi A, Basso C, et al. 12-lead ECG in the athlete: physiological versus pathological abnormalities. Br J Sports Med. 2009;43:669–76.
 5. Drezner JA, Sharma S, Baggish AL, et al. International criteria for electrocardiographic interpretation in athletes. Br J Sports Med. 2017;1:1–28.
 6. Drezner JA, Fischbach P, Froelicher V, et al. Normal electrocardiographic findings: recognizing physiological adaptations in athletes. Br J Sports Med. 2013;47:125–36.
 7. Drezner JA, Ackerman MJ, Cannon BC, et al. Abnormal electrocardiographic findings in athletes: recognizing changes suggestive of primary electrical disease. Br J Sports Med. 2013;47:153–67.
 8. Drezner JA, Ashley E, Baggish AL, et al. Abnormal electrocardiographic findings in athletes: recognizing changes suggestive of cardiomyopathy. Br J Sports Med. 2013;47:137–52.
Cervical Spine:
 1. Swartz EE, Boden BP, Courson RW, et al. National Athletic Trainers’ Association position statement: acute management of the cervical spine-injured athlete. J Athl Train. 2009;44(3):306–31. www.nata.org/sites/default/files/AcuteMgmtOfCervicalSpineInjuredAthlete.pdf.
 2. National Athletic Trainer Association. Appropriate prehospital management of the spine-injured athlete. Updated from 1998 document; 2015. https://www.nata.org/sites/default/files/executive-summary-spine-injury-updated.pdf.
 3. National Athletic Trainer Association. Consensus recommendations on the prehospital care of the injured athlete with a suspected catastrophic cervical spine injury. J Athl Train 2020;55(6):563–72.
Medical Organizations
 1. www.acep.org
  a. Sports Medicine section
https://www.acep.org/how-we-serve/sections/sports-medicine/
 2. www.amssm.org (American Medical Society for Sports Medicine)
 3. www.acsm.org (American College of Sports Medicine)
 4. www.aoasm.org (American Osteopathic Academy of Sports Medicine)
 5. www.aossm.org (American Orthopedic Society for Sports Medicine)
 6. https://ksi.uconn.edu/ (Korey Stringer Institute)
 7. www.nata.org (National Athletic Trainers’ Association)
 8. www.aamc.org
  a. AAMC Report VII Contemporary Issues in Medicine: Musculoskeletal Medicine Education Medical School Objectives Project. 2005
 9. www.cdc.gov
  a. https://www.cdc.gov/traumaticbraininjury/
  b. Concussion Assessment Tools and ED Discharge Instructions: https://www.cdc.gov/headsup/providers/index.html

Clinical experiences are critical for developing competency in MSK and sports medicine, in particular history taking and physical examination skills. Primarily, this will occur either longitudinally during clinical shifts in the ED, or during a dedicated orthopedic rotation covering ED consults. Learners at some institutions may have opportunities to rotate through a PCSM clinic, orthopedic clinic, and/or cover sporting or mass participation events. Clinical rotations also are necessary for achieving procedural competence in basic MSK ultrasonography, regional anesthesia, fracture and dislocation management, and joint aspiration techniques.

Formal didactics can reinforce reading and clinical experiences. These may be led by expert faculty either in person at individual programs/institutions, through video conferencing across institutions, or via recorded lectures online. Given the sizeable overlap between MSK and sports medicine and other content areas within EM, we recommend collaborating with expert faculty in wilderness medicine, emergency medical services/disaster medicine, military medicine, toxicology, ultrasound, pediatric EM, simulation, radiology, orthopedic surgery, PCSM, cardiology, rheumatology, neurology, physical medicine and rehabilitation, and neurosurgery to deliver didactic material. Suggested didactic topics are outlined in Table 4. Didactics may take the form of core content lectures, grand rounds presentations, case discussion, or hands-on workshops for skills instruction. Additionally, learners may attend live or online EM or sports medicine conferences.

Table 4 - Suggested didactic session topics.
PGY 1 Orientation sessions:
 1) Splinting
  Fracture/dislocation immobilization techniques
  Spine immobilization techniques
 2) Introduction to upper extremity (shoulder, elbow, wrist/hand)
  Physical examination demonstration and practice
  Radiography
  Fracture/dislocation reduction techniques
  Treatment of common fractures
 3) Introduction to lower extremity (hip, knee, foot/ankle)
  Physical examination demonstration and practice
  Radiography
  Fracture/dislocation reduction techniques
  Treatment of common fractures
General didactic sessions:
 1) The child with a limp
  Congenital dislocation of the hip
  Slipped capital femoral epiphysis
  Synovitis
  Septic arthritis (overlap with the swollen joint)
  Juvenile/rheumatoid arthritis (overlap with the swollen joint)
  Lyme arthritis (overlap with the swollen joint)
 2) The swollen joint
  Arthritis
   Septic (overlap with the child with the limp)
   Crystal arthropathies
   Juvenile/rheumatoid (overlap with the child with the limp)
   Osteoarthritis
   Reactive
   Lyme (overlap with the child with the limp)
 3) Interpretation of radiologic studies
 4) Minor traumatic brain injury
  Concussion
   Second impact syndrome
   Chronic traumatic encephalopathy
 5) Spine Trauma
  Dislocations/subluxations
  Fractures
  Sprains/strains
  Injuries to the nerve roots
 Spinal cord injuries
  Spinal cord injury without radiographic abnormality (SCIWORA)
 6) Elbow/hand/wrist
  Dislocations/subluxations
  Fractures (open and closed)
  Sprains
  Tendon lacerations/injuries/ruptures
  Soft tissue injuries
  High force injection injuries
 7) Shoulder
  Dislocations/subluxations
  Fractures (open and closed)
  Sprains (AC, SC)
  Calcific tendinitis
  Osteoarthritis
  Shoulder impingement syndrome
  Rotator cuff tears
  Adhesive capsulitis
  Thoracic outlet syndrome
 8) Foot/ankle
  Dislocations/subluxations
  Fractures (open and closed)
  Tendon injuries/ruptures
  Sprains
  Plantar fasciitis
 9) Knee
  Dislocations/subluxations
  Fractures (open and closed)
  Ligament injuries
  Tendon injuries/ruptures
  Patellofemoral pain syndrome
  IT band pain
  Crystal arthropathies
  Patellar tendinopathy
  Osgood-Schlatter
 10) Hip/pelvis
  Dislocations/subluxations
  Fractures (open and closed)
  Snapping hip syndrome
  Femoroacetabular impingement
  Greater trochanteric bursitis
 11) Pediatric fractures
  Epiphyseal
   Salter-Harris classification
  Greenstick
  Torus
  Apophyseal avulsion
 12) Soft-tissue extremity injuries
  Amputations/replantation
  Compartment syndromes
   Chronic exertional/exercise-induced compartment syndrome
  Rhabdomyolysis
  Injuries to joints
  Penetrating injuries
  Periarticular
  Sprains/strains
  Tendon injuries
   Lacerations/transections
   Ruptures
  Extremity vascular injuries
 13) Atraumatic bony abnormalities
  Aseptic/avascular necrosis
  Osteomyelitis
  Tumors
  Atypical fractures (osteoporotic, stress-related, tumor-related, congenital disorders)
 14) Atraumatic back pain
  Osteomyelitis
  Epidural abscess
  Disc disorders
  Inflammatory spondyloarthropathies
  Radiculopathy
  Spinal stenosis
  Cervical pain
  Thoracic pain
  Lumbosacral pain
   Cauda equina syndrome
   Sacroiliitis
   Sciatica
 15) Overuse syndromes
  Bursitis
  Muscle strains
  Peripheral nerve syndromes
   Thoracic outlet syndrome
   Chronic regional pain syndrome
  Tendinopathy
  Stress reaction/fracture
  Apophysitis
 16) Soft tissue infections
  Fasciitis
  Felon
  Gangrene
  Paronychia
  Tenosynovitis
  Cellulitis and other skin eruptions
   Bacterial
   Dermatophytes
   Viral
 17) Mass participation event coverage
  Fluid overload/volume depletion (overlap with syncope/collapse)
  Sodium metabolism (overlap with syncope/collapse)
  Temperature-related Illness (overlap with syncope/collapse)
  Asthma/reactive airway disease
   Exercise-induced asthma
   Exercise-induced laryngospasm
  Mass casualty incidents
 18) Syncope/collapse in exercise and sudden cardiac death
  ECG interpretation in athletes
   ARVD
   Hypertrophic obstructive cardiomyopathy
  Exercise collapse
  Sickle cell trait
  Fluid overload/volume depletion (overlap with mass participation)
  Sodium metabolism (overlap with mass participation)
  Temperature-related illness (overlap with mass participation)
 19) Special topics in athletes
  Exercise in pregnancy
  Malnutrition
   Low energy availability/relative energy deficiency in sports
   Amenorrhea
Simulation-based sessions:
 1) Safe equipment removal
   Face masks
   Helmets and shoulder pads
   Transfer and immobilization techniques
 2) Orthopedic procedures
   Arthrocentesis
   Compartment pressure measurement
   Joint aspiration/injection techniques
   Testing for open joint
 3) Anesthesia and acute pain management
   Local anesthesia (hematoma block)
   Regional nerve block (overlap with ultrasound)
   Analgesia
 4) MSK ultrasound
  Diagnostic ultrasound
   Joint effusion
   Tendon rupture/injury
   Muscle tear/hematoma
   Fracture
  Procedural ultrasound
   Joint aspiration/injection
   Regional nerve block
PGY, postgraduate year.

Simulation is commonly used in EM resident education for procedural training, crisis resource management, and exposure to low-frequency, high-risk situations (17), but the extent of its application for MSK and sports medicine instruction is unclear. Simulation brings a progressive teaching modality for EM residents to practice and improve MSK competencies. Learners should have the opportunity to simulate management of traumatic orthopedic injuries, dislocations, and procedures through mock oral board cases, high-fidelity simulator scenarios, commercially available task trainers, improvised low-technology trainers, or cadaver laboratories. Simulated patient encounters represent a further opportunity to practice history taking and examination skills.

Some programs have longitudinal specialty track instruction established as part of the training experience (18). Tracks may consist of focused journal clubs, targeted skills education, and additional clinical experiences guided by expert faculty in the designated track topic. The longitudinal exposure also creates enhanced opportunities for mentorship. Programs can consider the addition of a sports medicine track to provide additional exposure to MSK and sports medicine topics as resources allow.

Implementation

This curriculum is designed to be flexible. It can conceivably be administered within a 2-week or more ideally a 4-week block rotation, longitudinally over the duration of 36 or 48 months of residency training or a combination of the two experiences. Example educational opportunities which can be built into residency rotation schedules are outlined in Table 5. Since there is no ACGME requirement for dedicated MSK and sports medicine training time, how curricular components are implemented will be up to individual training programs. The cognitive objectives can largely be achieved within a defined time block, such as during a dedicated PCSM rotation or teaching block. Depending on the clinical experiences and other educational resources available, achievement of the skills and procedural competency objectives may take the entire length of residency training. For this reason, early exposure to MSK and sports medicine clinical experiences is recommended.

Table 5 - Suggested educational opportunities for completing curricular components.
Required or Elective Clinical Rotations (1-, 2-, or 4-wk Blocks) Longitudinal Experiences Single Experiences
Primary care sports medicine clinic
Orthopedic ED consults
Orthopedic clinic
Cast room
Inpatient orthopedic service
MSK ultrasound
Radiology
ED shifts
Didactics
Simulation
Cadaver laboratories
Sideline team coverage
Sports medicine scholarly track
MSK/sports journal clubs MSK/sports research
Mass event emergency planning
Mass participation event coverage
Sideline event coverage
Preparticipation physical examinations
National or regional conferences

Ideal implementation of the curriculum is dependent on availability of the following resources: self-directed educational content, MSK and sports medicine faculty champion(s), clinical rotations, simulation programming, and other clinical experiences. Fortunately, many of these resources are already in place and accessible. In addition to MSK and sports medicine textbooks geared toward emergency practice, a wide variety of online databases and FOAMed resources for MSK and sports medicine self-directed learning and teaching exists (see Table 3). Many EM programs currently have access to simulation materials or laboratories. A portion of the recommended curriculum is already included in existing trauma-related education. Since a large percentage of the curriculum content is accessible online, we recommend that it be organized through a national EM education body, such as the Society for Academic Emergency Medicine (SAEM) or CORD alongside the existing EM goals and objectives and the EM model.

Limitations to implementation center around the diversity of program structure across more than 250 EM residency programs in the United States. Facility resources, such as clinical settings, training equipment, and funding for purchasing of new equipment, such as ultrasound machines/probes or simulation materials, vary widely. EM faculty with advanced training in sports medicine is a limited resource at most residency programs. We recommend that programs without access to PCSM fellowship-trained EPs either appoint a MSK and sports medicine faculty champion or recruit outside faculty in orthopedics or PCSM to act as their “go-to” expert for MSK and sports medicine education. With increasing opportunities for virtual meetings and video conferencing, it may be feasible to arrange exchange lectures between expert faculty at different residency programs, similar to existing arrangements between regional fellowship consortiums in medical toxicology and PCSM. In the future, local, regional, or national “train the trainer” faculty development workshops may help nonspecialized EM faculty increase their comfort with teaching MSK and sports medicine topics. Learner time is more constricted at 36-month programs compared to 48-month programs; more emphasis might need to be placed on asynchronous learning at shorter programs. At all programs, longitudinal opportunities, such as team coverage, may not be feasible due to the variability of ED shift work schedules. Ultimately, achieving goals and objectives of the curriculum requires a multimodal approach tailored to the resources available at the individual training program.

Evaluation and Feedback

Learner Evaluation

Learner performance may be measured by a variety of evaluation methods, such as written tests, direct observation of skills, and oral examinations. It may be possible to isolate MSK and sports medicine multiple-choice questions from commercially available test preparation programs for precurriculum and postcurriculum comparison. Currently, however, most of these programs embed MSK questions within a larger category of “Traumatic Disorders,” which would pose logistical challenges to using them as a method of evaluation.

The annual resident in-training examination (ITE) does differentiate between “Traumatic Disorders” and “Musculoskeletal Disorders (Nontraumatic)” and may represent a readily accessible method for learner evaluation. However, only approximately 7 of the 225 questions on the ITE cover nontraumatic MSK disorders (10), and other sports medicine topics, such as concussion, environmental illness, and MSK trauma would not be easily identified. Thus, the ITE alone may not provide sufficient data to reliably demonstrate year-to-year improvement on an individual resident or residency program basis.

With more widespread adoption of the curriculum, a formal summative evaluation process including clinical skills examinations, dedicated MSK and sports medicine question banks, or assessment checklists may be developed and included as part of the curriculum material. Self-assessment of orthopedic competency and satisfaction with orthopedic training by graduated residents can be trended through the postresidency assessment tool.

Curriculum Evaluation

Since the curriculum is untested, formative data are vital for understanding the appropriateness of the educational experience, both in content and delivery. Curriculum evaluation will rely on surveys regarding usability, challenges associated with the curriculum setting/materials/administration, need for further faculty development, and faculty and learner satisfaction (see Supplemental Digital Content 1 http://links.lww.com/CSMR/A108 and 2 http://links.lww.com/CSMR/A109 for sample evaluation questions) in addition to the learner evaluations mentioned above. Residents at nonparticipating programs can be invited to complete the surveys to provide control data.

Conclusions

The EM model and the CORD goals and objectives set for EM residency programs on MSK and sports medicine provide basic guidance and expectations, but universal implementation as well as improvement is needed in the amount, quality, and depth of these experiences. Developing a standardized EM Musculoskeletal and Sports Medicine Model Curriculum aims to both revise and unify the existing MSK and sports medicine core content, and to reduce the variability in depth and breadth of MSK and sports medicine education across EM residency programs. The curriculum outlined above provides a standardized and comprehensive educational template for EM residencies, while utilization of educational and implementation strategies will increase and improve the clinical exposure of EM residents to these topics. This approach will ensure that all future EPs will acquire a solid set of clinical skills for diagnosing and managing MSK and sports medicine conditions in the ED. The resulting increased competency will improve patient care in emergencies related to physical exertion or environmental exposure, as well as semiurgent and nonemergent MSK and sports medicine conditions. Maintenance and improvement of the curriculum will rely on periodic evaluations of the learner, the resources available at training sites, and the curricular content to ensure that the curriculum continues to meet its goals.

The authors declare no conflict of interest and do not have any financial disclosures.

All contributing authors are members of the American Medical Society for Sports Medicine (AMSSM) Education Committee and AMSSM Emergency Medicine Curriculum Subcommittee. www.amssm.org.

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