6.9 Regional Musculoskeletal Syndromes, Back Pain & Sports Injuries

ABIM Internal Medicine Exam

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1 Chapter 0: The ABIM Exam, Blueprint & Study Strategy

0.1 Exam Format, Question Types & the 2026 Blueprint 0.2 Eligibility, Registration, Fees & Exam-Day Logistics 0.3 Scoring, the Passing Standard & Score Reports 0.4 Building a Blueprint-Weighted Study Plan

2 Chapter 1: Cardiovascular Disease (14% of Exam)

1.1 Ischemic Heart Disease & Acute Coronary Syndromes 1.2 Antithrombotic Therapy, Secondary Prevention & Mechanical Complications of MI 1.3 Atrial Fibrillation, Atrial Flutter & Stroke Prevention 1.4 Supraventricular Tachycardias, Ventricular Arrhythmias & Bradycardias 1.5 Heart Failure: Classification, Staging & Guideline-Directed Medical Therapy 1.6 Device Therapy, HFpEF & the Cardiomyopathies 1.7 Valvular Heart Disease & Endocarditis Prophylaxis 1.8 Pericardial Disease & Acute Aortic Syndromes 1.9 Hypertension: Classification, Diagnosis & Secondary Causes 1.10 Hypertensive Crises & Dyslipidemia 1.11 Adult Congenital Heart Disease & Coarctation of the Aorta 1.12 Syncope: Reflex, Orthostatic & Cardiac Causes 1.13 Cardiac Physical Examination, Murmurs & Antithrombotic Selection

3 Chapter 2: Endocrinology, Diabetes & Metabolism (9% of Exam)

2.1 Diabetes Mellitus: Diagnosis, Glycemic Targets & Pharmacotherapy 2.2 Insulin Therapy, Hyperglycemic Emergencies & Chronic Complications 2.3 Thyroid Function Testing & Hypothyroidism 2.4 Thyrotoxicosis, Thyroid Storm & Thyroid Nodules 2.5 Adrenal & Pituitary Disorders 2.6 Hypercalcemia, Hypocalcemia & Disorders of Mineral Metabolism 2.7 Osteoporosis & Paget Disease of Bone 2.8 Ovarian, Testicular & Reproductive Endocrine Disorders 2.9 Hypoglycemia, Endocrine Tumors, Polyglandular Syndromes & Severe Hypertriglyceridemia

4 Chapter 3: Gastroenterology & Hepatology (9% of Exam)

3.1 Esophageal Disease 3.2 Stomach & Duodenal Disease and Gastrointestinal Hemorrhage 3.3 Inflammatory Bowel Disease 3.4 Celiac Disease & Irritable Bowel Syndrome 3.5 Diverticular Disease & Colorectal Cancer Screening 3.6 Viral Hepatitis, Steatotic & Alcohol-Associated Liver Disease 3.7 Cirrhosis & the Complications of Portal Hypertension 3.8 Acute Pancreatitis 3.9 Chronic Pancreatitis & Biliary Tract Disease 3.10 Inherited, Autoimmune & Drug-Induced Liver Disease 3.11 Small Intestinal Disease, Ischemia & Gastrointestinal Complications of HIV

5 Chapter 4: Infectious Disease (9% of Exam)

4.1 Lower Respiratory Tract Infections & Sepsis Syndromes 4.2 Viral Respiratory Pathogens & Tuberculosis 4.3 Central Nervous System Infections 4.4 Skin, Soft Tissue, Bone & Joint Infections 4.5 Infective Endocarditis & Cardiovascular Infection 4.6 Clostridioides difficile & Catheter-Related Bloodstream Infection 4.7 HIV Diagnosis, Antiretroviral Therapy & Prevention 4.8 Opportunistic Infections & Sexually Transmitted Infections 4.9 Fever of Unknown Origin, Neutropenic Fever & Toxic Shock 4.10 Travel-Related Illness, Vector-Borne Disease & Outbreaks 4.11 Infection Prevention, Nosocomial Infection & Postexposure Prophylaxis 4.12 Rheumatic Fever, Poststreptococcal Disease, Enteric & Hepatic Infections

6 Chapter 5: Pulmonary Disease (9% of Exam)

5.1 COPD: Diagnosis, GOLD Classification & Initial Pharmacotherapy 5.2 Interventions That Reduce COPD Mortality & Exacerbation Management 5.3 Asthma: Diagnosis, Stepwise Therapy & Status Asthmaticus 5.4 Interstitial Lung Disease & Idiopathic Pulmonary Fibrosis 5.5 Sarcoidosis, Hypersensitivity Pneumonitis & Occupational Lung Disease 5.6 Pulmonary Embolism: Diagnosis, Risk Stratification & Anticoagulation 5.7 Pulmonary Hypertension & Sleep-Disordered Breathing 5.8 Acute Respiratory Distress Syndrome & Mechanical Ventilation 5.9 Pleural Disease, Empyema & Pneumothorax 5.10 Bronchiectasis, Cystic Fibrosis & Restrictive Lung Disease 5.11 Evaluation of Cough, Dyspnea, Hemoptysis & the Solitary Pulmonary Nodule

7 Chapter 6: Rheumatology & Orthopedics (9% of Exam)

6.1 Rheumatoid Arthritis: Diagnosis & Systemic Manifestations 6.2 Antirheumatic Pharmacotherapy & the Spondyloarthropathies 6.3 Gout: Pathophysiology & Acute Management 6.4 Urate-Lowering Therapy & Calcium Pyrophosphate Deposition Disease 6.5 Osteoarthritis 6.6 Systemic Lupus Erythematosus 6.7 Systemic Sclerosis, Sjogren Syndrome & Inflammatory Myopathies 6.8 The Vasculitides 6.9 Regional Musculoskeletal Syndromes, Back Pain & Sports Injuries 6.10 Other Primary Rheumatic Disorders & Mixed Connective Tissue Disease 6.11 Osteonecrosis & Metabolic Bone Disease

8 Chapter 7: Hematology (6% of Exam)

7.1 Approach to Anemia & the Microcytic Anemias 7.2 Macrocytic, Normocytic & Hemolytic Anemias 7.3 Hemoglobinopathies, Thalassemias & Paroxysmal Nocturnal Hemoglobinuria 7.4 Platelet Disorders, Thrombocytopenia & the Bleeding Patient 7.5 Coagulation Factor Disorders, Thrombophilia & Anticoagulant Reversal 7.6 Acute Leukemias, Chronic Leukemias & Myeloproliferative Neoplasms 7.7 Lymphomas & Plasma Cell Disorders 7.8 Myelodysplastic Syndrome, Myeloproliferative Neoplasms & Porphyria 7.9 Transfusion Medicine & Late Complications of Transplantation

9 Chapter 8: Medical Oncology (6% of Exam)

8.1 Breast, Lung, Colorectal & Prostate Cancer 8.2 Oncologic Emergencies 8.3 Genitourinary & Gynecologic Malignancies 8.4 Head and Neck, Bone & Soft Tissue Cancer and Cancer of Unknown Primary 8.5 Complications of Cancer & Its Treatment 8.6 Cancer Prevention, Survivorship & Psychosocial Care

10 Chapter 9: Nephrology & Urology (6% of Exam)

9.1 Acute Kidney Injury: Staging, Etiology & Urine Microscopy 9.2 Glomerular Disorders & Nephrotic Syndrome 9.3 Nephritic Syndromes, RPGN & Indications for Renal Replacement Therapy 9.4 Chronic Kidney Disease: Staging & Progression Retardation 9.5 Complications of Chronic Kidney Disease: Anemia, CKD-MBD & Acidosis 9.6 Hyponatremia, Hypernatremia & Water Balance 9.7 Potassium Disorders & Systematic Acid-Base Analysis 9.8 Renal Tubular Acidosis & Nephrolithiasis 9.9 Prostate Disorders, Urinary Incontinence & Other Urologic Conditions 9.10 Cystic Kidney Disease, Obstructive Uropathy, Tubulointerstitial Disease & Hematuria

11 Chapter 10: Neurology (4% of Exam)

10.1 Acute Ischemic Stroke: Syndromes & Reperfusion 10.2 Transient Ischemic Attack, Secondary Prevention & Hemorrhagic Stroke 10.3 Headache & Facial Pain 10.4 Seizures, Epilepsy & Movement Disorders 10.5 Multiple Sclerosis & Neuromuscular Junction Disorders 10.6 Motor Neuron Disease & Acute Peripheral Neuropathy 10.7 Cranial Neuropathies & Neuro-Ophthalmology 10.8 Peripheral Neuropathies, CNS Tumors & Other Neurologic Disorders

12 Chapter 11: Psychiatry & Behavioral Health (4% of Exam)

11.1 Major Depressive Disorder & Medical Mimics 11.2 Antidepressant Pharmacotherapy & Treatment-Resistant Depression 11.3 Bipolar Disorder, Mood Stabilizers & Lithium Toxicity 11.4 Anxiety, Stress-Related & Obsessive-Compulsive Disorders 11.5 Alcohol Use Disorder & Withdrawal 11.6 Pharmacotherapy for Alcohol & Opioid Use Disorder 11.7 Toxidromes, Psychiatric Emergencies & Suicide Risk Assessment 11.8 Psychotic, Somatic Symptom, Factitious & Personality Disorders 11.9 Eating Disorders, Sleep Disorders & Sexual Health

13 Chapter 12: Dermatology (3% of Exam)

12.1 Dermatitis, Papulosquamous & Inflammatory Dermatoses 12.2 Acne, Rosacea & Cutaneous Infections 12.3 Herpes Zoster & Autoimmune Blistering Diseases 12.4 Nodules, Tumors & Cutaneous Oncology 12.5 Dermatologic Emergencies & Severe Cutaneous Adverse Reactions 12.6 Pigment Disorders, Alopecia, Nail Disease & Photosensitivity 12.7 Vascular Dermatoses, Environmental Injury & Cutaneous Signs of Systemic Disease

14 Chapter 13: Obstetrics & Gynecology / Women's Health (3% of Exam)

13.1 Contraception, Preconception Care & Teratogenicity 13.2 Hypertensive Disorders of Pregnancy & Gestational Diabetes 13.3 Thyroid Disease & Venous Thromboembolism in Pregnancy 13.4 Menopause & Menopausal Hormone Therapy 13.5 Abnormal Uterine Bleeding, Endometrial Disease & Gynecologic Cancer Screening 13.6 Breast Disorders & Diseases of the Vulva and Vagina 13.7 Menstrual Disorders, Fibroids, Endometriosis & Early Pregnancy Complications

15 Chapter 14: Geriatric Syndromes (3% of Exam)

14.1 Comprehensive Geriatric Assessment & Frailty 14.2 Falls, Gait Assessment & Polypharmacy 14.3 Urinary Incontinence & Pressure Injuries in Older Adults 14.4 Mild Cognitive Impairment, Dementia & Its Subtypes 14.5 Delirium & the Pharmacotherapy of Cognitive Disorders 14.6 Palliative Care, Hospice & Advance Care Planning 14.7 Chronic Wounds, Nutrition, Swallowing, Constipation & Hip Fracture 14.8 Sensory Impairment, Dizziness, Elder Mistreatment & Care Settings

16 Chapter 15: Allergy & Immunology (2% of Exam)

15.1 Anaphylaxis: Recognition & Emergency Management 15.2 Urticaria & Angioedema 15.3 Drug Allergy, Desensitization & Adult Immunodeficiency 15.4 Food Allergy, Insect Venom Hypersensitivity, Serum Sickness & Contrast Reactions 15.5 Rhinitis, Conjunctivitis, Eosinophilic & Mast Cell Disorders

17 Chapter 16: Preventive Medicine, Immunization & Clinical Epidemiology

16.1 The USPSTF Framework & Evidence-Based Cancer Screening 16.2 Cardiovascular & Metabolic Screening and Primary Prevention 16.3 Adult Immunization & Vaccines in Special Populations 16.4 Clinical Epidemiology, Biostatistics & Study Design

18 Chapter 17: Miscellaneous - Ethics, Patient Safety & Quality Improvement (2% of Exam)

17.1 Principles of Bioethics & Decisional Capacity 17.2 Informed Consent, Treatment Refusal & Special Scenarios 17.3 Surrogate Decision-Making, Advance Directives & Confidentiality 17.4 Patient Safety Science, Medical Error & Diagnostic Reasoning 17.5 Quality Improvement Methods, Health Disparities & Health Equity

19 Chapter 18: Perioperative Medicine & Medical Consultation

18.1 Preoperative Cardiovascular Risk Assessment 18.2 Preoperative Pulmonary Risk & Perioperative Medication Management 18.3 Perioperative Anticoagulation, Bridging & Postoperative Complications

20 Chapter 19: Ophthalmology (1% of Exam)

19.1 The Acute Red Eye & Ophthalmic Emergencies 19.2 Painless Vision Loss & Chronic Ophthalmic Disease 19.3 Uveitis, Scleritis & Orbital Disease

21 Chapter 20: Otolaryngology & Dental Medicine (1% of Exam)

20.1 Dizziness, Vertigo & Epistaxis 20.2 Ear Disorders, Hearing Loss & Upper Respiratory Infections 20.3 Oral Cavity, Salivary Gland, Laryngeal & Taste and Smell Disorders

6.9 Regional Musculoskeletal Syndromes, Back Pain & Sports Injuries

Key Takeaways Explain This Topic AI

Back pain, shoulder, elbow, wrist and hand, hip and pelvic, knee, foot and ankle syndromes and other bursitis are the enumerated regional musculoskeletal topics.

Imaging is not indicated for acute low back pain without red flags, because incidental findings are common and do not change management.

Cauda equina syndrome with urinary retention, saddle anesthesia and bilateral leg weakness requires emergent magnetic resonance imaging and surgical decompression.

Rotator cuff tendinopathy produces painful abduction with preserved passive range, whereas adhesive capsulitis restricts passive range as well.

Trochanteric pain syndrome from gluteal tendinopathy is the usual cause of lateral hip pain and is often misattributed to true bursitis.

Last updated: August 2026

1. Low Back Pain

The first task is triage into three categories: non-specific mechanical pain (about 85%), radiculopathy or spinal stenosis , and serious underlying pathology (well under 5%).

Red flags that change management

Red flag Concern

Urinary retention, saddle anesthesia, bilateral leg weakness, bowel incontinence Cauda equina syndrome — emergent MRI and decompression

• Fever, injection drug use, recent bacteremia, indwelling device Vertebral osteomyelitis or epidural abscess
• History of cancer, unexplained weight loss, pain at night or at rest Metastatic disease
• Age over 70, osteoporosis, chronic corticosteroid use, minor trauma Compression fracture
• Progressive or severe neurologic deficit Cord or root compromise

Without red flags, do not image. Early imaging does not improve outcomes, and degenerative findings are ubiquitous in asymptomatic adults — disc bulges and facet arthropathy are present in most people over 50. Imaging generates procedures rather than answers.

Management of non-specific pain: remain active (bed rest worsens outcomes), heat, NSAIDs or acetaminophen, and physical therapy for persistent symptoms. Opioids and systemic corticosteroids are not indicated for acute non-specific back pain.

Nerve root syndromes and spinal stenosis

These are enumerated in the blueprint under Neurology as nerve root syndromes and mechanical lesions of the spine .

• Root Motor Sensory Reflex
• L4 Knee extension, dorsiflexion Medial calf Patellar
• L5 Great toe dorsiflexion , foot eversion Dorsum of foot, lateral leg None
• S1 Plantar flexion Lateral foot, sole Achilles

Lumbar spinal stenosis produces neurogenic claudication : bilateral buttock and leg pain worsened by standing and walking, relieved by sitting or lumbar flexion . Patients report walking further when leaning on a shopping cart. The critical contrast is with vascular claudication , which is relieved by standing still, is not posture-dependent, and comes with diminished pulses and a reduced ankle-brachial index.

2. Shoulder

Condition Key finding

Rotator cuff tendinopathy / impingement Painful arc of abduction; passive range preserved ; positive Neer and Hawkins tests

Rotator cuff tear Weakness on empty-can (supraspinatus) test; inability to hold arm elevated (drop-arm sign)

Adhesive capsulitis Loss of passive as well as active range , especially external rotation; associated with diabetes and thyroid disease

• Biceps tendinopathy Anterior shoulder pain; positive Speed test
• Acromioclavicular osteoarthritis Focal tenderness at the joint; pain on cross-body adduction
• Glenohumeral osteoarthritis Crepitus, global restriction, radiographic joint space loss

The single most useful discriminator is passive range of motion. Preserved passive range with painful active motion indicates a cuff or bursal problem; restricted passive range indicates capsular or glenohumeral disease.

3. Elbow, Wrist and Hand

Lateral epicondylosis (tennis elbow): pain over the lateral epicondyle, worse with resisted wrist extension . Overwhelmingly the more common of the two.

Medial epicondylosis (golfer elbow): pain with resisted wrist flexion and pronation.

Olecranon bursitis: fluctuant posterior swelling. Aspirate if warm, red or febrile — septic bursitis is common here.

De Quervain tenosynovitis: radial wrist pain; positive Finkelstein test ; classic in new parents and in repetitive thumb use.

Carpal tunnel syndrome: nocturnal paresthesia in the median distribution with thenar wasting in advanced disease. Associations include pregnancy, hypothyroidism, diabetes, obesity, acromegaly and amyloidosis. Nocturnal wrist splinting is first-line.

Dupuytren contracture: painless palmar fascial cords with flexion contracture, most often of the fourth and fifth digits.

Trigger finger: catching or locking with a palpable A1 pulley nodule.

4. Hip and Pelvis

Localizing the pain determines the differential , and this is the reasoning the exam rewards:

• Location Likely source
• Groin True hip joint — osteoarthritis, osteonecrosis, femoral neck fracture, labral tear
• Lateral Greater trochanteric pain syndrome — gluteus medius/minimus tendinopathy
• Posterior / buttock Lumbar spine referral, sacroiliac joint, ischial bursitis

Lateral hip pain is rarely true bursitis. It is usually gluteal tendinopathy , and the term greater trochanteric pain syndrome reflects that. It responds to load management and eccentric strengthening rather than to repeated injection.

Meralgia paresthetica — burning numbness over the anterolateral thigh from lateral femoral cutaneous nerve compression — is purely sensory with no weakness and no reflex change. It is associated with obesity, tight belts and pregnancy, and it is enumerated in the blueprint under peripheral neuropathy.

5. Knee

• Condition Key finding
• Meniscal tear Joint-line tenderness, mechanical locking or catching, positive McMurray test
• Anterior cruciate ligament tear Audible pop, immediate hemarthrosis, positive Lachman test (most sensitive)
• Medial collateral ligament injury Laxity with valgus stress at 30 degrees of flexion
• Patellofemoral pain Anterior pain worse with stairs and prolonged sitting; young, often female
• Pes anserine bursitis Tenderness 4 to 5 cm below the medial joint line
• Prepatellar bursitis Anterior swelling from kneeling; consider septic bursitis
• Baker cyst Popliteal fullness; rupture mimics deep vein thrombosis

Rapid effusion after injury: blood within two hours indicates anterior cruciate ligament tear, osteochondral fracture or patellar dislocation. Slower effusion over a day is more typical of meniscal injury.

The Ottawa knee rules identify who needs radiography after acute injury: age 55 or older, isolated patellar tenderness, fibular head tenderness, inability to flex to 90 degrees, or inability to bear weight for four steps both immediately and in the emergency department.

6. Foot and Ankle

Plantar fasciitis: heel pain worst with the first steps in the morning and after rest; point tenderness at the medial calcaneal tubercle. Treated with stretching, supportive footwear and load reduction. Imaging is unnecessary, and heel spurs are incidental.

Achilles tendinopathy: posterior heel pain; fluoroquinolone use is a recognized precipitant of tendinopathy and rupture .

Achilles rupture: audible pop, palpable gap, positive Thompson test (no plantar flexion on calf squeeze).

Morton neuroma: burning pain in the third web space with a palpable click on lateral compression.

Tarsal tunnel syndrome: burning plantar pain from posterior tibial nerve compression.

The Ottawa ankle rules limit unnecessary radiography: image only with bone tenderness at the posterior edge or tip of either malleolus, tenderness at the navicular or base of the fifth metatarsal, or inability to bear weight for four steps.

7. Sports Injuries and Trauma

A separately enumerated blueprint subsection. The internist-facing points:

Overuse injuries — stress fracture, tendinopathy, medial tibial stress syndrome — result from training errors, most commonly a rapid increase in volume or intensity. Stress fractures are frequently invisible on initial radiographs ; MRI is the sensitive test, and a normal early film does not exclude one.

The female athlete triad / relative energy deficiency in sport — low energy availability, menstrual dysfunction and low bone density — is a cause of stress fractures in young women and requires nutritional rather than orthopedic management.

Concussion is a clinical diagnosis; imaging is normal. Return to play follows a graduated protocol, and an athlete should never return the same day.

Exertional rhabdomyolysis presents with severe muscle pain, weakness and dark urine after unaccustomed exertion; treatment is aggressive intravenous fluid.

Exercise-associated hyponatremia results from excessive hypotonic fluid intake during endurance events and is treated with hypertonic saline, not with more free water.