MD Acumen · MRCGP SCA course · free practice resources
MRCGP SCA course · Starter Station B
Starter Station B · Knee pain
A 52-year-old self-employed decorator with a painful knee wants an MRI scan.
Reviewed and kept current
Video consultation · Undifferentiated presentation · Prescribing · Long-term condition · 12-minute case · 3 min reading · Last editorial review: 11 October 2026 · Next scheduled refresh: 11 April 2027 · Clinical content signed by Course Director, 11 October 2026.
Candidate instructions
Read this as you would outside the room
Read the brief as you would in the examination (RCGP: twelve consultations with simulated patients, each lasting twelve minutes, with 3 minutes' reading at the start of each). There is no reference material. Everything below the brief is folded until the consultation is over.
| Information | |
|---|---|
| Frame | You have 3 minutes to read, then 12 minutes. Video consultation. Everything below this brief is folded away until the consultation is over. |
| Your role | GP partner at a town practice, holding the afternoon's video list. |
| Patient | Paul Whitmore, 52. |
| Reason for consultation | “Right knee; needs a scan.” Booked by telephone. |
| Format | Video. He is at home in the kitchen; you can see his face and, if he stands, his knee and his walk. You cannot examine him; you may ask what he can do and show you. |
Information available
The records extract, printed as it appears.
| Problem list | Hypertension, well controlled. No other entries. |
| Medication | Ramipril 5 mg daily. Over-the-counter: ibuprofen 400 mg. Allergies: none recorded. |
| Nurse, 3 months ago | BP 132/82. BMI 31. “Knee mentioned; advised to book.” |
| Imaging | No knee imaging on record. |
| Occupation | Self-employed painter and decorator. |
Your task
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Assess his knee.
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Reach a working diagnosis with the alternatives you have considered.
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Agree a plan, including an answer to his request for a scan.
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Address his concerns.
Folded away
For the role player and the observer
Open these after the consultation, or during it if you are observing. The role-player script and every marking section are public (D-76): this is practice material, not an examination.
1 · Role-player script — opening line, story, ICE, hidden facts and triggers (examination findings last)
Candidates: do not open until you have consulted.
Persona and manner
- Paul Whitmore, 52, a self-employed painter and decorator; practical, plain-speaking, a little weary; you have put this off for months and have now decided what you need.
- You sit with the right leg out straight and rub the knee when it is mentioned. Not aggressive; you want to be taken seriously.
Opening line (verbatim)
- “It's my right knee, doctor — it's been giving me grief for about six months and I'm on it all day. I reckon I've torn the cartilage and I need an MRI so we can get on with fixing it.”
The story
- “An aching pain on the inner side, worse going down stairs, kneeling, and at the end of a working day.”
- “Stiff for a few minutes first thing and after sitting in the van. It eases off once I'm moving.”
- “Sometimes it feels like it'll give when I turn quickly on it.” It has never actually given way and you have never fallen.
- If asked: no injury or twist; it came on gradually. It never locks or gets stuck. No true giving way.
- Mild swelling at the end of a long day; never hot or red; no fever; you are not unwell.
- No hip pain, no back pain, no pain at night that wakes you, no weight loss.
- Ibuprofen two or three times a day on working days for four months; some indigestion; no black stools.
- You kneel on hard floors most days; knee pads “sometimes”; you climb ladders. Your weight has crept up about a stone in two years: “sandwiches in the van”. You walk the dog; no other exercise. You have never seen a physiotherapist: “What would they do?”
- Self-employed; no sick pay; a big contract starts next month and you cannot afford to be off. Your wife works part-time; two teenagers; a mortgage.
- A mate had his knee “scoped and was right as rain”. That is where the plan came from.
Ideas, concerns and expectations
- Idea: Torn cartilage that needs a scan and a keyhole operation.
- Concern: Not being able to work; “ending up with a knee replacement at 60 like my dad”.
- Expectation: An MRI “so we know”, then “whatever it takes”.
Impact
- Work: kneeling and ladders all day; the big contract next month; no sick pay.
- Home: a mortgage, two teenagers, your wife part-time.
- Exercise: the dog; nothing else; the weight creeping up.
Red flags
- Absent: No injury, no locking, no true giving way, no hot or red joint, no fever, no night pain, no weight loss, no hip or back symptoms.
- Absent: No black stools with the ibuprofen; blood pressure controlled.
Hidden facts and their triggers
- “I can't be off work, that's the thing” — released only say it with a sigh at minute two; explain only if asked
- “The ibuprofen's the only thing keeping me going” — released only at minute five; this opens the painkiller and stomach line
- The mate's keyhole operation — released only if asked where the idea of the scan came from
- Your father's knee replacement — released only if asked what worries you
- The indigestion from the ibuprofen — released only if asked about side-effects or the stomach
Behaviour
- Minute 2: “I can't be off work, that's the thing.” A sigh; do not explain unless asked.
- Minute 5: “The ibuprofen's the only thing keeping me going.”
- If the doctor explains that this fits wear and tear of the joint, that a scan would not change the plan and that keyhole operations do not help this kind of knee, and offers a real plan (physiotherapy with a strengthening programme, the weight, a gel instead of the tablets, knee pads and pacing, a review, and what would prompt referral): doubtful for a moment (“So no scan?”), then accept if the reasoning is clear and the plan concrete. Ask, “And if it doesn't get better?”
- If the doctor agrees to the MRI without discussion: “Great. How long will that take?” Leave satisfied.
- If the doctor refuses the MRI flatly without explaining: push back once (“My mate got one”), then go quiet and look at the door.
- If the doctor addresses work honestly (what you can and cannot do, a note for adjusted duties if needed): visibly relieved.
Examination findings, if the candidate states what they would examine and why
- Video: if the candidate asks you to stand and walk across the kitchen: you walk normally with a slight favouring of the right leg; you can squat part-way and stand again. If asked to point to the pain: the inner side of the knee.
- If the candidate states what they would examine in person and why, give the nurse's findings from tomorrow's appointment: tenderness along the inner joint line; a small effusion; crepitus; full extension; flexion to 120 degrees; no ligament laxity; a negative meniscal provocation test; hip movements full and painless; BMI 31.
2 · Examiner mark sheet — generic SCA scheme plus the key facts for this case
Domain grades — with the key facts that earn a clear pass at this station
| Domain (RCGP wording) · key facts for this case | CF (0) | F (1) | P (2) | CP (3) | Score |
|---|---|---|---|---|---|
1 · Data gathering and diagnosis
| ☐ | ☐ | ☐ | ☐ | /3 |
2 · Clinical management and medical complexity (×1.5)
| ☐ (0) | ☐ (1.5) | ☐ (3) | ☐ (4.5) | /4.5 |
3 · Relating to others
| ☐ | ☐ | ☐ | ☐ | /3 |
| Case total | /10.5 |
Global rating (recorded, not added to the total): ☐ Fail ☐ Bare Fail ☐ Bare Pass ☐ Pass
The domain grades (RCGP descriptors): CP clear pass — above the standard of a newly qualified, independent GP · P pass — sufficiently demonstrated at the standard · F fail — insufficiently demonstrated at the standard · CF clear fail — clearly demonstrated below the standard.
The RCGP grades each domain CF, F, P or CP and weights clinical management and medical complexity against the other two domains; the examination's maximum is 126 over twelve cases, which is 10.5 per case. The RCGP does not publish the mark each grade carries. MD Acumen's training sheet uses CF 0 · F 1 · P 2 · CP 3, with clinical management weighted ×1.5 (0 · 1.5 · 3 · 4.5), so that a case is marked out of 10.5 and a twelve-case circuit out of 126. A P in all three domains is 7.0; MD Acumen treats that line as the training standard for a case. The examination's pass mark is set by borderline regression for each diet and is published in the RCGP's diet summary reports; it is not a fixed fraction of 126.
Weighting rationale, in the RCGP's words: “To reflect the capability coverage within the clinical management and medical complexity domain this is weighted in comparison to the other two domains.”
3 · Expanded station standard — what earns a clear pass, pass, fail and clear fail here
Written to the standard of a newly qualified independent GP; the clear-pass row describes practice above that standard. It is a debriefing aid, not a checklist: the grade is a judgement that the essentials, the italic key facts on the mark sheet, were done well, at the patient's pace and in plain language. MD Acumen training standard; the RCGP does not publish case mark sheets.
| Grade | Data gathering and diagnosis | Clinical management and medical complexity | Relating to others |
|---|---|---|---|
| CP | Reasons aloud in the first three minutes that age, gradual onset, morning stiffness under half an hour and no locking point to wear of the joint, not a tear that needs imaging, and says what examination would confirm it. Picks up both cues, the sigh about work and the ibuprofen, and follows each. Counts the ibuprofen and asks about the stomach and the blood pressure tablet. Asks where the scan idea came from. | Explains that imaging would not change the plan and that keyhole operations are not offered for this kind of knee, and says what would change the decision. Offers the core treatment as a programme: therapeutic exercise with physiotherapy, weight management with a target, a gel first and the oral ibuprofen limited with the stomach and the ramipril in mind. Addresses work directly: knee pads, a kneeler, pacing, a note if needed. Sets expectations in months and the review date. | Uses the friend's story to explain why his case differs, without dismissing it. Names the fear about the contract and the mortgage and answers it with what he can and cannot do. Balances honesty about the long term with optimism about function, without the bone-on-bone language. Negotiates the ibuprofen reduction as his choice. Acknowledges the father's replacement and says what reduces that risk. Checks what he will do this week in his own words. |
| P | Establishes the mechanism and course: gradual, no injury. Asks the red flags and the mechanical symptoms: locking, true giving way, night pain, a hot swollen joint, hip and back. Quantifies the NSAID use and asks about the stomach. Explores the occupation, the kneeling and the work impact. Requests a focused examination and interprets the findings as a medial osteoarthritis pattern. Working diagnosis: osteoarthritis of the knee. | Explains that MRI is not indicated and why. Offers the core treatment: therapeutic exercise through physiotherapy or self-referral, weight management, a topical NSAID first and the oral NSAID limited with gastroprotection if it continues. Work adjustments: knee pads, pacing, a kneeler; a note for adjusted duties discussed. Explains that arthroscopy is not offered for degenerative knees. A safety-net for locking, a hot swollen joint or rapid deterioration. Follow-up in six to eight weeks. | Explores where the MRI idea came from and uses the friend's story to explain why his case differs. Names the work fear and responds practically, with what he can and cannot do and a note if needed. Explains the joint in plain language without catastrophising about bone on bone. Negotiates the ibuprofen reduction as his choice. A shared plan; checks what he will do this week. |
| F | Accepts “torn cartilage” as the diagnosis. No red-flag or mechanical screen. No work history, so the contract and the sick pay are never known. The ibuprofen not counted and the stomach not asked about. Does not ask where the scan idea came from. Does not request or interpret an examination. | Orders the MRI to satisfy the request. Or continues the oral ibuprofen without thought for the stomach or the ramipril, and without gastroprotection. No exercise plan, or physiotherapy mentioned without a route into it. No plan for work, so the contract decides what he does. No referral criteria explained and no expectations set. No safety-net for locking or a hot joint. No follow-up date. | Lectures about the weight. Refuses the scan without reasoning, so that he says “My mate got one” and goes quiet, or grants it to end the discussion. Ignores the self-employment and the income. Uses osteoarthritis, effusion and arthroscopy as labels without explanation. Does not pick up the sigh. |
| CF | No history of the knee beyond the request; no mechanical screen, so locking and true giving way are never asked; no work history, so the contract and the sick pay are never known; the ibuprofen and the stomach never discovered; the consultation a negotiation about the scan from the first minute, with no working diagnosis stated at the end of twelve minutes. | Unsafe or absent: an MRI ordered as the plan with no treatment; or the oral ibuprofen continued indefinitely with indigestion and an ACE inhibitor; or the scan refused and nothing offered in its place, so that he leaves with the same knee, the same tablets and no programme. | Dismissive of the request or collusive with it; moralising about the weight and the sandwiches so that he stops contributing; no acknowledgement of the contract, the mortgage or the father's knee replacement; ends without any check of what he has understood or will do this week. No partnership, and a man who will carry on with the ibuprofen and wait for the scan. |
Where candidates lose this station
- Accepting “torn cartilage” as the diagnosis and ordering the MRI, so that the plan is a scan and nothing else (statement D7)
- Refusing the scan without reasoning, so that he says “My mate got one” and goes quiet (statement R4)
- Missing “I can't be off work, that's the thing”, so that the plan ignores the contract and will not be followed (statement D3)
What the examiner is listening for in the last four minutes
By 8:00 the working diagnosis should have been stated: osteoarthritis of the knee, diagnosed clinically, with the reasons a scan would not change the plan. The examiner is listening for: the exercise programme with a route into physiotherapy; the weight as a target; the gel first and the ibuprofen limited with the stomach and the ramipril in mind; the work plan (pads, kneeler, pacing, a note if needed); expectations in months; the referral criteria and the safety-net for locking or a hot joint; the review date; and his own words on what he will do this week.
4 · RCGP feedback statements — where underperformance was identified — with case-specific examples
The ten statements below are postulated: the feedback an examiner would most likely attach at this station, chosen from the RCGP's standardised list of 26 feedback statements that applies to every SCA case and spans the three marking domains (Data Gathering and Diagnosis; Clinical Management and Medical Complexity; Relating to Others). They are a prediction from the case content, its complexity and the marks that matter, not an examiner's record: any statement on the full list can be attached to any case, and feedback plays no part in the mark. Record the statements that applied in the practice log.
| RCGP feedback statement (postulated top ten) | Underperformance it signals (generic) | Station-specific example |
|---|---|---|
| D1 · Data gathering was insufficient to enable safe assessment of the condition/situation Data gathering and diagnosis · Data gathering and interpretation | History too thin to decide safely: the presenting problem not characterised, the essential negatives not asked. |
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| D3 · Relevant psychological or social information insufficiently recognised or responded to Data gathering and diagnosis · Practising holistically, promoting health and safeguarding | The person's circumstances, mood, work or home not asked about, or heard and not acted on. |
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| D6 · The implications of relevant findings identified during the data gathering were insufficiently recognised or understood Data gathering and diagnosis · Data gathering and interpretation | A finding or result is elicited but its meaning is not recognised or not followed up. |
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| D7 · Differential diagnoses or hypotheses were inadequately generated or tested Data gathering and diagnosis · Making diagnosis/decisions | One diagnosis assumed; alternatives not generated, or generated but not tested with a question. |
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| C2 · The management plan relating to prescribing of medication was inappropriate or not reflective of current practice Clinical management and medical complexity · Clinical management | A drug started, continued or stopped against current guidance, or without the checks it needs. |
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| C3 · The management plan relating to investigations was inappropriate or not reflective of current practice Clinical management and medical complexity · Clinical management | Investigations ordered without purpose, omitted when needed, or not explained. |
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| C5 · The plan relating to the medical management of risk was inadequate or inappropriate Clinical management and medical complexity · Clinical management; Organisation, management and leadership | Clinical risk left unmanaged: no plan for the thing that could go wrong, or the risk not weighed. |
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| R3 · The circumstances, relevant cultural differences and/or preferences of those involved were insufficiently responded to Relating to others · Communication and consultation skills; Practising holistically, promoting health and safeguarding; Community orientation | The person's circumstances, culture or preferences not responded to in the plan. |
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| R4 · Explanations were inadequately shared or adapted for the person's needs Relating to others · Communication and consultation skills | Explanation in jargon, at the wrong pace, or not adapted to the person's level and concerns. |
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| R7 · Ownership or responsibility for decision-making was inadequate or inappropriate Relating to others · Fitness to practise; Making diagnosis/decisions; Maintaining an ethical approach | Decisions deferred, delegated or left to the patient when the doctor should own them. |
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The full list of 26 statements, with the generic meaning of each, is on the exam and the mark scheme.
5 · Examiner points of fact and guidelines
Points of fact the examiner should have to hand
Each statement is drawn from the named guideline, in its current version, with the date it was checked. The examiner marks against these facts; the candidate is not expected to quote them.
- Diagnose osteoarthritis clinically without investigations in people aged 45 and over who have activity-related joint pain and either no morning stiffness or morning stiffness lasting no longer than 30 minutes; do not routinely use imaging to diagnose osteoarthritis unless there are atypical features or features that suggest an alternative or additional diagnosis. NICE — NG226 Osteoarthritis in over 16s: diagnosis and management, section 1.1, diagnosis, October 2022, checked 10 Oct 2026
- Offer therapeutic exercise tailored to the person's needs as a core treatment for osteoarthritis, with information and support; offer weight-loss support to people living with overweight or obesity; the benefits of exercise accrue over months. NICE — NG226 Osteoarthritis in over 16s: diagnosis and management, section 1.3, non-pharmacological management: exercise; weight management, October 2022, checked 10 Oct 2026
- Offer a topical NSAID for knee osteoarthritis; if an oral NSAID is needed, use the lowest effective dose for the shortest time with a proton pump inhibitor; do not offer paracetamol or weak opioids routinely; do not offer glucosamine or strong opioids. NICE — NG226 Osteoarthritis in over 16s: diagnosis and management, section 1.4, pharmacological management, October 2022, checked 10 Oct 2026
- Do not refer people with osteoarthritis for arthroscopic lavage and debridement unless the knee has a clear history of mechanical locking; consider referral for joint replacement when symptoms substantially affect quality of life and non-surgical management has been tried. NICE — NG226 Osteoarthritis in over 16s: diagnosis and management, section 1.6, referral for joint surgery, October 2022, checked 10 Oct 2026
- NSAIDs can raise blood pressure and reduce the effect of ACE inhibitors, and the combination increases the risk of acute kidney injury, particularly with dehydration; an oral NSAID in a person taking ramipril warrants the lowest dose for the shortest time, blood pressure review and gastroprotection where it continues. NICE CKS — NSAIDs: prescribing issues, adverse effects and interactions: cardiovascular; renal; ACE inhibitors, current online version, checked 10 Oct 2026
- A fit note can state that the person may be fit for work with adjustments such as amended duties or workplace adaptations; for a self-employed person the note supports a conversation about what the work can look like rather than absence. GOV.UK (DWP) — Getting the most out of the fit note: guidance for healthcare professionals, may be fit for work; adjustments, 2022, updated 2024, checked 10 Oct 2026
- NG226: consider an intra-articular corticosteroid injection for short-term relief when other pharmacological treatments are ineffective or unsuitable, or to support therapeutic exercise; do not offer intra-articular hyaluronan. Do not routinely offer insoles, braces, tape, splints or supports unless there is joint instability or abnormal biomechanical loading, therapeutic exercise has not helped, and the aid is likely to improve movement and function; consider walking aids where they help. Do not offer acupuncture or dry needling for osteoarthritis. NICE — NG226 Osteoarthritis in over 16s: diagnosis and management, section 1.3, non-pharmacological management: devices and aids; acupuncture; section 1.4, intra-articular injections, October 2022, checked 10 Oct 2026
- NG226: manual therapy (manipulation, mobilisation or soft-tissue techniques) is considered for hip or knee osteoarthritis only alongside therapeutic exercise; people are told that joint pain may increase when exercise starts and that the benefit comes with long-term adherence. Referral for joint replacement rests on symptoms and function after non-surgical treatment has been tried; people are not excluded from referral because of age, sex or gender, smoking, comorbidities, or overweight or obesity. A review plan is agreed with the person, with support for self-management. NICE — NG226 Osteoarthritis in over 16s: diagnosis and management, section 1.3, manual therapy; exercise advice; section 1.6, referral for joint surgery; section 1.7, follow-up and review, October 2022, checked 10 Oct 2026
- Knee pain features that need urgent action: a hot, swollen, painful joint with fever or systemic illness (possible septic arthritis, same-day admission); a significant injury with inability to bear weight or bony tenderness (an X-ray under the Ottawa knee rule); true locking or a loose body (orthopaedic referral); and night pain, weight loss or constant unremitting pain (possible malignancy). A meniscal tear is suggested by a twisting injury, swelling delayed by hours, locking, joint-line tenderness and a positive McMurray test; a gradual onset without injury or locking favours osteoarthritis. NICE CKS — Knee pain: assessment, assessment: red flags; differentiating meniscal injury from osteoarthritis, current online version, checked 10 Oct 2026
- A fit note is not needed for the first seven calendar days of sickness, which an employee self-certifies. Since 1 July 2022 a nurse, occupational therapist, pharmacist or physiotherapist can issue one as well as a doctor; it can be completed and sent digitally without a handwritten signature, and can follow a telephone or video assessment. A self-employed person needs no fit note to adjust his own work; if he cannot work, it is the evidence for a benefit claim. GOV.UK (DWP) — Getting the most out of the fit note: guidance for healthcare professionals, when a fit note is needed; who can issue one; digital issue; assessment by telephone or video, 2022, updated 2024, checked 10 Oct 2026
- A driver must notify the DVLA of a condition that affects safe driving and lasts, or is expected to last, more than three months; shorter conditions need not be. A Group 1 driver (car, or van up to 3.5 tonnes) with a limb disability may continue to drive if he can control the vehicle safely, with adaptations if needed; the doctor tells the patient of the duty and records the advice. For a van driver with knee osteoarthritis the question is whether he can control the pedals safely. DVLA — Assessing fitness to drive: a guide for medical professionals, introduction: the duty to notify and the three-month rule; disabilities affecting the limbs, 2024 edition, checked 10 Oct 2026
- The Musculoskeletal health Topic Guide expects the GP to diagnose osteoarthritis clinically and explain why imaging is not needed, to offer the core treatments of exercise, weight management and information, to prescribe analgesia safely in the presence of other medicines and comorbidity, to advise on work and complete fit notes with adjustments where needed, to know the criteria for orthopaedic referral, and to agree a review that sets realistic expectations in months. RCGP — GP curriculum: Musculoskeletal health, Topic Guide: osteoarthritis; safe analgesia; fitness for work; referral criteria, 2025 curriculum (Being a GP), checked 10 Oct 2026
Working references for this station
| Issuer | Document | Version | Checked |
|---|---|---|---|
| NICE | NG226 Osteoarthritis in over 16s: diagnosis and management | October 2022 | 10 Oct 2026 |
| NICE CKS | NSAIDs: prescribing issues | current online version | 10 Oct 2026 |
| GOV.UK (DWP) | Getting the most out of the fit note: guidance for healthcare professionals | 2022, updated 2024 | 10 Oct 2026 |
| NICE CKS | Knee pain: assessment | current online version | 10 Oct 2026 |
| DVLA | Assessing fitness to drive: a guide for medical professionals | 2024 edition | 10 Oct 2026 |
| RCGP | GP curriculum, Topic Guides: Musculoskeletal health · Consulting in general practice · Continuity and quality of care, safety and prescribing | Being a GP, 2025 curriculum | 10 Oct 2026 |
12 statements, 746 words. Every statement is signed by the Course Director before it is published; a station whose facts have changed since signature carries no signature line until it is signed again.
6 · RCGP curriculum tags for this case
| RCGP curriculum (2025) | This case |
|---|---|
| Topic Guide(s) | Musculoskeletal health · Consulting in general practice · Continuity and quality of care, safety and prescribing |
| Core capabilities | Communicating and consulting · Data gathering and interpretation · Decision-making and diagnosis · Clinical management |
| SCA Clinical Experience Group(s) | New presentation of undifferentiated disease · Prescribing · Long-term condition, including cancer, multi-morbidity, and disability |
| AKT blueprint clinical area | Musculoskeletal medicine (moderate representation) |
| Case type | undifferentiated |
| Modality | video |
7 · My marks and reflection — practice log form
Record your three domain grades, your case total out of 10.5, your global rating, the RCGP feedback statements that applied, and what you will keep and change. The form is already labelled with this case and its web address; a copy of your entry is emailed to you, so your practice log builds up in your inbox and can be downloaded.
Record my marks and reflection for SCA-STARTER-B
Revision link for this case: mdacumen.com/sca-starterb-knee-pain
Independence & scope. Formative training material from MD Acumen Ltd; not a prediction of exam performance. Not affiliated with, endorsed by, or delivered on behalf of the Royal College of General Practitioners; the marking domains and feedback statements are the RCGP's published ones, and every descriptor on this page is an Acumen training tool calibrated to them. Clinical content reflects UK guidance at the date of editorial review — always check the current guideline. All patients are fictional.
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