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Most shoulder problems seen by the primary care physician involve impingement syndrome or problems at the acromioclavicular joint. Despite the complexity of the structures involved, most of these conditions can be diagnosed and treated without difficulty. MRI or other imaging studies are seldom needed but can be used to confirm a questionable diagnosis. Referral to an orthopedic surgeon is appropriate if shoulder problems persist for 3 to 6 months or if there is evidence of a medium or large rotator cuff tear, severe shoulder stiffness, or a complicated fracture.

Acute sinusitis is difficult to diagnose. Diagnosis depends on obtaining a complete history and physical examination in addition to use of radiographic diagnostic aids and, if necessary, sinus aspiration. Once the diagnosis is made, empirical treatment with antibiotic agents and adjunctive measures should be started. Because most acute sinus infections are caused by H influenzae and S pneumoniae, the preferred antibiotic for treatment is amoxicillin or TMP-SMZ. Timely and appropriate therapy prevents complications. Symptoms persisting after completion of an appropriate course of treatment are an indication for referral to an otolaryngologist.

Guillain-Barré syndrome is a relatively common disease with a low mortality rate. Early recognition and institution of treatment lead to a more favorable outcome, especially in more severe cases. Because the patient's condition may deteriorate rapidly, it is crucial to keep the patient in the hospital until his or her condition is confirmed to be stable. Plasmapheresis improves symptoms when instituted within 2 weeks of symptom onset. Treatment with high-dose intravenous immune globulin produces similar results. Speed of recovery varies, but often occurs in a few weeks or months.

Rupture of the Achilles tendon is relatively uncommon, but most primary care physicians are occasionally faced with evaluation and treatment of such an injury. Diagnosis is not difficult and is based almost solely on the history and physical findings. To avoid misdiagnosis, the Thompson test should be performed in any evaluation of ankle pain. The three management options are casting, open surgical repair, and percutaneous surgical repair. Incidence of rerupture is slightly higher with casting, but the greater costs and higher risk of complications with surgical treatment seem to outweigh the benefits. Because there is no conclusive evidence that functional activity is any better with surgical repair, we recommend casting for a minimum of 8 weeks. After this, the patient should wear a heel lift and begin a supervised physical rehabilitation program.

Stress fractures are an increasingly common injury in competitive athletes, especially runners. Amenorrheic athletes are at particularly high risk. A radionuclide bone scan should be considered when the index of suspicion for stress fracture is high. Plain radiographs are of little use in establishing the diagnosis in the early stages of the injury. Early diagnosis and prompt institution of conservative therapy allow for a favorable outcome in most cases. Avoidance of or reduced participation in the inciting activity is important for pain control. Certain stress fractures, such as those involving the femoral neck, should be monitored closely and treated aggressively with internal fixation when conservative measures fail. Runners who have exercise-induced amenorrhea should be advised to decrease their training intensity to a level where menses resume. Cyclic therapy with conjugated estrogens and progesterone should also be considered, as should daily calcium supplementation.