Abstract
BACKGROUND: Musculoskeletal (MSK) complaints are among the most common reasons for visits to primary care and outpatient clinics. While many cases are attributed to identifiable pathology, a significant proportion of patients present with persistent MSK symptoms despite normal physical examinations and imaging findings. These presentations pose diagnostic and management challenges and often result in patient frustration, clinician uncertainty, and overutilization of healthcare resources. OBJECTIVE: This narrative review aims to provide a comprehensive, evidence-informed, and practical framework for clinicians to evaluate and manage patients with MSK complaints in the absence of clear diagnostic abnormalities. METHODS: A targeted narrative review was performed using PubMed, MEDLINE, and major international clinical guidelines to identify relevant literature on the evaluation and management of musculoskeletal (MSK) pain without objective abnormalities. Evidence and expert consensus were synthesized into a biopsychosocial diagnostic and management framework specifically tailored for primary care and general outpatient settings. KEY FINDINGS: The review underscores the importance of empathetic communication, structured clinical assessment, and early exclusion of serious pathology. It presents a broad differential diagnosis encompassing mechanical, neuropathic, nociplastic, referred, and functional pain mechanisms. Management strategies are organized across key domains, including watchful follow-up, patient education, graded physical activity, stress and lifestyle management, psychosocial and occupational support, and functional goal setting. Pharmacologic therapy-such as short-term use of paracetamol or NSAIDs, and selected antidepressants for chronic nociplastic pain-should be considered cautiously and within a multidisciplinary, shared-decision framework. Opioid use is discouraged due to limited efficacy and high potential for harm. CONCLUSION: Patients presenting with MSK complaints and normal diagnostic findings benefit most from a structured, individualized, and patient-centered approach that integrates clinical reasoning, effective communication, and functional rehabilitation. Applying this framework enables clinicians to address the multidimensional nature of such presentations while avoiding unnecessary investigations or interventions.